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Background: CT and transesophageal echocardiography (ETE) are commonly used in the diagnosis of acute aortic syndrome (AAS). Recent studies are underlining the additive value of contrast echocardiography during ETE (EETE) in the evaluation of the aortic diseases.Aim of the study: investigate the role of the EETE compared to unenhanced ETE (UETE) in AAS characterization, assuming CT as reference standard.Methods: 25 patients with suspected AAS were evaluated through UETE. ETEE scans were acquired after the i.v. administration of contrast agent (Sonovue,Bracco). In both the ETE evaluation, operators had to define the pathology, underlining additive features (numbers of entrance tears, intramural haematoma or penetrating aortic ulcer (PAU) associated, false lumen thrombosis, aortic wall rupture). The image quality was evaluated through a 1 to 4 score.Results: Compared to the 76% of UTEE evaluation, EETE images quality was sub-optimal/optimal in 100% of the patients (p.0.02). We detected: 5 type B aortic dissection, 2 type A aortic dissection,6 PAU, 6 intramural haematoma (but 3 of them were associated to other aortic diseases), one traumatic aortic rupture. In 8 patients AAS was rule out by CT scan; while EETE images were clearly negative for the presence of AAS, UETE images didn't allowed a definitive diagnosis (in 2 patients UETE images were suspicious for type A aortic dissection, and in one patient for PAU). The negative predictive value of ETEE was 100%. In type B aortic dissection patients, several entrance tears and a wide ascending aortic haematoma, not previously detected with UETE were identified. In type A aortic dissection, EETE identified a complete intimal laceration in a previous aortic stenting deployment site only suspected by UTEE, while in another patient ETEE defined the aortic arch entrance tear with a retrograde aortic dissection, not detectable during UETE examination.In PAU characterization, EETE achieved a proper crater dimension evaluation and in one patient unveiled the presence of a not previously seen haematoma. In the post-traumatic aortic rupture, EETE ruled out the presence of an active replenishment of the aortic wall haematoma. This important information wasn't achieved through colour Doppler UETE.Conclusion: EETE is highly accurate in AAS evaluation. Compared to UTEE, EETE provides better quality images and additive morphological data, regarding the aortic wall characteristics and the flow dynamics. These information play a major role inthe study of the patient and indeed may influence the clinical decision making and the therapeutic management.