Limited Circumferential Dissection of the Ascending Aorta Mimicking an Acute Coronary Syndrome
Brijesh Patel, MD; Liam Morris, MD; Nuri I. Akkus, MD; Alireza Hamidian Jahromi, MD; Vyas Rao, MD, FACS
CASE HISTORY A 52-year-old hypertensive female transferred from an outside hospital to our unit for management of an acute coronary syndrome. She presented initially with sudden onset severe chest pain radiating to the neck, right jaw, and right arm, associated with nausea and shortness of breath. On examination, the blood pressure (BP) was 177/59 mmHg, and the pulse was 77 beats per minute. There was a diastolic decrescendo murmur located over the lower left sternal border. Peripheral pulses were equally palpable bilaterally. The remainder of the examination was unre- markable. An electrocardiogram showed sinus rhythm, left ventricular hypertrophy, and ST-T wave abnormalities in the anterolateral leads (Figure 1). A chest radiograph (chest X-ray, CXR) showed a mildly prominent cardiac silhouette with perihilar congestion (Figure 2). Troponin level on admission was 0.03 μg/l, which subsequently increased to 0.14 μg/l (normal range <0.03 μg/l).
A transthoracic echocardiogram (TTE) showed a nor- mal left ventricular (LV) ejection fraction, LV hypertrophy, moderate aortic regurgitation (AR) (Figure 3A), and normal LV wall motion. A transesophageal echocardiogram (TEE) showed a type-A aortic dissection limited only to the ascend- ing aorta, just distal to the structurally normal aortic valve, with the intimal flap prolapsing into the left ventricle (Figure 3B), causing moderate aortic regurgitation (Figure 3C). CT angiogramof the chest showed a linear filling defect limited to the ascending aorta above the aortic valve annulus (Figure 4). Surgery revealed a circular dissection of the ascending aorta disrupting the normal anatomical suspension of the aortic leaflets (Figure 5A). The dissection was surgically repaired with pledgeted horizontal mattress stitches, and the native aortic valve was re-suspended (Figure 5B). The patient made a full recovery after surgery. DISCUSSION
Acute aortic dissection is a medi- cal emergency in which having a high degree of clinical suspicion is of critical importance for prompt diagnosis and treatment. Herein, we described a novel case of a limited circumferential aortic type-A dissection mimicking an acute coronary syndrome. The patient did not have pain radiating to back, widened mediastinum on CXR, or significant BP difference in the upper extremities. Uncontrolled hypertension and history of smoking, coupled with TTE findings of normal LV wall motion and AR led to clinical suspicion of aortic dissection. Only a few cases of limited circumferential type-A dissection are reported in the literature. 1-4 TEE is a highly sensitive and specific imaging modality used to diagnose aortic dissection. This type of
Figure 1: Twelve lead electrocardiogram (ECG) showing sinus rhythm, left ventricular hypertrophy, and ST-T wave abnormalities in the anterolateral leads.
J La State Med Soc VOL 166 November/December 2014 251
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