Screening, evaluation, and early management of acute aortic dissection in the ED

A Case of Acute Aortic Dissection Complicated by Bowel Malperfusion

Acute aortic dissection (AAD) is a life-threatening condition with high mortality rates. Prompt diagnosis and intervention are crucial to minimize complications; high suspicion for AAD should be exercised in patients presenting with acute sheering chest pain. While obtaining a proper history and performing a physical examination are important in the diagnostic process, not all cases present with typical symptoms. This can make diagnosis challenging, especially in patients who present with cognitive disorientation, making it difficult to take a proper history. We present the case of a 57-year-old male who presented to the emergency department (ED) of a community hospital with cognitive disorientation and abdominal pain that began two days prior to presentation and was associated with nausea, vomiting, and diarrhea. Laboratory results showed that the patient had an elevated white blood cell count, hyperkalemia, acute renal injury, and elevated lactate levels. Initial chest radiography and computed tomography showed no acute findings. Urine toxicology was positive for cocaine. The elevated lactate levels and cocaine use prompted us to order a computed tomography angiography (CTA) of the abdomen and pelvis with suspicion for bowel ischemia. He was found to have an abdominal aortic dissection with extrinsic compression of the patent true lumen. He was then transferred to a tertiary care facility, and a repeat CTA of the chest, abdomen, and pelvis showed a type A aortic dissection with extensive bowel ischemia. The patient was deemed too unstable for surgical repair and expired. The case highlights the challenges of diagnosing AAD due to its varied presentations and emphasizes the importance of maintaining a high suspicion for the condition in high-risk individuals. Additionally, the case highlights the potential complications associated with AAD.

Three-dimensional modelling and hemodynamic simulation of the closure of multiple entry tears in type B aortic dissection

BACKGROUND

Stanford type B aortic dissection (TB-AD) is a life-threatening vascular condition with high rates of morbidity and mortality. Currently, thoracic endovascular aortic repair (TEVAR) is widely performed to treat TB-AD, and some studies have analyzed the influence of stents on hemodynamics using computational fluid dynamics (CFD) models. However, the accuracy of TB-AD simulation models are not satisfactory, they are often constructed as a regular ideal model. Furthermore, it is unclear which tear should be closed for the best treatment when there are multi entry tears.

PURPOSE

The aims of this paper were to provide an assessment method for the selection of the surgical closure location for type B aortic dissection. Five 3D models of multiple entry tears in type B aortic dissection were produced using real patient computed tomography (CT) images to perform hemodynamic analyses of flow velocity streamlines, wall pressure, and wall shear stress.

METHODS

A Boolean operation was adopted to establish 3D models with multiple entry tears in type B aortic dissection based on patient-specific CT images. The Mimics and Ansys plug-in The Integrated Computer Engineering and Manufacturing code for Computational Fluid Dynamics (ICEM CFD) software were applied to mesh the 3D models. The flow velocity streamlines, wall pressures, and wall shear stresses were then analyzed in the finite element analysis software Fluent. Five 3D models were produced to compare the hemodynamic characteristics of different entry tear numbers, as well as the changes of different closure positions before and after closure.

RESULTS

The false lumen of the model with two entry tears had a higher wall pressure than that of model with multiple entry tears, which may tend to squeeze the true lumen and expand the false lumen. The load distribution of the vessel in the model with multiple entry tears had a more balanced flow velocity, and its wall pressure and shear stress were lower than that of model with two entry tears. For aortic dissection with two entry tears, the closure of the proximal entry tear was recommended, which helped to isolate and thrombose the false lumen, thereby improving the blood supply function of the true lumen. Because the postoperative vascular flow velocity and mechanical load performance of the vascular wall were still higher than those of normal blood vessels, the postoperative blood vessels remained pathological, and TEVAR did not restore the blood vessels to their original healthy state.

CONCLUSIONS

Type B aortic dissection with two entry tears tend to squeeze the true lumen and expand the false lumen, resulting in a new entry tear and deterioration into multiple entry type B aortic dissection. The model of the vessel with multiple entry tears had a more balanced distribution in flow velocity and a smaller wall pressure and shear stress than that of the vessel with two entry tears. The closure of the proximal entry tear was considered an ideal solution for type B aortic dissection with two entry tears.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Learning curve for open surgical repair of acute type A aortic dissection

There is scarce evidence about the surgeon learning curve of acute type A aortic dissection surgery and whether the optimal procedure number exists when training a cardiovascular surgeon. A total of 704 patients with acute type A aortic dissection surgery performed by 17 junior surgeons who can identify their first career surgery from January 1, 2005, to December 31, 2018, are included. The surgeon experience volume is defined as the cumulative number of acute type A aortic dissection surgery of the surgeon since January 1, 2005. The primary outcome was in-hospital mortality. The possibility of non-linearity and cutoffs for surgeon experience volume level was explored using a restricted cubic spline model. The results revealed that more surgeon experience volume is significantly correlated to a lower in-hospital mortality rate (r = - 0.58, P = 0.010). The RCS model shows for an operator who reaches 25 cumulative volumes of acute type A aortic dissection surgery, the average in-hospital mortality rate of the patients can be below 10%. Furthermore, the longer duration from the 1st to 25th operations of the surgeon is significantly correlated to a higher average in-hospital mortality rate of the patients (r = 0.61, p = 0.045). Acute type A aortic dissection surgery has a prominent learning curve in terms of improving clinical outcomes. The findings suggest fostering high-volume surgeons at high-volume hospitals can achieve optimal clinical outcomes.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Pitfalls in medicine: pain out of proportion to examination findings

Most life-threatening conditions form a coherent clinical picture, with examination findings confirming the patient's history. However, pain out of proportion to examination findings can also signify an emergency – acute compartment syndrome, bowel ischaemia, necrotising fasciitis and acute aortic dissection may all present in this way. A lack of situational awareness leads doctors to erroneously rely on examination findings to flag impending catastrophe, but in such cases misdiagnosis or delayed treatment can have dire consequences. Patients with unexplained pain risk significant morbidity and mortality, and doctors are vulnerable to litigation and reputational damage. This article addresses this danger, exploring the causes and pathology of pain that is out of proportion, and presenting an approach to mitigate risk and prevent catastrophe.

Case report: Diagnosis and emergency surgery on a young patient with extensive aortic dissection without any risk factors

Background

Type A aortic dissection is a very dangerous, fatal, and emergency condition for surgery. Acute aortic dissection is a rare condition, such that many patients will not survive without reconstructive surgery.

Case presentation

We present a case 24-year-old male who came with symptoms of shortness of breath and cough. The patient underwent ECG, chest radiology, and ultrasound, where the patient was found to have right pleural effusion while his ECG was normal. In the history taken from the patient, he had no underlying disease, no history of heart diseases in his family. For a better diagnosis, ETT and aortic CT angiography was performed on the patient which confirmed the evidence of dissection. Immediately after the diagnosis, necessary arrangements were made for open heart surgery and the patient was prepared for surgery. The patient was admitted in the cardiac surgery ICU for 5 days and his medication was carefully administered. After the conditions were stabilized, the patient was transferred to the post-cardiac surgery ICU ward. The patient was discharged from the hospital one week after the surgery and returned to the office as an OPD one week after his discharge.

Conclusion

Various risk factors can play a role in creating aortic dissection. Therefore, it is necessary to pay attention to patients’ history for achieving a quick and definitive diagnosis. Therefore, to control the complications of placing the cannula as well as the duration of the surgery, it is very important to reduce the duration of pumping on the patient and to be very careful during the cannula placement.

Review of Malpractice Lawsuits in the Diagnosis and Management of Aortic Aneurysms and Aortic Dissections

OBJECTIVE

Aortic aneurysms and dissections are prevalent causes of morbidity and mortality. The management of aortic pathologies may be called into question in malpractice suits. Malpractice claims were analyzed to understand common reasons for litigation, medical specialties involved, patient injuries, and outcomes.

METHODS

Litigation cases in the Westlaw database from September 1st, 1987 to October 23 rd, 2019 were analyzed. Search terms included "aortic aneurysm" and "aortic dissection." Data on plaintiff, defendant, litigation claims, patient injuries, misdiagnoses, and case outcomes were collected and compared for aortic aneurysms, aortic dissections, and overall cases.

RESULTS

A total of 346 cases were identified, 196 involving aortic aneurysms and 150 aortic dissections. Physician defendants were emergency medicine (29%), cardiology (20%), internal medicine (14%), radiology (11%), cardiothoracic (10%) and vascular surgery (10%). Litigation claims included "failure to diagnose and treat" (61%), "delayed diagnosis and treatment" (21%), "post-operative complications after open repair" (10%) and "negligent post-operative care" (10%). Patients with aneurysms presented with abdominal (63%) and back pain (37%), while dissections presented with chest pain (78%), abdominal pain (15%), and shortness of breath (14%). Misdiagnoses included gastrointestinal (12%), other cardiovascular (9%), and musculoskeletal conditions (9%), but many were not specified (58%). Overall, 83% of cases were wrongful death suits. Injuries included loss of consortium (23%), emotional distress (19%), and bleeding (17%). In 53% of the cases, the jury ruled in favor of the defendant. 25% of cases ruled for the plaintiff. 22% of cases resulted in a settlement. The mean rewarded for each case was $1,644,590.66 (SD: $5,939,134.58; Range: $17,500-$68,035,462).

CONCLUSION

For aortic pathologies, post-operative complications were not prominent among the reasons why suits were brought forth. This suggests improvements in education across all involved medical specialties may allow for improved diagnostic accuracy and efficient treatment, which could then translate to a decrease in associated litigation cases.

Point-of-care Ultrasound Diagnosis of Type B Aortic Dissection on the Suprasternal Notch View

Aortic dissection (AD) is a life-threatening but uncommon and challenging diagnosis to make in the emergency department. Cardiac point-of-care ultrasound (POCUS) is often used to evaluate patients with chest pain and may be used to rapidly diagnose Stanford type A AD on the suprasternal notch view if there is the visualization of a dissection flap. In contrast, a diagnosis of type B AD on the suprasternal notch view is rare and has only been reported in one previous case report. We report the case of a patient who presented with chest pain and was accurately diagnosed with type B AD using the suprasternal notch view.

Thymoma mimicking an aortic aneurysm: always expect the unexpected

Thymic epithelial tumours (TETs) are rare lesions that represent less than 1% of all malignancies in adults. Presentation occurs in three ways: asymptomatic, with local thoracic symptoms or with paraneoplastic symptoms. Heterotopic ossifications are rare histological features in neoplasms and non-neoplastic lesions. Here, we present a 49-year-old male patient with a thymoma type B2 mimicking an aortic aneurysm. Alongside the thymoma, a cholesterol granuloma with unusual ossification features was found as well. This clinical presentation and pathological diagnosis are unusual findings.

Detection of Type B Aortic Dissection in the Emergency Department with Point-of-Care Ultrasound

Aortic dissection (AD) is a rare, time-sensitive, and potentially fatal condition that can present with subtle signs requiring timely diagnosis and intervention. Although definitive diagnosis is most accurately made through computed tomography angiography, this can be a time-consuming study and the patient may be unstable, thus preventing the study’s completion. Chest radiography (CXR) signs of AD are classically taught yet have poor diagnostic reliability. Point-of-care ultrasound (POCUS) is increasingly used by emergency physicians for the rapid diagnosis of emergent conditions, with multiple case reports illustrating the sonographic signs of AD. We present a case of Stanford type B AD diagnosed by POCUS in the emergency department in a patient with vague symptoms, normal CXR, and without aorta dilation. A subsequent review of CXR versus sonographic signs of AD is described.

Chronic Type A Aortic Dissection: Rare Presentation of Incidental Pericardial Effusion

Aortic dissection is the most devastating sequelae of aortopathy other than aortic rupture. However, aortic dissection can be asymptomatic in the acute phase with delayed symptomatic presentation or incidental diagnosis upon chest imaging. We report a case of a 63-year-old male who was diagnosed with pericardial effusion upon preoperative workup for elective cholecystectomy. Further investigations confirmed hemorrhagic pericardial effusion secondary to a chronic dissecting ascending aortic aneurysm. The patient condition was successfully managed with open surgical repair with an uneventful postoperative course. This case demonstrates an extremely rare presentation of incidental hemorrhagic pericardial effusion caused by a chronic dissecting ascending aortic aneurysm.

Virtual TEVAR: Overcoming the Roadblocks of In-Silico Tools for Aortic Dissection Treatment

The use of in silico tools for the interventional planning of complex vascular conditions, such as Aortic Dissections has been often limited by high computational cost, involving long timescales for accurate results to be produced and low numbers of patients, precluding the use of statistical analyses to inform individual-level models. In the paper [Theranostics 2018; 8(20):5758-5771. doi:10.7150/thno.28944], Chen et al. proposed a novel algorithm to compute patient-specific 'virtual TEVAR' that will help clinicians to approach individual treatment and decision-making based on objective and quantifiable metrics and validated on a cohort of 66 patients in real time. This research will significantly impact the field and has the potential to transform the way clinical interventions will be approached in the future.

Ripping the Myth: Patients' Symptomatic Descriptions of Acute Thoracic Aortic Dissection

CONTEXT

The objective of this retrospective project was to assess the frequency with which patients presenting to an emergency department had used the descriptive terms "ripping" and "tearing" to describe their symptoms from later-confirmed acute thoracic aortic dissection.

METHODS

The authors conducted a retrospective chart review from 58 patients who had presented to two suburban and urban emergency departments with suspected acute thoracic dissection between 1997 and 2015. They reviewed charts for patients' pain descriptors in ambulance personnel records and initial notes and dictations from ED triage nurses, staff nurses, and physicians. These pieces of documentation would have been made before the diagnosis of acute thoracic aortic dissection could been confirmed.

RESULTS

The authors identified a sample subset of 29 (50% of total charts pulled) patients later confirmed to have had an acute thoracic aorta dissection. They found that no sample patients used either the descriptors "ripping" or "tearing" when communicating their presenting symptoms. In this paper, the authors will provide several alternative terms patients have been shown to offer for this life-threatening condition.

CONCLUSIONS

Although the terms "ripping" and "tearing" have historically been associated with acute thoracic aortic dissections, these project results indicate that clinicians may consider other descriptive symptomatic terms from patients when evaluating patients' symptoms for this potential life-threatening condition.

Deciphering chest pain in women

The causes of chest pain range from benign sources such as muscle strain to life-threatening diagnoses such as aortic dissection and myocardial infarction. The likelihood and presentations of disorders causing chest pain are different between women and men. This article highlights important features in determining a correct diagnosis.

Preoperative evaluation value of aortic arch lesions by multidetector computed tomography angiography in type A aortic dissection

The purpose of this study was to preoperatively evaluate the value of aortic arch lesions by multidetector computed tomography (MDCT) angiography in type A aortic dissection (AD).From January 2013 to December 2015, we enrolled 42 patients with type A AD who underwent MDCT angiography in our hospital. The institutional database of patients was retrospectively reviewed to identify MDCT angiography examinations for type A AD. Surgical corrections were conducted in all patients to confirm diagnostic accuracy.In this study, the diagnostic accuracy of MDCT angiography was 100% in all 42 patients. The intimal tear site locations that were identified in patients included the ascending aorta (n = 25), aortic arch (n = 12), and all other sites (n = 5). Compared with the control group, there were significant differences in the aortic arch anatomy among the cases. Regarding the distance between the left common carotid and left subclavian arteries, compared with the control group, most cases with type A AD had a significant variation.MDCT angiography plays an important role in detecting aortic arch lesions of type A AD, especially in determining the location of the intimal entry site and change of branch blood vessels. Surgeons can formulate an appropriate operating plan, according to the preoperative MDCT diagnosis information.

The Interdisciplinary Management of Acute Chest Pain

BACKGROUND

Acute chest pain of non-traumatic origin is a common reason for presentation to physician's offices and emergency rooms. Coronary heart disease is the cause in up to 25% of cases. Because acute chest pain, depending on its etiology, may be associated with a high risk of death, rapid, goal-oriented management is mandatory.

METHODS

This review is based on pertinent articles and guidelines retrieved by a selective search in PubMed.

RESULTS

History-taking, physical examination, and a 12-lead electrocardiogram (ECG) are the first steps in the differential diagnostic process and generally allow the identification of features signifying a high risk of lifethreatening illness. If the ECG reveals ST-segment elevation, cardiac catheterization is indicated. The timedependent measurement of highly sensitive troponin values is a reliable test for the diagnosis or exclusion of acute myocardial infarction. A wide variety of other potential causes (e.g., vascular, musculoskeletal, gastroenterologic, or psychosomatic) must be identified from the history if they are to be treated appropriately. Elderly patients need special attention.

CONCLUSION

Acute chest pain is a major diagnostic challenge for the physician. Common errors are traceable to non-recognition of important causes and to an inadequate diagnostic work-up. Future studies should be designed to help optimize the interdisciplinary management of patients with chest pain.

Incidental findings and recommendations are common on ED CT angiography to evaluate for aortic dissection

PURPOSE

The aim of this study was to assess the outcomes, incidental findings, recommendations, and adherence to recommendations on computed tomography angiography (CTA) studies obtained in the emergency department (ED) to evaluate for aortic dissection.

METHODS

The institutional database of ED patients was retrospectively reviewed to identify CTA examinations for dissection during 2014. The radiology report and electronic medical records were reviewed to assess outcomes, radiology report incidental findings, and recommendations, as well as adherence to these recommendations.

RESULTS

There were 370 dissection CTAs performed during the 12-month study period. The average age of the patients was 63 years (range, 15-97 years). Eighty-seven patients (23.5%) had clinically significant aortic pathology including 46 patients (12.4%) with dissection and 19 (5.1%) which were new. Three hundred twenty-nine (88.9%) of patients had at least 1 incidental finding. One hundred six (28.6%) of patients had recommendations on the radiology report, and 44.3% of these were for pulmonary nodules. Thirty recommendations (28.3%) were acted upon, most commonly related to pulmonary nodule.

CONCLUSION

Computed tomography angiography is useful in detecting aortic pathology. However, emergency physicians should be aware of the potential for clinically significant incidental findings and recommendations. Adherence to recommendations was limited, and future research could investigate mechanisms to improve compliance.

What Lies behind the Ischemic Stroke: Aortic Dissection?

Introduction. Some cases with aortic dissection (AD) could present with various complaints other than pain, especially neurological and cardiovascular manifestations. AD involving the carotid arteries could be associated with many clinical presentations, ranging from stroke to nonspecific headache. Case Report. A 71-year-old woman was admitted to emergency department with vertigo which started within the previous one hour and progressed with deterioration of consciousness following speech disorder. On arrival, she was disoriented and uncooperative. Diffusion magnetic resonance imaging (MRI) of brain was consistent with acute ischemia in the cerebral hemisphere. Fibrinolytic treatment has been planned since symptoms started within two hours. Echocardiography has shown the dilatation of ascending aorta with a suspicion of flap. Computed tomography (CT) angiography has been applied and intimal flap has been detected which was consistent with aortic dissection, intramural hematoma of which was reaching from aortic arch to bilateral common carotid artery. Thereafter, treatment strategy has completely changed and surgical invention has been done. Conclusion. In patients who are admitted to the emergency department with the loss of consciousness and stroke, inadequacy of anamnesis and carotid artery involvement of aortic dissection should be kept in mind.

The Predictive Value of Admission Fragmented QRS Complex for In-Hospital Cardiovascular Mortality of Patients with Type 1 Acute Aortic Dissection

BACKGROUND

Fragmented QRS (fQRS) arises from impaired ventricular depolarization due to heterogeneous electrical activation of ischemic and/or infarcted ventricular myocardium. The short- and long-term prognostic values of fQRS have been reported for myocardial infarction, heart failure, fatal cardiac arrhythmias, and sudden cardiac death. The aim of this study was to investigate the predictive value of admission fQRS complex for in-hospital cardiovascular mortality of patients with type 1 acute aortic dissection (AAD).

METHODS

In this retrospective study, 203 consecutive patients with type 1 AAD who had been admitted to either of two large-volume tertiary hospitals between December 2008 and October 2013 were included. The patients were divided into two groups according to the presence or absence of the fQRS complex on admission.

RESULTS

In-hospital cardiovascular mortality (P < 0.001), major adverse cardiovascular events (P < 0.001), acute renal failure (P = 0.022), multiorgan dysfunction (P < 0.001), and acute decompensated heart failure (P < 0.001) were observed to be significantly more frequent in the fQRS-positive group than in the fQRS-negative group. fQRS (odds ratio [95% confidence interval]: 4.184 [1.927-9.082], P < 0.001), operation duration (4.184 [1.927-9.082], P = 0.001), and Killip class IV (3.900 [1.699-8.955], P = 0.001) were found to be significant independent predictors of in-hospital cardiovascular mortality after adjustment of other risk factors in the multivariate analysis.

CONCLUSIONS

fQRS is a simple, inexpensive, and readily available electrocardiographic entity that provides an additional risk stratification level beyond that provided by conventional risk parameters in predicting in-hospital cardiovascular mortality in type 1 AAD.

Controlled pericardiocentesis in patients with cardiac tamponade complicating aortic dissection: experience of a centre without cardiothoracic surgery

BACKGROUND

Cardiac tamponade has been reported in 18.7% of patients with acute type A aortic dissection and its presence is associated with worse outcomes. Emergency aortic repair together with intra-operative pericardial drainage is the recommended treatment approach. However, controversy surrounds how to manage patients with haemopericardium and cardiac tamponade who cannot survive until surgery.

PURPOSE

To describe a case series of patients with critical cardiac tamponade complicating aortic dissection admitted to a hospital without cardiothoracic surgery, and in whom preoperative controlled pericardial drainage was performed.

METHODS AND RESULTS

Single centre retrospective study: during a nine-year period, 21 patients with Stanford type A aortic dissection were admitted at our centre; six of them (28.6%) presented clinical and echocardiographic signs of cardiac tamponade (four males; mean age 58±17 years). In this subgroup, controlled pericardiocentesis was safely performed with no major immediate complications and it was effective in five patients, improving haemodynamic instability and allowing transfer to the operating room.

CONCLUSIONS

Preoperative controlled pericardiocentesis can be lifesaving when managing patients with critical cardiac tamponade (pulseless electrical activity or refractory hypotension) complicating acute type A aortic dissection, namely when cardiac surgery is not immediately available.

[Value of emergency echocardiography using the example of acute aortic dissection]

A 52-year-old woman was admitted to our emergency department with a suspected diagnosis of a thoracic disc prolapse. She presented with acute thoracic and vertebral pain of sudden onset that increased on movement and change of body position. An emergency echocardiography that was performed at the bedside showed aortic insufficiency, dilation of the aortic root, and membrane dissection in the ascending aorta. A thoracic contrast-enhanced CT angiogram verified acute aortic dissection Stanford type A, which resulted in immediate referral to the department of cardiothoracic surgery for an emergency replacement of the ascending aorta. In the emergency department, emergency bedside echocardiography facilitates the rapid evaluation of potential differential diagnoses in patients presenting with acute thoracic pain.