Related Experiment Videos
Diagnosis and therapeutic consequences of intramural aortic hematoma
T Schappert1, V Sadony, F Schoen
1Department of Thoracic and Cardiovascular Surgery, Essen University Medical School, Germany.
Insights
Sudden chest pain without heart attack, but with aortic intramural hematoma, requires emergency surgery. This finding is crucial for diagnosing and treating aortic dissections, even without a visible intimal flap.
Area of Science:
- Cardiovascular Surgery
- Diagnostic Imaging
- Thoracic Aortic Disease
Background:
- Aortic dissection diagnosis typically relies on identifying an intimal flap via transesophageal echocardiography (TEE).
- Classic symptoms include sudden chest pain and absence of acute myocardial infarction.
- Emergent surgery is standard for type A aortic dissection.
Observation:
- Three patients presented with classic aortic dissection symptoms but lacked a visible intimal flap on TEE.
- Echocardiography revealed aortic wall thickening consistent with intramural hematoma in these patients.
- Associated findings included aortic ectasia and pericardial effusion in some cases.
Findings:
- Surgery was performed on all three patients using the standard approach for type A dissection.
- Histopathology confirmed no intimal tear, indicating intramural hematoma as the primary finding.
- Two patients had favorable outcomes post-surgery; one patient died after reoperation.
Implications:
- Aortic intramural hematoma, when accompanied by typical dissection symptoms, necessitates emergent surgical intervention.
- TEE findings of intramural hematoma should be considered a surgical emergency, even without a clear intimal flap.
- This challenges traditional diagnostic criteria and highlights the importance of clinical presentation in surgical decision-making for aortic emergencies.
Abstract:
The classical triad of sudden devastating chest pain, electrocardiographic absence of acute myocardial infarction, and identification of an upstream flap in the ascending aorta by transesophageal echocardiography (TEE) indicates aortic type A dissection requiring emergent surgery. Among 34 patients presenting with clinical signs and symptoms of an aortic dissection, three did not show the mandatory flap in the upstream aorta. The only echocardiographic finding was aortic wall thickening indicating an intramural hematoma. Two of these patients showed early aortic ectasia and one showed a pericardial effusion. Despite the missing flap echocardiographically, surgery was performed in all three patients. The surgical approach was the same as that for patients with a type A dissection. Two patients are doing well after the procedure, and one patient died after reoperation. The postoperative histologic work-up confirmed that there was no intimal tear or dissection of the intimal layer. We conclude that the echocardiographic finding of an intramural hematoma combined with typical clinical signs of chest pain, with myocardial infarction ruled out, requires emergent surgical intervention.