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Eur J Cardiothorac Surg 2003;23:850-851
© 2003 Elsevier Science NL
Letter to the Editor |
Department of Cardiovascular Surgery, Bursa Yüksek Ihtisas Teaching and Research Hospital, Duacinari, Bursa 16330, Turkey
Received 2 January 2003; accepted 22 January 2003.
* Corresponding author. Bursa Yüksek Ihtisas Teaching and Research Hospital, Department of Cardiovascular Surgery, Duacinari, 16330, Bursa, Turkey. Tel.: +90-224-360-5050; fax: +90-224-360-5055
e-mail: syavuz{at}ttnet.net.tr
Key Words: Intimo-intimal intussusception • Aortic dissection • Aortic regurgitation • Left ventricle
We read with great interest the case report by Touati et al. [1]. They have drawn our attention to a rare clinical presentation of acute aortic dissection. We congratulate the authors on successful surgical treatment in such a complicated case.
We have recently reported another rare complication of aortic dissection [2]. We have experienced a case in which aortic dissection was complicated with aortic regurgitation by a rare mechanism occurring intimal flap prolapsing through the aortic valve into the left ventricle.
A 31-year-old man was admitted to our hospital with increasing severe chest pain for 3 h. He had no history of hypertension. Peripheral pulses were bilaterally palpable. On admission, patient had an episode of acute pulmonary edema. On physical examination, a systolic ejection murmur and a diastolic decrescendo murmur were audible along the left sternal border. Electrocardiogram showed no signs of myocardial infarction.
Transesophageal echocardiographic study showed severe aortic regurgitation, but failed to detect an intimal flap and a false lumen in the ascending aorta. However, we found undulating echoes at the level of the aortic valve. Coronary arteries could not be visualized by coronary angiography. On aortogram, a thin circular filling defect was observed at left ventricular outflow tract on the diastole and above the aortic valve in the systole. Aortography showed dilated aortic root and grade IV aortic regurgitation.
Suspecting an aortic dissection,the patient underwent urgent operation. The right axillary artery was exposed through an incision below and parallel to the right clavicle for arterial cannulation [3]. Aortic cannulation was performed as the sites of aortic cannulation and cross-clamp application were intact.
At operation,the proximal intimal flap was dissected circumferentially and was cut all the way around 5 cm above the aortic valve ring and was invaginated into the left ventricle. The coronary arteries were involved with dissection. The aortic valve could not be preserved because of its damaged structure after exclusion of intussuscepted dissection flap from left ventricular cavity. Surgical treatment consisted of replacement of the ascending aorta and aortic valve without circulatory arrest with coronary artery bypass grafting under moderate hypothermia. Postoperative course was uneventful, and he was discharged on postoperative day 10.
In acute aortic dissection the primary intimal tear usually is transverse, and rarely exceeds more than half the circumference of the aorta. Total disruption of intimal continuity with a circumferential intimal tear is an unusual presentation of aortic dissection. It is called as intimo-intimal intussusception. Intussusception of the intimal flap downstream into the aortic arch leads to obstruction of the great supra-aortic vessels.
Another unusual presentation of aortic dissection is full circumferential detachment of the ascending aortic intima and intussusception into the left ventricle, partly occluding the coronary vessels. It may cause detachment of the aortic commissures, leading to prolapse of the leaflets and acute aortic insufficiency.
Transesophageal echocardiography is considered to be the most practical and reliable procedure for the diagnosis of acute aortic dissection. Impaired coaptation of the aortic valve induced by diastolic prolapse of the intimal flap into the left ventricular outflow tract is a newly encountered echocardiographic sign in proximal aortic dissection [4,5]. Two-dimensional echocardiography demonstrates a back-and-forth movement of the cylinder-shaped intima as it prolapses into the left ventricle and thrusts into the aorta during diastole and systole, respectively. In such complicated situations, we agree with the authors that the absence of an intimal flap in the ascending aorta can lead to delayed diagnosis and treatment.
References
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