Extremely localized aortic dissection and intussusception of the intimal flap into the left ventricle

Stanford type A aortic dissection frequently deforms the aortic root and causes aortic regurgitation (AR). On the rare occasion, massive AR can occur due to circumferential intimal disruption and prolapse of the cylinder-shaped intimal flap into the left ventricle. Because of the critical, general, and hemodynamic state of such patients, surgery for this condition carries a high risk. A 62-year-old woman suffered acute chest pain and fell into cardiogenic shock. Computed tomography and transthoracic echocardiography failed to identify the etiology of this rapid hemodynamic collapse. Transesophageal echocardiography (TEE) demonstrated circumferential intimal disruption, 3 centimeters above the aortic valve annulus; a very localized aortic dissection in the proximal ascending aorta; and a to-and-fro motion of cylinder-shaped intima causing severe AR. The dissection did not affect the aorta beyond the intimal tear, and TEE was the only useful modality for the diagnosis. Emergency replacement of the ascending aorta and resuspension of the aortic valve was successfully performed. Residual AR was absent, and the postoperative course was uneventful.