Frequency and explanation of false negative diagnosis of aortic dissection by aortography and transesophageal echocardiography

Objectives. This study was designed to define the frequency and explanation of false negative diagnosis of aortic dissection by aortography and transesophageal echocardiography. Background. Aortography and transesophageal echocardiography have been widely utilized to diagnose aortic dissection. Previous reports have not fully addressed the reasons why these studies yield false negative results in large number of patients with aortic dissection. Methods. Sixty-five consecutive patients with aortic dissection underwent aortography and transesophageal echocardiography. Diagnosis of aortic dissection was confirmed at operation or by computed tomography in all patients. Results. Biplane transesophageal echocardiograms yielded false negative results in two patients (sensitivity 97% [63 of 65]). Both patients had well localized DeBakey type II aortic dissection. The diagnosis was probably missed because of image interference from the air-filled trache and mainstem bronchi. In both patients, the dissection was readily identified by aortography. Aortograms yielded false negative results in 15 patients (sensitivity 77% [50 of 65]); the aortic dissection was type I in 7 patients, type II in 1 and type III in 7. The dissection in all 15 patients was readily identified by transesophageal echocardiography. The missed diagnosis was probably due to completely thrombosed false lumen or intramural hematom with noncommunicating dissection in 13 patients and to large ascending aortic aneurysm with nearly equal flow on both sides of the intimal flap in 2. In no patient was the diagnosis missed by both aortography and transesophageal echocardiography. Conclusion. Transesophageal echocardiography is an excellent screening tool for aortic dissection. However, it may miss small type II aortic dissections localized to the upper portion of the ascending aort because of image interference from the air-filled trachea. An intramural hematom cannot be easily visualized by aortography, and this lesion is the principal reason for false negative aortographic findings.