Correlation of echocardiographic myocardial deformation variables and vascular Doppler ultrasound variables in the classification of Type-Entry-Malperfusion (TEM) for aortic dissection

Introduction

Aortic dissection (AD) involves the rupture of the intimal layer of the aortic wall and, despite its frequency, is considered a rare disease, with a prevalence ranging from 1% to 3%. The annual incidence rate of type A AD is approximately 3 per 100,000 individuals (1). Currently, AD poses a significant clinical challenge, with reported 5-year survival rates ranging from 55% to 85% in acute cases of type A and type B dissections, and operative mortality rates as low as 12% (2-4). The mortality rate is initially around 1% per hour without treatment, rising to 50% by the third day (5). Even after successful surgery, complications related to AD contribute to 31% to 66% of deaths in type B cases, which generally carry a lower risk compared to type A AD (6-9).

Clinical decision-making regarding endovascular treatment must consider how anatomical structures and hemodynamic parameters adapt to the underlying pathophysiological mechanisms of AD. For this reason, classification systems define the disease according to the location of the intimal tear and the degree of aortic segment involvement (10).

AD necessitates comprehensive investigation that surpasses anatomical and geometric assessments of the aortic artery, as classified in the Stanford and DeBakey classifications. Emerging evidence indicates that rupture sites can lead to challenging myocardial perfusion and affect other target organs (10-12). Consequently, the recently integrated Type-Entry-Malperfusion (TEM) classification aims to expand the assessment of dissection not only concerning the area of rupture but also regarding cardiovascular involvement amid perfusion difficulties (13,14).

The aim of this study was to evaluate the relationship between TEM classification and conventional echocardiographic parameters, as well as advanced echocardiographic techniques for myocardial deformation using speckle tracking in patients with AD. It is important to note that myocardial deformation assessment involves a semi-automated analysis of grayscale echocardiographic studies, where the spatial movement of derived functional units (speckles) allows quantitative analysis of myocardial function. Speckle tracking is a subset of deformation imaging used to assess left ventricular (LV) function in conditions such as diastolic dysfunction, cardiomyopathies, and ischemic heart disease (15-18).

Therefore, based on the premise that the thrombolysis in myocardial infarction (TIMI) classification evaluates both the location and extent of the dissection, as well as assesses radiological or clinical evidence of impaired tissue perfusion in distal organs, particularly in cases involving the descending aorta, incorporating vascular compliance assessment of the aortic artery through Doppler techniques can aid in identifying these distal malperfusion abnormalities. This article is presented in accordance with the STROBE reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-664/rc).

Methods

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Research Ethics Committees of the Lenmed Ahmed Kathrada Private Hospital (No. 3.805.967). All patients provided informed consent by signing a consent form.

Sample size

The sample size was determined based on a study conducted by Narayan et al. (19), where malperfusion according to the TEM classification was the primary outcome variable. With a statistical power of 80% and a significance level (alpha) of 5%, the calculation indicated a need for 123 patients with AD. To account for potential sample attrition, a total of 134 patients were selected for inclusion in this study.

Patients with a history of myocardial infarction (MI), endocarditis, and AD associated with connective tissue disorders such as Marfan syndrome, Loeys-Dietz syndrome, and Turner syndrome were excluded from participation.

Assessment procedures

Due to the severity of the disease, assessments were conducted in the operating room, with patients already adequately sedated before thoracic incision. Clinical data, including age, gender, body mass index (BMI), body surface area (BSA), and histories of hypertension, diabetes mellitus, and hypercholesterolemia, were extracted from electronic medical records.

Laboratory data on biomarkers indicative of myocardial and vascular damage, such as smooth muscle myosin heavy chain (smMHC), calponin, soluble elastin fragments (sELAF), cardiac troponin I (cTnI), and creatine kinase-MB (CK-MB), were obtained from the hospital’s electronic medical records. Additionally, electrocardiograms (ECGs) were analyzed for potential alterations in electrical activity, focusing on ST-segment T-wave abnormalities, bundle branch blocks, and pathological Q waves.

Classification of AD

In the context of AD, the TEM classification system is utilized to delineate the anatomical characteristics of the dissection and its impact on target organs. Developed specifically for this purpose, the TEM classification enhances the accuracy and comprehensiveness of assessing disease complexity and categorizing patients with AD. This classification system not only advances understanding of disease mechanisms but also aids in making informed decisions regarding the extent of surgical intervention and predicting prognosis.

As depicted in Figure 1, the classification of malperfusion within the TEM system is defined as follows:

• M0: no clinical or radiologic indicators of malperfusion are identified.
• M1: cardiac malperfusion denotes extension of the dissection into one or more coronary arteries. Ischemic involvement may be present or absent (M1⁺ or M1⁻) and can manifest as electrocardiographic abnormalities or elevations in cardiac biomarkers.
• M2: supra-aortic malperfusion reflects dissection involving one or more vessels originating from the aortic arch or collapse of the true lumen at this level. This pattern may result in cerebral ischemia or upper extremity hypoperfusion, presenting with pulse deficit, pain, pallor, or paresthesia.
• M3: visceral and lower limb malperfusion arises when the dissection extends to the visceral, renal, or iliac arteries, or when true-lumen collapse causes secondary occlusion. Clinically, this may manifest as intestinal ischemia (abdominal pain, ileus, or bloody diarrhea), renal failure (anuria or elevated creatinine), or lower extremity ischemia (pulse deficit, pain, pallor, paresthesia).

Figure 1 TEM classification. The TEM system combines three components to describe acute aortic dissection: T (Type), Stanford classification (A, B, or non-A non-B); E (Entry), location of the primary intimal tear (E0: no entry tear identified; E1: ascending aorta between the aortic valve and the brachiocephalic trunk; E2: aortic arch between the brachiocephalic trunk and the left subclavian artery; E3: descending aorta distal to the left subclavian artery); and M (Malperfusion), absence (M0) or presence of malperfusion affecting coronary arteries (M1), supra-aortic branches (M2), or visceral, spinal, renal, or lower limb circulation (M3).

This classification framework provides a structured approach to identifying and stratifying the severity of malperfusion in patients with AD, thereby guiding appropriate clinical management strategies.

To assess the correlation of malperfusion in each subgroup (M0, M1, M2, and M3) with echocardiographic variables, the following historical scores were assigned: 1 point for each of the following variables: valve dilatation and aortic regurgitation, heart failure [ejection fraction (EF) <50%], fatal rupture of the aorta through the adventitia into the pericardial, right atrium, or left pleural cavity, stroke, arrhythmias, renal failure, paraparesis or paraplegia resulting from interrupted blood supply to a specific vascular bed, and pulseless electrical activity.

Echocardiography

All transesophageal echocardiography (TEE) images were prospectively collected to ensure optimal image quality by the same examiner certified in echocardiography. The images for assessing AD before and after repair were acquired using an EPIC CVx ultrasound system (Philips Medical Systems, Andover, MA, USA) equipped with an X8-2T probe. Subsequently, the images for analyzing myocardial function and LV myocardial deformation were obtained after chest closure using transthoracic echocardiography with a GE Vivid E95 ultrasound machine (GE Vingmed Ultrasound AS, Horten, Norway). The images were recorded with ECG tracings during at least three consecutive cardiac cycles. All images were acquired at a frame rate of 55–90 frames per second and then reviewed offline using EchoPac software (version 112, GE Vingmed Ultrasound AS) following the recommended guidelines (20).

Conventional echocardiographic measurements of LV function were obtained, including EF (LVEF), calculated using the modified Simpson’s rule for systolic function. Additionally, parameters such as mitral Doppler E and A waves, deceleration time (DT), as well as Doppler diastolic velocities of the lateral and septal mitral annulus (e’ lateral and e’ septal), were assessed. All these variables were used to estimate LV diastolic function.

Myocardial deformation was analyzed using two-dimensional strain imaging derived from the three apical views of the LV. When image quality was satisfactory, the second of three consecutively acquired cardiac cycles was used for analysis. Strain was calculated from the full-thickness (mesocardial) layer, with end-systolic values recorded and post-systolic deformation excluded. The temporal reference point was manually aligned to the onset of the QRS complex. End-systole was defined by aortic valve closure, confirmed by the Doppler flow signal in the LV outflow tract during LV global longitudinal strain (GLS) measurement. The endocardial boundary was manually traced at end systole, and the region of interest was adjusted to exclude the pericardium. Tracking integrity, strain curve integrity, and measured peak values were verified. Segments with persistently inadequate tracking were excluded from the analysis, with a maximum of two excluded segments considered tolerable. LV segmentation into 18 segments was performed following the methodology described by Voigt et al. [2019] (21).

Doppler vascular blood flow

A portable continuous wave Doppler device with spectral analysis capabilities (Nicolet Vascular Versalab SE, San Carlos, CA, USA) was employed for signal capture and processing. It was interfaced with a notebook for data acquisition, enabling the quantification of blood flow parameters such as peak systolic velocity (PSV), resistivity index (RI), pulsatility index (PI), and temporal characterization. These measurements were specifically conducted to assess blood flow in the descending aorta, obtained via the subcostal window. This setup facilitated detailed assessment and analysis of descending aortic blood flow dynamics in the study.

Image analysis

The vascular, echocardiographic, and Doppler ultrasound images obtained in the operating room were transferred in DICOM format to the echocardiography laboratory workstation at Hospital das Clínicas, Ribeirão Preto Medical School. Echocardiographic images depicting myocardial deformation were acquired at a frame rate of 55–90 frames per second and subsequently analyzed offline using EchoPac software (version 112, GE Vingmed Ultrasound AS), in accordance with established guidelines (15). For the analysis of vascular Doppler ultrasound data, CareFusion 7.0 software (Nicolet Vascular Versalab SE, San Carlos, CA, USA) was utilized, employing Doppler ultrasound signal processing methodologies as recommended by Yan et al. [2019] (22).

Statistical analysis

Continuous variables were presented as mean ± standard deviation, while nominal variables were expressed as absolute frequency (n) and relative frequency (%). The Shapiro-Wilk test was employed to assess the distribution of the data. Pearson’s correlation coefficient was utilized to evaluate correlations between the TEM classification and various echocardiographic variables when the data followed a normal distribution. Alternatively, when the data did not exhibit a normal distribution, Spearman’s correlation coefficient was applied. Statistical analyses were performed using GraphPad Prism, version 9.1.2 (GraphPad Software, San Diego, CA, USA).

To interpret the strength of correlations, the classification established by Munro (23) was utilized: low correlation: 0.26–0.49; moderate correlation: 0.50–0.69; high correlation: 0.70–0.89; very high correlation: 0.90–1.00.

Results

The characteristics of the patients are summarized in Table 1. Initially, 134 patients with acute aortic dissection (AAD) were enrolled in the study. However, 20 patients were excluded due to difficult acoustic window conditions. The patients had a mean age of 56.6±11.8 years, a BMI of 26.73±4.30 kg/m², a BSA of 1.70±0.230 m², and a systolic blood pressure (SBP) of 152.7±14.85 mmHg.

All the patients had type A AD and no evidence of electrocardiographic alterations of myocardial damage. Specifically, 48 patients had rupture of the intimal layer in the ascending aorta (E1) and cardiac malperfusion (M1⁻), 28 patients had rupture of the intimal layer in the ascending aorta (E1) and cardiac malperfusion (M1⁻) with a bicuspid aortic valve, and 38 had rupture of the entrance to the aortic arch (E2) without evidence of myocardial malperfusion, but with evidence of supra-aortic malperfusion (M2⁺), due to clinical symptoms of upper limb malperfusion (pulse deficit, pain, pallor, paresthesia) (Figure 2).

Figure 2 Type A aortic dissection. TEE images showing rupture of the intimal layer of the ascending aorta indicated by the yellow arrows, resulting in separation of the TL and the FL. Color Doppler imaging helped to delineate the direction of flow, thereby enhancing the distinction between the two lumens. FL, false lumen; TEE, transesophageal echocardiography; TL, true lumen.

The study results revealed a weak correlation when evaluating conventional echocardiographic variables for diastolic and systolic parameters in relation to myocardial malperfusion within the TEM classification. However, advanced echocardiographic techniques (speckle tracking) assessing myocardial deformation parameters showed a strong correlation with variables in subcategories E1 and M1⁻, E1 and M1⁻ with a bicuspid aortic valve (M1⁻ Bi), and E2 and M2⁺ (Table 2).

The GLS myocardial deformation parameter demonstrated significant relevance in correlation with the TEM classification, particularly in the M1 category. The results indicate strong correlations between various malperfusion parameters, such as E1 and M1⁻ (r=0.8333, P<0.0001), E1 and M1⁻ Bi (r=0.8872, P<0.0001), and E2 and M2⁺ (r=0.8872, P<0.0001) (Figure 3).

Figure 3 Correlation of myocardial malperfusion parameters with GLS. The image on the right depicts the graphical representation of myocardial strain with mapping of the most affected segments. E1 and M1⁻: intimal layer rupture in the ascending aorta with cardiac malperfusion; E1 and M1⁻ Bi: intimal layer rupture in the ascending aorta with cardiac malperfusion and a bicuspid aortic valve; E2 and M2+: aortic arch rupture with evidence of supra-aortic malperfusion. ANT, anterior; AVC, aortic valve closed; ER, ejection rate; GLPS, global longitudinal peak strain; GLS, global longitudinal strain; HR, heart rate; INF, inferior; LAT, lateral; POST, posterior; PSD, peak strain delay; r, correlation coefficient; SEPT, septal.

As for the analysis of serum myocardial biomarkers in all patients, the results indicated a weak correlation with conventional echocardiographic variables. However, they demonstrated a strong correlation with GLS (Table 3).

Myocardial injury biomarker variables, such as CK-MB (r=0.8797, P<0.0001) and cTnI (r=0.6659, P<0.0001), exhibited a strong correlation with GLS (Figure 4).

Figure 4 Correlation of myocardial injury biomarkers with GLS. CK-MB, creatine kinase-MB; cTnI, cardiac troponin I; GLS, global longitudinal strain; r, correlation coefficient.

Regarding the assessment of vascular compliance variables in the TEM classification, our findings demonstrate a strong correlation between Doppler spectral flow profiles in the descending aorta and serum levels of smMHC and sELAF (Table 4).

The vascular hemodynamic profile of the descending aortic artery, measured in the subcostal window, exhibited a triphasic profile in all patients with AD. Doppler spectral profiling revealed a significant correlation of biomarkers such as smMHC (r=0.8793, P<0.0001) and sELAF (r=0.7623, P<0.0001) with PI, indicating reduced vascular compliance (Figure 5).

Figure 5 Evaluation of flow in the descending aorta using spectral Doppler techniques includes measuring the following parameters: PDV, PSV, MPSV, and EDV. AU, aortic unit; CK, creatine kinase; EDV, end-diastolic velocity; MPSV, mean peak systolic velocity; PDV, peak diastolic volume; PI, pulsatility index; PSV, peak systolic velocity; r, correlation coefficient; smMHC, smooth muscle myosin heavy chain.

Discussion

This study revealed that the majority of patients had type A AD, with the highest incidence of rupture occurring in the ascending aorta. This highlights the correlation observed between the myocardial deformation variables assessed by the GLS and the malperfusion variables categorized by the TEM classification. On the other hand, various mechanical compliance parameters of the post-dissection descending aorta, assessed using Doppler spectral profiles, such as PI and RI, showed a strong correlation with serum analysis markers such as smMHC and sELAF.

It’s notable that while ECG findings typically manifest within the first 12 hours of admission, their utility in definitively diagnosing AD is limited and absent in many cases (24). For instance, in type A dissections involving rupture of the ascending aorta and affecting at least one major coronary artery (categorized as M1 in the TEM classification), characteristic ECG changes indicative of ischemia are expected. However, data from IRAD indicate that nearly 19% of AD patients exhibit ECG changes suggestive of myocardial ischemia, with 7% showing concurrent MI (24,25). Other findings such as ventricular hypertrophy, Q wave abnormalities, and ST segment changes are nonspecific and indicate the presence of cardiac abnormalities (7). Nevertheless, ECG findings play a crucial role in prognosticating AD patients, with ST segment abnormalities independently associated with increased hospital mortality in multivariate analyses (26).

Current guidelines from the European Society of Cardiology recommend using TEE for hemodynamically unstable AD patients prior to transfer or upon arrival in the operating room (27). TEE demonstrates high sensitivity (94–100%) and specificity (77–100%) in identifying the site of rupture and distinguishing between true and false lumens. Meta-analyses have shown TEE to be comparable to helical computed tomography and magnetic resonance imaging in detecting AD, although its accuracy is operator-dependent and its availability may be limited in certain settings (28).

TEE’s ability to visualize the intimate flap characteristic of AD is aided by color flow imaging, which helps distinguish reverberation artifacts from actual pathology. Beyond anatomical assessment, TEE provides critical information for preoperative planning, including the involvement of coronary and head/neck vessels, presence of aortic regurgitation, rupture site, and proximal extent of the dissection flap. It also aids in detecting complications such as pericardial effusion, cardiac tamponade, and assessing LV function (13).

While conventional transthoracic echocardiographic parameters did not show significant correlation in our study, it is established that certain “high-risk” characteristics such as aortic regurgitation, dilated aortic root with pericardial effusion, inferior hypokinesia, and bicuspid aortic valve are associated with AD. Transthoracic echocardiography is valuable not only in diagnosing AD but also in identifying signs indicative of alternative diagnoses such as pericardial effusion, right heart dilatation (suggestive of pulmonary embolism), and regional wall abnormalities (suggestive of MI) (29).

Our findings support a significant correlation between TEM classification and GLS assessment of myocardial deformation. GLS demonstrates greater sensitivity in detecting myocardial deformation abnormalities compared to other echocardiographic parameters. Given that myocardial ischemia initiates with flow heterogeneity in the subendocardial layer, where longitudinally oriented fibers predominate, it is understandable that GLS abnormalities in these patients may manifest as early systolic stretch, reduced systolic shortening, and post-systolic shortening (tardokinesis) (30,31). Strain parameters are increasingly used in screening for acute MIs without ST-segment elevation and have shown significant correlation with global infarct mass in chronic ischemic heart disease, surpassing LVEF in detecting small and medium-sized infarctions (32-35).

TEM classification extends beyond anatomical assessment and myocardial malperfusion to include evaluation of malperfusion in distal organs. AD presents with diverse clinical manifestations, typically as a sudden tearing pain in the chest or back due to intimal layer rupture from aortic pressure flow (36). This can lead to compression or occlusion of aortic branches, causing acute ischemia affecting the arms (20% of patients), kidneys (15%), brain (5%), and mesentery or spinal cord (3%) (37). Neurological symptoms, including paraplegia (2–5% of patients), complicate diagnosis significantly (38,39).

Our study underscores the significant correlation between vascular lesion types and pulsatility indicated by echocardiographic parameters. It’s important to note that smMHC, a marker of smooth muscle cell necrosis in the aortic media, demonstrates high sensitivity and specificity in early detection post-AD onset (40,41). Conversely, sELAF, a marker of aortic wall degradation, remains debated for its diagnostic utility, with studies reporting varying results regarding its clinical significance in AD (42,43).

Doppler spectral analysis proves valuable in assessing aortic artery vascular compliance. Our study shows that as biomarker levels increase, aortic artery compliance decreases, suggesting a broad correlation. This underscores the critical role of vascular compliance assessment in managing acute type A AD, where vascular alterations and hypotension are associated with increased hospital mortality and neurological complications (44,45).

The TEM classification provides valuable prognostic and predictive information on the surgical outcomes of AD. While the Stanford and DeBakey classifications are popular for their simplicity in describing AD pathology, the TEM classification offers enhanced anatomical detail through alphanumeric categorization. However, its application in clinical practice can be hampered by its complexity and the need for verbal transmission of malperfusion details from radiologists to surgeons, which lacks standardized quantification. Future refinements could involve subclassifying the malperfusion section of the TEM system to reduce ambiguity without overcomplicating its usefulness in clinical settings.

Limitations

The correlation findings from this study warrant careful interpretation due to several factors. Firstly, the analysis of myocardial deformation using speckle tracking echocardiography may be influenced by variables such as advanced age, myocardial hypertrophy, and other pathologies that can lead to myocardial fibrosis. These conditions can potentially alter myocardial strain measurements obtained through speckle tracking techniques, affecting the accuracy and reliability of correlations observed.

Secondly, the PI and levels of sELAF are known to vary with advancing age. This variability could introduce confounding factors when correlating these biomarkers with echocardiographic variables, potentially impacting the robustness of the observed correlations.

These limitations underscore the need for cautious interpretation of the study’s results. Future research should consider these variables and possibly adjust for them to enhance the accuracy and applicability of findings related to myocardial deformation and vascular compliance in patients with AD.

Conclusions

In this study, conventional echocardiographic variables demonstrated limited correlation with the TEM classification, whereas advanced myocardial deformation parameters, particularly GLS, showed strong associations with malperfusion categories, especially E1/M1 and E2/M2. Likewise, vascular compliance indices assessed by Doppler ultrasound, such as the PI, correlated significantly with circulating biomarkers of aortic wall injury. These findings highlight the value of the TEM classification as a comprehensive tool for the assessment of AD, integrating anatomical, hemodynamic, and functional parameters, and extending its prognostic utility beyond the traditional Stanford and DeBakey systems. Incorporating quantitative measures such as GLS and PI may enhance the ability to predict surgical outcomes and postoperative complications. Future multicenter studies with more heterogeneous populations are warranted to validate these results and establish TEM as an integrated standard for the evaluation of AD.

Acknowledgments

I sincerely thank all collaborators, including research assistants, surgeons, perfusionists, anesthesiologists, echocardiographers, and the ICU team, for their invaluable support and cooperation. Their assistance in granting access to the surgical center and other hospital facilities, as well as in providing unrestricted use of various educational resources, was greatly appreciated. I am also deeply grateful for their extensive expertise in surgical techniques and cardiology, which was essential for the care of patients with aortic dissection.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-664/rc

Data Sharing Statement: Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-664/dss

Funding: This study did not receive direct financial support from any funding agency. However, Dr. Sapalo, one of the authors, holds a scholarship funded by the São Paulo Research Foundation (FAPESP) (No. 2025/01284-0).

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-664/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Research Ethics Committees of the Lenmed Ahmed Kathrada Private Hospital (No. 3.805.967). All patients provided informed consent by signing a consent form.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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