Painless Aortic Dissection-Diagnostic Dilemma With Fatal Outcomes: What Do We Learn?

An Uncommon Presentation of Acute Thoracic Aortic Dissection

We present a case of a 40-year-old Caucasian male with past medical history of polysubstance abuse (cocaine and methamphetamine), who presented to the emergency department (ED) complaining of intermittent cough with associated chest discomfort and shortness of breath for 2 weeks. Initial vital signs demonstrated borderline tachycardia (98 beats per minute), tachypnea (37 times per minutes), and hypoxia (oxygen saturation 89% on room air), and his physical exam was grossly unremarkable. A preliminary workup including a computed tomography angiography (CTA) revealed a type A aortic dissection with both thoracic and abdominal involvement for which the patient was admitted. This patient had resection of the ascending aorta with graft placement, cardiopulmonary bypass, aortic root replacement using composite prosthesis and left and right coronary reconstruction and reimplantation and survived a complicated hospital course. This case demonstrates the classic association known to exist between recreational drug use, specifically stimulants such as cocaine and amphetamines, and acute aortic dissection (AAD). However, such a presentation of borderline subacute, painless dissection in the setting of polysubstance use raises further questions, since uncommon AAD is typically found in higher-risk populations such as those with connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome), bicuspid aortic valve, chronic hypertension, or previous aortic pathology. We therefore suggest clinicians strongly consider uncommon AAD as part of their differential diagnosis in patients with known or highly suspected polysubstance abuse.

Accidental and Late Diagnosis of Type A Aortic Dissection: Mimicking Unstable Angina Pectoris

Aortic dissection is an infrequent diagnosis that usually presents with acute onset of sharp and severe tearing pain. It rarely presents with atypical symptoms, accompanied by a higher mortality risk that arises the delay in diagnosis. In this report, we discuss a type A aortic dissection case with a presentation of heaviness-like chest pain with no evidence of aortic dissection in his first echocardiography. The patient was treated for acute coronary syndrome (ACS), but on the follow-up, echocardiography aortic dissection was diagnosed accidentally. Differentiation between ACS and aortic dissection is critical in patient management. Each one has an entirely different treatment approach, and misdiagnosis can lead to catastrophic outcomes.

Murmurs other than the early diastolic murmur in aortic dissection

The purpose of this review is to draw attention to the presence and significance of murmurs other than the murmur of aortic regurgitation, in patients with aortic dissection. For that purpose, a literature search was conducted using Pubmed and Googlescholar. The search terms were "dissecting aneurysm of the aorta", "systolic murmurs", "ejection systolic murmurs", "holosystolic" murmurs, "continuous murmurs", and "Austin-Flint" murmur. Murmurs other than the murmur of aortic regurgitation, which were associated with aortic dissection, fell into the categories of systolic murmurs, some of which were holosystolic, and continuous murmurs, the latter attributable to fistulae between the dissecting aneurysm and the left atrium, right atrium, and the pulmonary artery, respectively. Mid-diastolic murmurs were also identified, and these typically occurred in association with both the systolic and the early diastolic murmurs. Among patients with systolic murmurs clinical features which enhanced the pre-test probability of aortic dissection included back pain, stroke, paraplegia, unilateral absence of pulses, interarm differences in blood pressure, hypertension, shock, bicuspid aortic valve, aortic coarctation, Turner's syndrome, and high D-dimer levels, respectively. In the absence of the murmur of aortic regurgitation timely diagnosis of aortic dissection could be expedited by increased attention to parameters which enhance pretest probability of aortic dissection. That logic would apply even if the only murmurs which were elicited were systolic murmurs.

Acute liver failure and seizure: a case report of an unusual presentation of acute painless aortic dissection

Background

Painless aortic dissection presenting with seizure and acute liver failure is uncommon. We described a case of early recognition leading to successful treatment of painless aortic dissection with atypical presentation.

Case summary

A young lady presented with generalized tonic-clonic seizures coupled with hepatitic pattern of deranged liver function test. Examination revealed blood pressure of 99/75 mmHg and hepatic flap. Electrocardiography showed sinus tachycardia. Urgent bedside echocardiography showed preserved cardiac function without significant valvular pathology, but noted a moderate pericardial effusion. Abdominal Ultrasound excluded liver cirrhosis or biliary obstructions. Viral hepatitis serologies and anti-liver panel were negative. She was progressively hypotensive with concurrent acute liver failure and oliguric acute kidney injury. Despite no chest pain, her rising serum troponin and widened mediastinum prompted an urgent computed-tomography aortogram, which showed a 4.3 cm dilatation of ascending thoracic aorta with acute haemopericardium and cardiac tamponade. She was diagnosed with malperfusion syndrome from Stanford type A aortic dissection. She underwent emergent ascending aorta and aortic arch repair and dialysis. She experienced complete recovery in her kidney, liver, and neurological function post-operatively.

Discussion

Painless aortic dissection masquerade as acute liver failure is uncommon. We describe a successful early recognition of malperfusion syndrome from painless aortic dissection, thus providing window for timely, life-saving intervention. Clinical challenges in this case include: (i) atypical presentation of aortic dissection, (ii) worsening acute liver failure which could lead to unnecessary liver transplantation, and (iii) risk of contrast-induced nephropathy in the setting of acute renal failure.

Painless type A aortic dissection

Aortic dissection is an uncommon diagnosis that typically presents with acute onset of severe pain. It rarely presents with minimal to no symptoms, which carries a higher mortality risk given the delay in diagnosis. An adequate interpretation of risk factors, clinical findings and auxiliary tests constitutes a greater value for clinicians to detect this life-threatening condition. This report describes a case of type A aortic dissection in an asymptomatic patient presenting with an abnormal electrocardiogram (ECG).

Painless retrograde type A aortic dissection followed conservative treatment of type B aortic dissection: a case report

Background

Retrograde type A aortic dissection (RTAD) is a fatal aortic disease secondary to descending aortic dissection, and might be misdiagnosed due to its atypical symptoms lead to catastrophic outcomes.

Case presentation

We herein reported a case of a 40-year old Chinese non-comorbid man who received conservative treatment for acute type B aortic dissection and progressed to RTAD in a painless manner in a week. After open surgical aortic repair with stented elephant truck technique, the patient survived without obvious complication and cured with a satisfactory outcome in a half-year follow-up.

Conclusion

This case indicates that RTAD may present without typical symptoms, early diagnosis and open surgical procedure are imperative for treating RTAD.

Is there any association between aortic root rotation angle and aortic dissection?

Introduction

Thoracic aortic dissection is a probable fatal condition that requires early diagnosis and management. The underlying etiology of this disorder is an important issue that has not been completely responded yet. In the current study, the association between aortic root rotation and ascending aortic dissection has been assessed.

Methods

This is a non-randomized retrospective case-control study conducted on twenty-five cases referring with ascending aortic dissection and seventy-five controls that underwent computed tomography (CT) angiography for reasons other than aortic dissection. Aortic root rotation angle and aortic diameter for both cases and controls were measured and then compared.

Results

There was no significant difference regarding age and gender distribution (P value = 0.22 and 0.38 respectively) between patients in case and control groups. The mean values of aortic root rotation angle and aortic diameter in cases were 22.5 ± 10.5° and 43.1 ± 12.5 mm versus 15.7 ± 10.7° and 30.7 ± 5.3 mm in controls (P value = 0.007 and 0.001 respectively). Direct relation was found between aortic root rotation angle and aortic diameter (P value = 0.007, r = 0.276). Mean of aortic root rotation angle was significantly higher in females (P value = 0.02). No association between cases' age with either aortic root rotation angle or aortic diameter was found (P value = 0.33, r = 0.098, and P value = 0.085, r = 0.173 respectively).

Conclusion

Based on the findings of the current study, aortic root rotation angle was independently in direct association with thoracic aortic dissection. In addition, females had higher aortic root rotation angles.

How to prevent inadvertent emergency anticoagulation in acute type A aortic dissection: when in doubt, don't

Inadvertent emergency anticoagulation in patients with acute type A aortic dissection (ATAAD) has been sparsely reported. There are case reports bringing this potential critical incident to attention, however, little is known about the number of undetected and unreported cases. We approach this issue based on a case report of inadvertent emergency anticoagulation in ATAAD and attempt to shed light on aspects that may have contributed to the critical incident: The challenge of distinguishing an ATAAD from an acute coronary syndrome (ACS) and the potential underestimation of incidents of ATAAD. We also discuss errors and biases in medical decision making, and provide suggestions that may help raise awareness of how ATAAD can be mimicking ACS in clinical practice.