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Case 1/2014--syncope due to cardiogenic shock in a 25-year-old male patient.

Politi TR, Gutierrez P - Arq. Bras. Cardiol. (2014)

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The transthoracic echocardiography showed dissection of the ascending aortawith cardiac tamponade (compression of the right atrium)... This is a case of a male patient, 25 years of age with no previously described clinicalhistory that sought medical attention complaining of malaise and feeling faint... Theclinical picture had started 1 hour before he sought the local hospital emergency room.The patient clinical evolution was dramatic, presenting at the examination as shock,initially of undetermined etiology, going to aortic dissection and cardiac tamponade,and culminating in death within hours of symptom onset, before any surgicalintervention... The clinicalpicture and therapeutic approach are sufficiently different to justify the separation ofthis entity into two groups: type-A Stanford dissection, involving the ascending aortaextending or not to descending aorta and type-B Stanford dissection, which involves onlythe descending aorta, with this classification being the most widely accepted.From a purely surgical standpoint, De Bakey et al classified dissecting aneurysms into three groups: type Icorresponds to the dissection starting in the ascending aorta extending for a varyingdistance, distally; type II is the dissection limited to the ascending aorta; and typeIII is the dissection started after the emergence of the left subclavian artery and thatprogresses to the abdominal aorta with a varying extent... In this case, we found a type-AStanford aortic dissection, with probable hypertensive etiology, as demonstrated byechocardiography, in addition to the lack of evidence of any risk factors described inthe literature, whether in the past medical history, at the clinical evaluation or inthe tests performed, to justify another etiology... The onset of pain is almost alwayssudden, being characterized as a sharp, stabbing or throbbing pain, associated withsweating and may be limited to the thorax or be retrosternal, radiating to the back,abdomen, upper or lower limbs... It canalso be associated with dyspnea and pulmonary edema... In the present case, the patientreported no chest pain and two possible explanations are offered for the painless aorticdissection: first, the dissection can cause a protrusion (bulging) of the intima intothe inner layer and reinsert the lumen of true aorta, without moving the adventitia tothe outer layer; and second, the dissection can occur very slowly, without sudden orviolent distension of the adventitia, and thus it can be painless... Fever may accompany a third of thepatients with dissecting aneurysms, and is generally not associated withendocarditis... The gold standard treatment is the surgicalintervention and the traditionally proposed surgery is the interposition of thesupracoronary tube, of which in-hospital mortality rate varies, ranging between 10 and30%... Unfortunately, this patient did not survive long enough toundergo such treatment. (Dr. Tiago Rodrigues Politi) ascending aorta dissection. (Dr. Tiago Rodrigues Politi) Systemic arterial hypertension, ascending aorta aneurysm, cardiac tamponade. (Dr.Tiago Rodrigues Politi)... It is noteworthy, in this case, the prolapse of internal layer of the dissection,leading to blood flow obstruction... It is an unusual complication of acute aorticdissection, which does not appear even in some fairly comprehensive anatomopathologicaldescriptions of this disease. (Dr. Paulo Gutierrez) Acute aortic dissection and aortic obstruction by the internal lamina of the slicedarterial wall; probable systemic arterial hypertension. (Dr. Paulo Gutierrez) Alfredo José Mansur(ajmansur@incor.usp.br) Desidério Favarato(dclfavarato@incor.usp.br) Vera Demarchi Aiello (anpvera@incor.usp.br)

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(A) Open ascending aorta showing the dissection with the inner layer of thearterial wall protruding into the valve plane. The white arrow shows this region,with the section taken for histological analysis. The light blue arrow indicatesthe tear that defines the dissection orifice, in this case affecting the entirecircumference of the artery - artistic illustration of the pathological process.The arrow indicates a clot in false lumen, pushing down the inner part of theaortic wall. LA: left atrium; AV: aortic valve; LV: left ventricle.
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f04: (A) Open ascending aorta showing the dissection with the inner layer of thearterial wall protruding into the valve plane. The white arrow shows this region,with the section taken for histological analysis. The light blue arrow indicatesthe tear that defines the dissection orifice, in this case affecting the entirecircumference of the artery - artistic illustration of the pathological process.The arrow indicates a clot in false lumen, pushing down the inner part of theaortic wall. LA: left atrium; AV: aortic valve; LV: left ventricle.

Mentions: Acute aortic dissection is a cardiovascular emergency with high mortality, ranging from50 to 68% in 48 hours, 70% at 1 week and 85% in 1 month1. The intimal tear is transversal, located in 70% of casesin the aorta ascending (just above the aortic valve), 20% in the descending aorta afterthe aortic arch, and 10% in the transverse aorta. Once started, the dissectionprogression can be distal, retrograde or occur in both directions and be of varyingextension1,2. In the present case, the aortic dissection started inthe ascending portion, retrograde, with bending of the anterior plan between the trueand false lumen, generating a mechanical obstruction to the left ventricular outflowtract (Figure 4).


Case 1/2014--syncope due to cardiogenic shock in a 25-year-old male patient.

Politi TR, Gutierrez P - Arq. Bras. Cardiol. (2014)

(A) Open ascending aorta showing the dissection with the inner layer of thearterial wall protruding into the valve plane. The white arrow shows this region,with the section taken for histological analysis. The light blue arrow indicatesthe tear that defines the dissection orifice, in this case affecting the entirecircumference of the artery - artistic illustration of the pathological process.The arrow indicates a clot in false lumen, pushing down the inner part of theaortic wall. LA: left atrium; AV: aortic valve; LV: left ventricle.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3987335&req=5

f04: (A) Open ascending aorta showing the dissection with the inner layer of thearterial wall protruding into the valve plane. The white arrow shows this region,with the section taken for histological analysis. The light blue arrow indicatesthe tear that defines the dissection orifice, in this case affecting the entirecircumference of the artery - artistic illustration of the pathological process.The arrow indicates a clot in false lumen, pushing down the inner part of theaortic wall. LA: left atrium; AV: aortic valve; LV: left ventricle.
Mentions: Acute aortic dissection is a cardiovascular emergency with high mortality, ranging from50 to 68% in 48 hours, 70% at 1 week and 85% in 1 month1. The intimal tear is transversal, located in 70% of casesin the aorta ascending (just above the aortic valve), 20% in the descending aorta afterthe aortic arch, and 10% in the transverse aorta. Once started, the dissectionprogression can be distal, retrograde or occur in both directions and be of varyingextension1,2. In the present case, the aortic dissection started inthe ascending portion, retrograde, with bending of the anterior plan between the trueand false lumen, generating a mechanical obstruction to the left ventricular outflowtract (Figure 4).

View Article: PubMed Central - PubMed

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

The transthoracic echocardiography showed dissection of the ascending aortawith cardiac tamponade (compression of the right atrium)... This is a case of a male patient, 25 years of age with no previously described clinicalhistory that sought medical attention complaining of malaise and feeling faint... Theclinical picture had started 1 hour before he sought the local hospital emergency room.The patient clinical evolution was dramatic, presenting at the examination as shock,initially of undetermined etiology, going to aortic dissection and cardiac tamponade,and culminating in death within hours of symptom onset, before any surgicalintervention... The clinicalpicture and therapeutic approach are sufficiently different to justify the separation ofthis entity into two groups: type-A Stanford dissection, involving the ascending aortaextending or not to descending aorta and type-B Stanford dissection, which involves onlythe descending aorta, with this classification being the most widely accepted.From a purely surgical standpoint, De Bakey et al classified dissecting aneurysms into three groups: type Icorresponds to the dissection starting in the ascending aorta extending for a varyingdistance, distally; type II is the dissection limited to the ascending aorta; and typeIII is the dissection started after the emergence of the left subclavian artery and thatprogresses to the abdominal aorta with a varying extent... In this case, we found a type-AStanford aortic dissection, with probable hypertensive etiology, as demonstrated byechocardiography, in addition to the lack of evidence of any risk factors described inthe literature, whether in the past medical history, at the clinical evaluation or inthe tests performed, to justify another etiology... The onset of pain is almost alwayssudden, being characterized as a sharp, stabbing or throbbing pain, associated withsweating and may be limited to the thorax or be retrosternal, radiating to the back,abdomen, upper or lower limbs... It canalso be associated with dyspnea and pulmonary edema... In the present case, the patientreported no chest pain and two possible explanations are offered for the painless aorticdissection: first, the dissection can cause a protrusion (bulging) of the intima intothe inner layer and reinsert the lumen of true aorta, without moving the adventitia tothe outer layer; and second, the dissection can occur very slowly, without sudden orviolent distension of the adventitia, and thus it can be painless... Fever may accompany a third of thepatients with dissecting aneurysms, and is generally not associated withendocarditis... The gold standard treatment is the surgicalintervention and the traditionally proposed surgery is the interposition of thesupracoronary tube, of which in-hospital mortality rate varies, ranging between 10 and30%... Unfortunately, this patient did not survive long enough toundergo such treatment. (Dr. Tiago Rodrigues Politi) ascending aorta dissection. (Dr. Tiago Rodrigues Politi) Systemic arterial hypertension, ascending aorta aneurysm, cardiac tamponade. (Dr.Tiago Rodrigues Politi)... It is noteworthy, in this case, the prolapse of internal layer of the dissection,leading to blood flow obstruction... It is an unusual complication of acute aorticdissection, which does not appear even in some fairly comprehensive anatomopathologicaldescriptions of this disease. (Dr. Paulo Gutierrez) Acute aortic dissection and aortic obstruction by the internal lamina of the slicedarterial wall; probable systemic arterial hypertension. (Dr. Paulo Gutierrez) Alfredo José Mansur(ajmansur@incor.usp.br) Desidério Favarato(dclfavarato@incor.usp.br) Vera Demarchi Aiello (anpvera@incor.usp.br)

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