Table of Contents    
CASE REPORT
Year : 2020  |  Volume : 11  |  Issue : 1  |  Page : 81-82  

Dissecting aortic aneurysm associated with severe aortic regurgitation in an asymptomatic young female


Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India

Date of Submission26-May-2019
Date of Decision27-May-2019
Date of Acceptance11-Jul-2019
Date of Web Publication11-Mar-2020

Correspondence Address:
Dr. H S Natraj Setty
#493, 4th Cross, 7th Main, J.P. Nagar 3rd Phase, Bengaluru - 69, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsbm.JNSBM_149_19

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   Abstract 


An aortic aneurysm is a rare clinical entity since most patients will present with complications of dissection or rupture before the size of aneurysm reaches that magnitude. The classical presentation of a patient with acute aortic dissection (AAD) is characterized by severe chest, back, or abdominal pain, ripping or tearing in nature (mimics myocardial infarction). However, some patients present with painless AAD. We hereby present a case report of a 28-year aged female who presented with palpitation from the past 2 years, diagnosed to have aortic aneurysm with dissection and severe aortic regurgitation. She eventually underwent Bentall's procedure and had an uneventful recovery.

Keywords: Aortic aneurysm, aortic dissection, computed tomography


How to cite this article:
Natraj Setty H S, Rama C, Murthy P R, Jadav S, Murthy K, Patil R, Raj S, Reddy B, Srinivas B C, Raghu T R, Manjunath C N. Dissecting aortic aneurysm associated with severe aortic regurgitation in an asymptomatic young female. J Nat Sc Biol Med 2020;11:81-2

How to cite this URL:
Natraj Setty H S, Rama C, Murthy P R, Jadav S, Murthy K, Patil R, Raj S, Reddy B, Srinivas B C, Raghu T R, Manjunath C N. Dissecting aortic aneurysm associated with severe aortic regurgitation in an asymptomatic young female. J Nat Sc Biol Med [serial online] 2020 [cited 2020 Jul 11];11:81-2. Available from: http://www.jnsbm.org/text.asp?2020/11/1/81/280124




   Introduction Top


Aortic dissection has a high mortality rate, it is common in elderly males. Clinical manifestation of Aortic dissection can be variable presentation. Acute Aortic dissections involving the ascending aorta are considered surgical emergencies. In contrast, dissections confined to the descending aorta are treated medically. The Bentall procedure for management of aortic root dilatation was first described in 1968 by Bentall and De Bono. This involves surgical replacement of the ascending aorta and aortic valve with composite tubular graft.


   Case Report Top


A 28-year-old female presented with palpitations from the past 2 years, no history of chest pain, back pain, and dyspnea. On examination, pulse was 80 bpm, high volume and blood pressure was 130/50 mmHg. Auscultation revealed an early diastolic murmur in the aortic area. The patient is a known case of hypertension on medications with calcium channel blocker and angiotensin receptor blocker (amlodipine and telmisartan). Routine blood investigations were normal. Lipid profile revealed a rise in low-density lipoprotein. Venereal Disease Research Laboratory, HIV, and connective tissue profile were normal. Chest X-ray showed left ventricular enlargement. Ultrasound abdomen and renal Doppler scans were normal. Two-dimensional echo showed aneurysmal dilatation of ascending aorta. Computed tomography (CT) aortogram revealed type A dissection of aorta with dilatation in sinus of Valsalva for a length of 36.5 mm, aorta at the level of maximum dimensions of sinuses of Valsalva 76.9 mm, proximal ascending aorta 77.7 mm × 87.2 mm, distal ascending aorta 66.0 mm × 72.0 mm, aortic arch 31.9 mm, aorta of the level of diaphragm 34.6 mm × 30.1 mm, aorta at the level of origin of renal arteries 21.6 mm × 21.8 mm, and aorta above bifurcation 25.7 mm × 23.9 mm [Figure 1]a and [Figure 1]b. The patient was planned for Bentall's procedure. The procedure was done using a St. Jude composite graft, a mechanical prosthetic valve [Figure 2]. The patient underwent the procedure successfully and had an uneventful recovery. Postprocedure echo showed normally functioning aortic disc prosthesis, with mild valvular aortic regurgitation (AR) with left ventricular ejection fraction 50%. The patient was continued with antihypertensive medication with angiotensin receptor blocker and anticoagulant warfarin 5 mg, acetylsalicylic acid 75 mg (Ecosprin), atorvastatin 20 mg, and the patient is on regular follow-up.
Figure 1: (a) Computed tomography aortogram showing type A dissection of aorta with dilatation in sinus of Valsalva for a length of 36.5 mm and ascending aneurysm. (b) Computed tomography aortogram showing dissection of aorta and ascending aneurysm

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Figure 2: Postoperative computed tomography aortogram showing St. Jude composite graft, mechanical prosthetic valve

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   Discussion Top


Aortic dissection is a relatively uncommon, though catastrophic disease which requires early and accurate diagnosis and treatment for patient survival.[1] The most common presenting symptoms of acute aortic dissection (AAD) are acute pain in the chest or back. The diagnosis of AAD has many potential difficulties. The aortic dissection may mimic other more common conditions, such as acute coronary syndromes, pulmonary thromboembolism, congestive heart failure, and cerebrovascular accident.[2] Acute dissections involving the ascending aorta are considered surgical emergencies. In contrast, dissections confined to the descending aorta are treated medically unless the patient demonstrates progression or continued hemorrhage into the pleural or retroperitoneal space. The natural history of thoracic aneurysms is progressive expansion with subsequently increased wall stress and eventual rupture.[3] Aneurysms can affect different locations of the aorta: the aortic root, ascending aorta, aortic arch, or the descending aorta.[4] Diagnosis is by imaging tests, for example, transesophageal echocardiography, CT angiography, magnetic resonance imaging, and contrast aortography.[4] CT is the most commonly used to diagnose aortic dissection due to its high specificity and sensitivity and its availability. However, CT had limitations since it cannot detect AR.[5] The treatment always involves aggressive blood pressure control and serial imaging to monitor the progression of dissection. Endovascular stent-grafts are used for certain patients, especially when dissection involves the descending thoracic aorta. One-fifth of patients die before reaching the hospital, and up to one-third die of operative or perioperative complications.[6] We report a 28-year-old female presented with palpitations from the past 2 years, diagnosed as dissecting aortic aneurysm. The patient was planned for Bentall's procedure which was successful, and the patent had an uneventful recovery.


   Conclusion Top


Acute Aortic Dissection is a life-threatening disease with a very high rate of cardiovascular morbidity and mortality. Optimal medical and surgical approach, prompt diagnosis is extremely important to life-saving. Continuous advances in imaging and treatment technologies are improving short- and long-term outcomes in patients with AAD. Several surgical approaches are described. The goals of surgical therapy are to prevent extension, excise the intimal tear, and replace the segment of aorta susceptible to rupture with an interposition synthetic graft.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Baliga RR, Nienaber CA, Bossone E, Oh JK, Isselbacher EM, Sechtem U, et al. The role of imaging in aortic dissection and related syndromes. JACC Cardiovasc Imaging 2014;7:406-24.  Back to cited text no. 1
    
2.
Zhan S, Hong S, Shan-Shan L, Chen-Ling Y, Lai W, Dong-Wei S, et al. Misdiagnosis of aortic dissection: Experience of 361 patients. J Clin Hypertens (Greenwich) 2012;14:256-60.  Back to cited text no. 2
    
3.
Bonow RO, Mann DL, Zipes DP, Libby P. Braunwald's Heart Disease A Textbook of Cardiovascular Medicine 9th Edn. Elsevier saunders Publisher © Sunders; 2012.  Back to cited text no. 3
    
4.
Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y. Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: Systematic review and meta-analysis. Arch Intern Med 2006;166:1350-6.  Back to cited text no. 4
    
5.
Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The task force for the diagnosis and treatment of aortic diseases of the European society of cardiology (ESC). Eur Heart J 2014;35:2873-926.  Back to cited text no. 5
    
6.
Isselbacher EM. Thoracic and abdominal aortic aneurysms contemporary reviews in cardiovascular medicine. Circulation 2005;111:816-28.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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