Delayed presentation of acute aortic syndrome Srinivasan Sattiraju, Emil Missov
A 69-year-old woman with a history of myocardial infarction came to hospital after more than 24 h of intermittent chest pain, shortness of breath, and diaphoresis. On admission, a 12-lead ECG showed sinus tachycardia without evidence of ischaemia. Biomarkers of myocardial necrosis were negative. A portable chest radiograph and a bedside transthoracic echocardiogram showed pathognomonic ﬁndings of acute type A aortic dissection (ﬁgure; videos). The patient underwent urgent repair of the aortic root. The patient survived the immediate postoperative course despite complications of haemodynamic instability, hypotension, and acute renal failure, but later succumbed to multiorgan failure.
Delayed presentation of acute aortic syndrome is plagued by high mortality and morbidity. The location of the intimal tear in acute type A aortic dissection is in the immediate vicinity of the sinuses of Valsalva 65% of the time. The sensitivity and speciﬁcity of chest radiography is 81% and 89%, respectively. The sensitivity of transthoracic echocardiography is between 78% and 100%; its speciﬁcity ranges from 87% to 96%. Transthoracic echocardiography is a valuable diagnostic tool in cases when more sensitive techniques (transoesophageal echocardiography, CT, magnetic resonance angiography) are not readily available or are impractical.
Published Online November 8, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)60846-6 Division of Cardiology, Carle Clinic, Urbana, IL, USA (S Sattiraju MD); and Division of Cardiology, University of Minnesota Medical Center, Minneapolis, MN, USA (E Missov MD) Correspondence to: Dr Emil Missov, Division of Cardiology, University of Minnesota Medical Center, Minneapolis, MN 55455, USA [email protected]
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Aortic valve Intimal flap
Figure: Aortic dissection Transthoracic echocardiogram shows an intimal ﬂap of aortic dissection originating in the sinuses of Valsalva, immediately above the aortic valve.
www.thelancet.com Published online November 8, 2013 http://dx.doi.org/10.1016/S0140-6736(13)60846-6