• Is there a dissection or dissecting aneurysm? If there is aneurysmal enlargement, surgical attention is even more urgent, since the chances of rupture are greater. Look for true aortic lumen size, false lumen size, flow characteristics and thrombus in the false lumen, and morphology of the outer boundary of the false lumen. More often, aneurysmal dilatation of the false lumen precludes optimal assessment of the outer boundary even with multiplane imaging. This is true even if there is no dilatation of the distal portion of the ascending aorta.
• Does the dissection involve the intra pericardial portion of the ascending aorta? Look for morphology of the intrapericardial aorta from the anulus to the level of the right pulmonary artery crossing in detail since rupture of this portion of the aorta often results in rapid death from tamponade. Care needs to be exerted to look at the aortic wall thickness and periaortic morphology when the typical double barrel appearance of aortic dissection is not present to exclude intramural hematoma or retrograde extension of an arch dissection.
• Is the aortic root architecture disturbed? Look for aortic valve morphology and mobility, aortic sinuses thickness and geometry, asymmetric thickening of the aortic sinus or aortic valve prolapse, severity of aortic regurgitation, and relationship of the intimal flap to coronary ostia. Severe aortic regurgitation may be the only sign and may preclude optimal assessment of the root in a rare dissection involving the aortic sinus. The intimal flap may disrupt the aortic commissure or even prolapse into the left ventricle causing aortic insufficiency. All these have impact on the surgery.
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