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Chou PC, Chien SC. Man With Chest Pain. Ann Emerg Med 2020; 73:236-247. [PMID: 30797293 DOI: 10.1016/j.annemergmed.2018.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Po-Chen Chou
- Emergency Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shih-Chieh Chien
- Critical Care Medicine, Mackay Memorial Hospital, Taipei, Taiwan
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2
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Abstract
In case of complete circumferential dissection of the ascending aorta, the dissected flap has the potential to fold backwards, causing several complications. We report two cases of Stanford type A acute aortic dissection (AAD) whose intimal flaps intussuscepted into the left ventricular outflow tract.Case 1: A 41-year-old man with AAD in whom transthoracic echocardiography (TTE) showed the dissected flap as folded back into the left ventricular outflow tract, causing severe aortic regurgitation (AR) with rapidly progressing acute pulmonary edema. Despite performing salvage surgery, the patient could not be rescued.Case 2: An 81-year-old man with annuloaortic ectasia developed Stanford type A AAD. TTE showed an extremely mobile intimal flap intussuscepting into the left ventricular outflow tract. However, AR was not severe as it was prevented by the flap itself. The patient was rescued by performance of the modified Bentall procedure.
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Affiliation(s)
- Yohsuke Yanase
- Department of Cardiovascular Surgery, Hokkaido Prefectural Kitami Hospital, Kitami, Hokkaido, Japan
| | - Akihito Ohkawa
- Department of Cardiovascular Surgery, Hokkaido Prefectural Kitami Hospital, Kitami, Hokkaido, Japan
| | - Satomi Inoue
- Department of Cardiovascular Surgery, Hokkaido Prefectural Kitami Hospital, Kitami, Hokkaido, Japan
| | - Yukihiro Niida
- Department of Anesthesiology, Hokkaido Prefectural Kitami Hospital, kitami, Hokkaido, Japan
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3
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Inokuchi T, Sasaki O, Nishioka T, Ito H, Yoshimoto N, Yamabi H, Imanaka K, Sasaki H. Momentary and wide aortic regurgitation as an indicator of aortic dissection. Gen Thorac Cardiovasc Surg 2015; 65:167-170. [PMID: 26449356 DOI: 10.1007/s11748-015-0595-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 10/01/2015] [Indexed: 11/30/2022]
Abstract
A 55-year-old female with a history of hypertension was admitted for dyspnea, epigastralgia and nausea. A chest X-ray showed pulmonary congestion. Transthoracic echocardiography (TTE) revealed severe left ventricular dysfunction with akinesis of the infero-posterior wall and Doppler color-flow mode showed mild aortic regurgitation (AR). Noninvasive positive pressure ventilation, intravenous heparin and diuretics were administered. Follow-up TTE revealed a dissection flap as well as momentary and wide AR only during isovolumetric relaxation. Contrast-enhanced computed tomography of the chest revealed Stanford type A aortic dissection. A momentary and wide AR in echocardiograms might serve as an important and useful indicator of aortic dissection in patients with acute myocardial infarction and congestive heart failure.
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Affiliation(s)
- Takafumi Inokuchi
- Division of Cardiology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | - Osamu Sasaki
- Division of Cardiology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan.
| | - Toshihiko Nishioka
- Division of Cardiology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | - Hiroyuki Ito
- Division of Cardiology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | - Nobuo Yoshimoto
- Division of Cardiology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | - Hideaki Yamabi
- Division of Cardiovascular Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Kazuhito Imanaka
- Division of Cardiovascular Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Hideki Sasaki
- Division of Cardiovascular Surgery, Ehime Prefectural Central Hospital, Matsuyama, Japan
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4
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Abstract
Despite improved outcomes of acute type A aortic dissection (AAAD), many patients die at the moment of onset, and hospital mortality is still high. This article reviews the latest literature to seek the best possible way to optimize outcomes. Delayed diagnosis is caused by variation in or absence of typical symptoms, especially in patients with neurological symptoms. Misdiagnosis as acute myocardial infarction is another problem. Improved awareness by physicians is needed. On arrival, quick admission to the OR is desirable, followed by assessment with transesophageal echocardiography, and malperfusion already exists or newly develops in the OR; thus, timely diagnosis without delay with multimodality assessment is important. Although endovascular therapy is promising, careful introduction is mandatory so as not to cause complications. While various routes are used for the systemic perfusion, not a single route is perfect, and careful monitoring is essential. Surgical treatment on octogenarians is increasingly performed and produces better outcomes than conservative therapy. Complications are not rare, and consent from the family is essential. Prevention of AAAD is another important issue because more patients die at its onset than in the following treatment. In addition to hereditary diseases, including bicuspid aortic valve disease, the management of blood pressure is important.
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Affiliation(s)
- Kazumasa Orihashi
- Department of Surgery II, Kochi Medical School, Nankoku, Kochi, Japan
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Lajevardi SS, Sian K, Ward M, Marshman D. Circumferential intimal tear in type A aortic dissection with intimo-intimal intussusception into left ventricle and left main coronary artery occlusion. J Thorac Cardiovasc Surg 2012; 144:e21-3. [PMID: 22676981 DOI: 10.1016/j.jtcvs.2012.05.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 05/07/2012] [Indexed: 10/28/2022]
Affiliation(s)
- Sepehr Seyed Lajevardi
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, University of Sydney, Sydney, Australia.
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Bonser RS, Ranasinghe AM, Loubani M, Evans JD, Thalji NM, Bachet JE, Carrel TP, Czerny M, Di Bartolomeo R, Grabenwöger M, Lonn L, Mestres CA, Schepens MA, Weigang E. Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection. J Am Coll Cardiol 2011; 58:2455-74. [PMID: 22133845 DOI: 10.1016/j.jacc.2011.06.067] [Citation(s) in RCA: 160] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Accepted: 06/07/2011] [Indexed: 01/11/2023]
Abstract
Acute type A aortic dissection is a lethal condition requiring emergency surgery. It has diverse presentations, and the diagnosis can be missed or delayed. Once diagnosed, decisions with regard to initial management, transfer, appropriateness of surgery, timing of operation, and intervention for malperfusion complications are necessary. The goals of surgery are to save life by prevention of pericardial tamponade or intra-pericardial aortic rupture, to resect the primary entry tear, to correct or prevent any malperfusion and aortic valve regurgitation, and if possible to prevent late dissection-related complications in the proximal and downstream aorta. No randomized trials of treatment or techniques have ever been performed, and novel therapies-particularly with regard to extent of surgery-are being devised and implemented, but their role needs to be defined. Overall, except in highly specialized centers, surgical outcomes might be static, and there is abundant room for improvement. By highlighting difficulties and controversies in diagnosis, patient selection, and surgical therapy, our over-arching goal should be to enfranchise more patients for treatment and improve surgical outcomes.
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Yamabi H, Imanaka K, Sato H, Matsuoka T. Extremely localized aortic dissection and intussusception of the intimal flap into the left ventricle. Ann Thorac Cardiovasc Surg 2012; 17:431-3. [PMID: 21881338 DOI: 10.5761/atcs.cr.10.01594] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Stanford type A aortic dissection frequently deforms the aortic root and causes aortic regurgitation (AR). On the rare occasion, massive AR can occur due to circumferential intimal disruption and prolapse of the cylinder-shaped intimal flap into the left ventricle. Because of the critical, general, and hemodynamic state of such patients, surgery for this condition carries a high risk. A 62-year-old woman suffered acute chest pain and fell into cardiogenic shock. Computed tomography and transthoracic echocardiography failed to identify the etiology of this rapid hemodynamic collapse. Transesophageal echocardiography (TEE) demonstrated circumferential intimal disruption, 3 centimeters above the aortic valve annulus; a very localized aortic dissection in the proximal ascending aorta; and a to-and-fro motion of cylinder-shaped intima causing severe AR. The dissection did not affect the aorta beyond the intimal tear, and TEE was the only useful modality for the diagnosis. Emergency replacement of the ascending aorta and resuspension of the aortic valve was successfully performed. Residual AR was absent, and the postoperative course was uneventful.
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Affiliation(s)
- Hideaki Yamabi
- Department of Cardiovascular Surgery, Saitama Medical Center, Kawagoe, Saitama, Japan.
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Isoda S, Osako M, Kimura T, Mashiko Y, Yamanaka N, Nakamura S, Maehara T. Coronary Malperfusion due to Flap Suffocation after Acute Type A Dissection Surgery. Ann Thorac Cardiovasc Surg 2012; 18:144-7. [DOI: 10.5761/atcs.cr.11.01707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Lentini S, Perrotta S. Aortic dissection with concomitant acute myocardial infarction: From diagnosis to management. J Emerg Trauma Shock 2011; 4:273-8. [PMID: 21769215 PMCID: PMC3132368 DOI: 10.4103/0974-2700.82221] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Accepted: 10/31/2010] [Indexed: 12/16/2022] Open
Abstract
Acute aortic dissection an extremely severe condition having a high risk of mortality. The classic symptom may mimic other conditions such as myocardial ischemia, leading to misdiagnosis. Coronary malperfusion associated with aortic dissection is relatively rare, but when it occurs, it may have a fatal result for the patient. The diagnosis of acute coronary syndrome may lead to the inappropriate administration of thrombolytic or anticoagulant treatment resulting in catastrophic consequences. Emergency imaging techniques help to guide the correct diagnosis. Transthoracic echocardiography is useful as a first imaging test, and may be followed by transesophageal echocardiography, or other imaging techniques. Surgery represents the treatment for these patients. However, with the aim to stabilize the patient and to reduce myocardial damage, initial preoperative endovascular coronary intervention has been reported.
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Affiliation(s)
- Salvatore Lentini
- Cardiovascular and Thoracic Department, University Hospital "G. Martino", University of Messina, Messina, Italy
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10
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Ishige A, Tanaka H, Ueda T, Ninomiya M, Ohtsuka T. Type A aortic dissection with transient myocardial ischemia caused by intimal flap inverting into the left ventricle. J Echocardiogr 2011; 9:112-4. [PMID: 27277179 DOI: 10.1007/s12574-010-0075-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Revised: 11/01/2010] [Accepted: 11/02/2010] [Indexed: 11/29/2022]
Abstract
A 41-year-old man with sudden onset of chest oppression and downslope ST depression was diagnosed as having type A aortic dissection with angina pectoris and aortic regurgitation. Intraoperative transesophageal echocardiogram (TEE) showed intimal flap inverting into the left ventricle through the aortic valve. This case was rare in that transient myocardial ischemia was induced not by dissection of the aortic root reaching the coronary ostia but by back-and-forth movement of the intimal flap, covering the coronary ostia and interrupting the coronary artery flow. TEE was important for correct diagnosis.
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Affiliation(s)
- Akiko Ishige
- Department of Cardiology, Tokyo Metropolitan Fuchu Hospital (currently Tokyo Metropolitan Tama Medical Center), 2-8-29 Musashidai, Fuchu, Tokyo, 183-8524, Japan.
| | - Hiroyuki Tanaka
- Department of Cardiology, Tokyo Metropolitan Fuchu Hospital (currently Tokyo Metropolitan Tama Medical Center), 2-8-29 Musashidai, Fuchu, Tokyo, 183-8524, Japan
| | - Tetsuro Ueda
- Department of Cardiology, Tokyo Metropolitan Fuchu Hospital (currently Tokyo Metropolitan Tama Medical Center), 2-8-29 Musashidai, Fuchu, Tokyo, 183-8524, Japan
| | - Mikio Ninomiya
- Department of Cardiovascular Surgery, Tokyo Metropolitan Fuchu Hospital (currently Tokyo Metropolitan Tama Medical Center), 2-8-29 Musashidai, Fuchu, Tokyo, 183-8524, Japan
| | - Toshiya Ohtsuka
- Department of Cardiovascular Surgery, Tokyo Metropolitan Fuchu Hospital (currently Tokyo Metropolitan Tama Medical Center), 2-8-29 Musashidai, Fuchu, Tokyo, 183-8524, Japan
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11
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Pagel PS, Gandhi SD, Shah JR, Butler EG, Almassi GH. A 2-Day History of Shortness of Breath and Intermittent Dull Substernal Chest Pain in a 42-Year-Old Man: A Case of Acute Insecticide Toxicity or Something More Ominous? J Cardiothorac Vasc Anesth 2009; 23:732-4. [DOI: 10.1053/j.jvca.2008.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2008] [Indexed: 11/11/2022]
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Abstract
Acute aortic regurgitation is frequently recognised in patients with Stanford Type A aortic dissection. However, diastolic prolapse of the aortic intimal flap into the left ventricle can cause aortic regurgitation in rare cases. Here is presented an image report of severe aortic regurgitation that was secondary to the back-and-forth intimal flap movement of acute Type A aortic dissection by the use of transthoracic echocardiography and multidetector row CT.
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Affiliation(s)
- S-M Ko
- Department of Radiology, Konkuk University Hospital, Konkuk University School of Medicine, Hwayang-dong, Gwangjin-gu, Seoul, Korea.
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13
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Affiliation(s)
- William Whitley
- Departments of Anesthesia, Emory University Hospital, Atlanta, Georgia, USA.
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14
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Sanders LHA, Newman MAJ, Gara KL, Price RA. Radiological diagnosis and classification of antegrade and retrograde Stanford type A intimal intussusception. Int J Cardiovasc Imaging 2006; 23:659-65. [PMID: 17160426 DOI: 10.1007/s10554-006-9182-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2006] [Accepted: 10/12/2006] [Indexed: 11/28/2022]
Abstract
Intimal intussusception is an uncommon variation of aortic dissection, resulting from circumferential detachment and stripping of the intima in the setting of a Stanford type A dissection. The resultant tube of detached intima may prolapse either antegrade into the aortic lumen or retrograde into the left ventricular cavity. We classify these forms of dissection as antegrade and retrograde Stanford type A intimal intussusception. We present two cases with intimal intussusception and a review of the current literature. The majority of previous cases have been reported in the cardiology and cardiothoracic surgical literature, with few previous radiological reports.
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Affiliation(s)
- Lucas H A Sanders
- Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Perth, WA 6009, Australia.
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Sato Y, Satokawa H, Takase S, Misawa Y, Yokoyama H. Prolapse of Aortic Intimal Flap Into the Left Ventricle A Rare Cause of Global Myocardial Ischemia in Acute Type A Aortic Dissection. Circ J 2006; 70:214-5. [PMID: 16434818 DOI: 10.1253/circj.70.214] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A 62-year-old woman experienced an acute type A aortic dissection complicated with profound shock caused by acute myocardial ischemia. Intraoperative transesophageal echocardiography (TEE) identified a circumferentially dissected intimal flap at 5.5 cm above the aortic valve, prolapsing into the left ventricle through the aortic valve during diastole and obstructing both coronary ostia. Acute aortic dissection must be kept in mind when presented with myocardial ischemia and TEE is the most useful method for detecting a prolapsing cylindrical intimal flap.
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Affiliation(s)
- Yoichi Sato
- Department of Cardiovascular Surgery, Fukushima Medical University School of Medicine1 Hikarogaoka, Fukushima 960-1295, Japan.
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