Do all type 2 aortic dissection require emergency surgery?

Do all type 2 aortic dissection require emergency surgery? We represent a case of asymptomatic isolated chronic ascending aortic dissection that lasted for 15 years in which a patient was only followed up with medical therapy that saved him from early surgical intervention. presentation, he was hypertensive with blood pressure of 159/ INTRODUCTION 85 mmHg, his heart rate was 87/min, respiratory rate was 12/ Aortic dissection is one of the emergency and dramatic path- min. Other systemic examinations were evaluated to be nor- ologies of the cardiovascular surgery. Dissection of the aorta mal. The ECG records showed no changes. The transthoracic begins with the tear of intima of the ascending or descending echocardiography (TTE) revealed ejection fraction of 50%, portion of the thoracic aorta. Moreover, the tear permits the degenerative aortic and mitral valve with mild to moderate blood to enter the aortic wall causing intramural hematoma mitral insufficiency, mild tricuspid insufficiency, moderate to that may progress from the side of tear to the distal part of the severe aortic insufficiency, diastolic left ventricular dysfunction aorta (1, 2). Aorta dissection mostly presents many adverse grade 1, left chambers dilatation, ascending aorta and sinus events such as severe chest pain, dyspnea. In addition to these, valsalva dilatation of 47 mm and 46 mm, respectively. due to high risk of mortality, surgical approach on correction of Meanwhile, TEE revealed myxomatous mitral and aortic aortic dissection is usually mandatory. valve, severe aortic valve insufficiency, moderate to severe Asymptomatic chronic aortic dissection may progress in a mitral valve insufficiency, mild tricuspid valve insufficiency, longer period and diagnosed accidentally. Diagnosing the par- ascending aorta and sinus valsalva dilation of 46 mm. A con- tial aortic dissection on the ascending part of aorta will require trast computed tomography (CT) scan was performed and surgical treatment even if no symptoms referring to the pres- revealed ascending aorta dilatation of 48.5 mm without aortic ence of aortic dissection. We feel that this case’s condition dissection and sinus valsalva of 46 mm (Fig. 1). The descending needs to reach a compromise on this issue because there is a aorta appeared to be normal, measuring 26.5 mm at its widest lack of well-defined management that relates to the localized diameter. ascending aorta dissection, which does not extend to the distal Coronary angiography revealed a lesion on OM1 (80–90%) on or proximal aorta over time in many literatures. its midportion where by the other coronary arteries were nor- mal. On operation, following standard cannulation aortotomy was done where by the left main coronary artery osteal on the CASE REPORT ascending aorta position was found to have a chronic dissec- A 61-year-old Turkish man was referred to our center’s cardi- tion flap with dimension of 15 mm × 30 mm in size (Fig. 2). ology department due to his dyspnea and chest pain. On Dissection flap was resembling a mobil atheroma with free- Received: September 25, 2017. Accepted: December 16, 2017 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx254/4822187 by Ed 'DeepDyve' Gillespie user on 16 March 2018 ˙ 2 T. Iyigün et al. Figure 1: Thorax CT angiography showing the dilatation of ascending aorta of a patient before surgery on admission to our center. Figure 3: Thorax MR of a patient 15 years ago shows a dissection flap. had a localized aortic dissection resembling that of chronic aortic dissection type II that lasted for 15 years without showing any symptom. Our patient had also hypertensive with pericardial and pleural effusion that may indicate a ruptured aorta. Due to high risk of rupture and being accompanied with other cardiac path- ologies (mitral valve insufficiency and coronary lesion), modified Bentall procedure was planned in concordant with coronary artery bypass and mitral valve replacement. Aortic dissection presents with severe chest pain, acute hemo- dynamic instability, absence or unilateral peripheral pulses, Figure 2: A picture that shows a chronic dissection flap of a patient during surgery. neurologic complications and aortic insufficiency (2). However, our patient was presented to our clinic with chest pain and dys- pnea that may have been related to a coronary lesion and valve floating tip. That the case being, modified Bentall procedure, insufficiency. He did not have symptoms related to aortic dissec- CABG on OM1 and mitral valve replacement was perfomed. tion though he was under hypertensive therapy. After observing such unexpected case (resembling type II aor- Transthoracic two-dimensional echocardiography (TTE) is tic dissection) on surgery a patient was then questioned for fur- very effective in evaluating the aortic root, but the mid and dis- ther details on his medical history. Fifteen years ago, he was tal ascending aorta, aortic arch and descending aorta are not presented emergently to a cardiologist with chest pain, palpita- seen. It also provides important information on aortic valvular tion and sweating. On physical examination, he was hypotensive regurgitation, and the function and dimensions of the left ven- with sinus tachycardia. Both echocardiography and thorax mag- tricle (4). Our patient was diagnosed with TTE that revealed netic resonance (MR) revealed pericardial effusion on posterior only the dilatation of aorta without dissection. For further side of the heart (hemopericardium) with dissection flap (Fig. 3). evaluation contast thorax CT (thorax CT) was performed in our His follow-up period was uneventful and he was then discharged case and aortic dilatation was observed but dissection was not from hospital with medical therapy, Echocardiography control seen on his last thorax CT scan. This may be due to that iso- (every 6 months) and thorax CT control (every 1 year). The last lated aortic dissection flap may have been endothelized within thorax CT (that we took in our clinic did not demostrate dissec- that period of fifteen years since then. However Thorax CT is tion flap (Fig. 1). Both imagings of Figs 1 and 3 were avaluated the most frequent first imaging modality performed, with very under the same radyologic level for accuracy. high sensitivity and specificity (5). Conversly, this could have been a sporadic case that we could have reported. DISCUSSION Asymptomatic localized aortic dissection is a rare condition Aortic dissection develops when a tear in the inner wall of the that may require early surgical intervention when diagnosed or aorta causes blood to flow between the layers of the wall of the followed up with medication depending on the underlying aorta, causing the layers apart (1). Aortic dissection occurs more cause or predisposition to rupture. Our patient was diagnosed commoninpatients withahistoryofhigh-blood pressure that with other medical heart condition such as aortic dilatation. affect blood vessel wall integrity (3). Aortic dissection is a cardio- This may have been a condition experienced in 15 years in rela- vascular emergency and can quickly lead to death, even with tion to a patient’s medical history under medical therapy. optimal treatment, due to insufficiency blood supply to other In recent years, these type of patients with isolated asecend- organs and sometimes rupture of the aorta. In our case, a patient ing aortic dissection are referred either for emergency surgery Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx254/4822187 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Do all type 2 aortic dissection require emergency surgery? 3 or elective surgery depending on hemodynamic condition. Our 3. Mehta RH, O’Gara PT, Bossone E, Nienaber CA, Myrmel T, preference and recommendation in these kinds of cases are to Cooper JV, et al. International Registry of Acute Aortic perform early surgery to be able to avoid adverse events due to Dissection (IRAD) Investigators. Acute type A aortic dissec- aortic dissection. tion in the elderly: clinical characteristics, management, and outcomes in the current era. J Am Coll Cardiol 2002;40: 685–92. CONFLICT OF INTEREST STATEMENT 4. Tsai TT, Evangelista A, Nienaber CA, Trimarchi S, Sechtem None declared. U, Fattori R, et al. International Registry of Acute Aortic Dissection (IRAD). Long-term survival in patients presenting with type A acute aortic dissection: insights from the REFERENCES International Registry of Acute Aortic Dissection (IRAD). 1. vonKodolitschY,SchwartzAG, Nienaber CA. Clinical predic- Circulation 2006;114:I350–6. tion of acute aortic dissection. Arch Intern Med 2000;160:2977–82. 5. Nienaber CA, Fattori R, Lund G, Dieckmann C, Wolf W, von 2. Cohen R, Mena D, Carbajal-Mendoza R, Arole O, Mejia JO. A Kodolitsch Y, et al. Nonsurgical reconstruction of thoracic case report on asymptomatic ascending aortic dissection. Int aortic dissection by stent-graft placement. N Engl J Med 1999; J Angiol 2008;17:155–61. 340:1539–45. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx254/4822187 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Do all type 2 aortic dissection require emergency surgery?

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Abstract

We represent a case of asymptomatic isolated chronic ascending aortic dissection that lasted for 15 years in which a patient was only followed up with medical therapy that saved him from early surgical intervention. presentation, he was hypertensive with blood pressure of 159/ INTRODUCTION 85 mmHg, his heart rate was 87/min, respiratory rate was 12/ Aortic dissection is one of the emergency and dramatic path- min. Other systemic examinations were evaluated to be nor- ologies of the cardiovascular surgery. Dissection of the aorta mal. The ECG records showed no changes. The transthoracic begins with the tear of intima of the ascending or descending echocardiography (TTE) revealed ejection fraction of 50%, portion of the thoracic aorta. Moreover, the tear permits the degenerative aortic and mitral valve with mild to moderate blood to enter the aortic wall causing intramural hematoma mitral insufficiency, mild tricuspid insufficiency, moderate to that may progress from the side of tear to the distal part of the severe aortic insufficiency, diastolic left ventricular dysfunction aorta (1, 2). Aorta dissection mostly presents many adverse grade 1, left chambers dilatation, ascending aorta and sinus events such as severe chest pain, dyspnea. In addition to these, valsalva dilatation of 47 mm and 46 mm, respectively. due to high risk of mortality, surgical approach on correction of Meanwhile, TEE revealed myxomatous mitral and aortic aortic dissection is usually mandatory. valve, severe aortic valve insufficiency, moderate to severe Asymptomatic chronic aortic dissection may progress in a mitral valve insufficiency, mild tricuspid valve insufficiency, longer period and diagnosed accidentally. Diagnosing the par- ascending aorta and sinus valsalva dilation of 46 mm. A con- tial aortic dissection on the ascending part of aorta will require trast computed tomography (CT) scan was performed and surgical treatment even if no symptoms referring to the pres- revealed ascending aorta dilatation of 48.5 mm without aortic ence of aortic dissection. We feel that this case’s condition dissection and sinus valsalva of 46 mm (Fig. 1). The descending needs to reach a compromise on this issue because there is a aorta appeared to be normal, measuring 26.5 mm at its widest lack of well-defined management that relates to the localized diameter. ascending aorta dissection, which does not extend to the distal Coronary angiography revealed a lesion on OM1 (80–90%) on or proximal aorta over time in many literatures. its midportion where by the other coronary arteries were nor- mal. On operation, following standard cannulation aortotomy was done where by the left main coronary artery osteal on the CASE REPORT ascending aorta position was found to have a chronic dissec- A 61-year-old Turkish man was referred to our center’s cardi- tion flap with dimension of 15 mm × 30 mm in size (Fig. 2). ology department due to his dyspnea and chest pain. On Dissection flap was resembling a mobil atheroma with free- Received: September 25, 2017. Accepted: December 16, 2017 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx254/4822187 by Ed 'DeepDyve' Gillespie user on 16 March 2018 ˙ 2 T. Iyigün et al. Figure 1: Thorax CT angiography showing the dilatation of ascending aorta of a patient before surgery on admission to our center. Figure 3: Thorax MR of a patient 15 years ago shows a dissection flap. had a localized aortic dissection resembling that of chronic aortic dissection type II that lasted for 15 years without showing any symptom. Our patient had also hypertensive with pericardial and pleural effusion that may indicate a ruptured aorta. Due to high risk of rupture and being accompanied with other cardiac path- ologies (mitral valve insufficiency and coronary lesion), modified Bentall procedure was planned in concordant with coronary artery bypass and mitral valve replacement. Aortic dissection presents with severe chest pain, acute hemo- dynamic instability, absence or unilateral peripheral pulses, Figure 2: A picture that shows a chronic dissection flap of a patient during surgery. neurologic complications and aortic insufficiency (2). However, our patient was presented to our clinic with chest pain and dys- pnea that may have been related to a coronary lesion and valve floating tip. That the case being, modified Bentall procedure, insufficiency. He did not have symptoms related to aortic dissec- CABG on OM1 and mitral valve replacement was perfomed. tion though he was under hypertensive therapy. After observing such unexpected case (resembling type II aor- Transthoracic two-dimensional echocardiography (TTE) is tic dissection) on surgery a patient was then questioned for fur- very effective in evaluating the aortic root, but the mid and dis- ther details on his medical history. Fifteen years ago, he was tal ascending aorta, aortic arch and descending aorta are not presented emergently to a cardiologist with chest pain, palpita- seen. It also provides important information on aortic valvular tion and sweating. On physical examination, he was hypotensive regurgitation, and the function and dimensions of the left ven- with sinus tachycardia. Both echocardiography and thorax mag- tricle (4). Our patient was diagnosed with TTE that revealed netic resonance (MR) revealed pericardial effusion on posterior only the dilatation of aorta without dissection. For further side of the heart (hemopericardium) with dissection flap (Fig. 3). evaluation contast thorax CT (thorax CT) was performed in our His follow-up period was uneventful and he was then discharged case and aortic dilatation was observed but dissection was not from hospital with medical therapy, Echocardiography control seen on his last thorax CT scan. This may be due to that iso- (every 6 months) and thorax CT control (every 1 year). The last lated aortic dissection flap may have been endothelized within thorax CT (that we took in our clinic did not demostrate dissec- that period of fifteen years since then. However Thorax CT is tion flap (Fig. 1). Both imagings of Figs 1 and 3 were avaluated the most frequent first imaging modality performed, with very under the same radyologic level for accuracy. high sensitivity and specificity (5). Conversly, this could have been a sporadic case that we could have reported. DISCUSSION Asymptomatic localized aortic dissection is a rare condition Aortic dissection develops when a tear in the inner wall of the that may require early surgical intervention when diagnosed or aorta causes blood to flow between the layers of the wall of the followed up with medication depending on the underlying aorta, causing the layers apart (1). Aortic dissection occurs more cause or predisposition to rupture. Our patient was diagnosed commoninpatients withahistoryofhigh-blood pressure that with other medical heart condition such as aortic dilatation. affect blood vessel wall integrity (3). Aortic dissection is a cardio- This may have been a condition experienced in 15 years in rela- vascular emergency and can quickly lead to death, even with tion to a patient’s medical history under medical therapy. optimal treatment, due to insufficiency blood supply to other In recent years, these type of patients with isolated asecend- organs and sometimes rupture of the aorta. In our case, a patient ing aortic dissection are referred either for emergency surgery Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx254/4822187 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Do all type 2 aortic dissection require emergency surgery? 3 or elective surgery depending on hemodynamic condition. Our 3. Mehta RH, O’Gara PT, Bossone E, Nienaber CA, Myrmel T, preference and recommendation in these kinds of cases are to Cooper JV, et al. International Registry of Acute Aortic perform early surgery to be able to avoid adverse events due to Dissection (IRAD) Investigators. Acute type A aortic dissec- aortic dissection. tion in the elderly: clinical characteristics, management, and outcomes in the current era. J Am Coll Cardiol 2002;40: 685–92. CONFLICT OF INTEREST STATEMENT 4. Tsai TT, Evangelista A, Nienaber CA, Trimarchi S, Sechtem None declared. U, Fattori R, et al. International Registry of Acute Aortic Dissection (IRAD). Long-term survival in patients presenting with type A acute aortic dissection: insights from the REFERENCES International Registry of Acute Aortic Dissection (IRAD). 1. vonKodolitschY,SchwartzAG, Nienaber CA. Clinical predic- Circulation 2006;114:I350–6. tion of acute aortic dissection. Arch Intern Med 2000;160:2977–82. 5. Nienaber CA, Fattori R, Lund G, Dieckmann C, Wolf W, von 2. Cohen R, Mena D, Carbajal-Mendoza R, Arole O, Mejia JO. A Kodolitsch Y, et al. Nonsurgical reconstruction of thoracic case report on asymptomatic ascending aortic dissection. Int aortic dissection by stent-graft placement. N Engl J Med 1999; J Angiol 2008;17:155–61. 340:1539–45. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx254/4822187 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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Journal of Surgical Case ReportsOxford University Press

Published: Jan 1, 2018

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