title: Point-of-care focused cardiac ultrasound for the assessment of thoracic aortic dimensions, dilation, and aneurysmal disease.
abstract: OBJECTIVE
  Thoracic aortic aneurysm and thoracic aortic dissection are related and potentially deadly diseases that present with nonspecific symptoms. Transthoracic echocardiography (TTE) may detect thoracic aortic pathology and is being increasingly performed by the emergency physician at the bedside; however, the accuracy of point-of-care (POC) focused cardiac ultrasound (FOCUS) for thoracic aortic aneurysm and thoracic aortic dissection has not been studied. The objective of this pilot study was to explore the agreement, sensitivity, and specificity of FOCUS for thoracic aortic dimensions, dilation, and aneurysm compared with CT angiography (CTA) as the reference standard.
  
  
  METHODS
  This study was a retrospective pilot analysis of image and chart data on consecutive patients presenting to an urban, academic emergency department (ED) between January 2008 and June 2010, who had both a FOCUS and a CTA for suspicion of thoracic aorta pathology. Thoracic aorta dimensions were measured from recordings by three ultrasound-trained emergency physicians blinded to any initial FOCUS and CTA results. CTA measurements were obtained by a radiologist blinded to the FOCUS results. Using cutoffs of 40 and 45 mm, we calculated the sensitivity and specificity of FOCUS for aortic dilation and aneurysm with the largest measurement on CT as the reference standard. Bland-Altman plots with 95% limits of agreement were used to demonstrate agreement for aortic measurements, kappa statistics to assess the degree of agreement between tests for aortic dilation, and intraclass correlation for interobserver and intraobserver variability.
  
  
  RESULTS
  Ninety-two patients underwent both FOCUS and CTA during the study period. Ten FOCUS studies had inadequate visualization for all measurements areas. Eighty-two patients were included in the final analysis. Mean (±SD) age was 58.1 (±16.6) years and 58.5% were male. Sensitivity, specificity, and the observed kappa value (95% confidence interval [CI]) between FOCUS and CTA for the presence of aortic dilation at the 40-mm cutoff were 0.77 (95% CI = 0.58 to 0.98), 0.95 (95% CI = 0.84 to 0.99), and 0.74 (95% CI = 0.58 to 0.90), respectively. The mean difference (95% limits of agreement) for the Bland-Altman plots was 0.6 mm (-5.3 to 6.5) for the sinuses of Valsalva, 4 mm (-2.7 to 10.7) for the sinotubular junction, 1.5 mm (-5.8 to 8.8) for the ascending aorta, and 2.2 mm (-5.9 to 10.3) for the descending aorta.
  
  
  CONCLUSIONS
  In this retrospective pilot study, FOCUS demonstrated good agreement with CTA measurements of maximal thoracic aortic diameter. FOCUS appears to be specific for aortic dilation and aneurysm when compared to CTA, but requires further prospective study.
authors.affiliation: Department of Emergency Medicine, Yale University, New Haven, CT, USA. richard.taylor@yale.edu
authors.forename: R Andrew
authors.initials: RA
authors.lastname: Taylor
authors.forename: Isabel
authors.initials: I
authors.lastname: Oliva
authors.forename: Reinier
authors.initials: R
authors.lastname: Van Tonder
authors.forename: John
authors.initials: J
authors.lastname: Elefteriades
authors.forename: James
authors.initials: J
authors.lastname: Dziura
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Moore
mesh_terms: D001013:Aorta, Thoracic / Q000000981:diagnostic imaging*; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging; D001018:Aortic Diseases / Q000000981:diagnostic imaging*; D004108:Dilatation, Pathologic / Q000000981:diagnostic imaging; D004452:Echocardiography / Q000295:instrumentation*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D019095:Point-of-Care Systems; D012189:Retrospective Studies; D012680:Sensitivity and Specificity