A 360-Degree Aortic Dissection Tear Mimicking Massive Aortic Regurgitation
A 38-year-old previously healthy man was admitted to our hospital with computed tomographic diagnosis of type A acute aortic dissection. The onset was characterized by syncope and acute, oppressive chest pain. The patient had intubation and deep sedation at another emergency unit because of pain and severe agitation. All peripheral pulses were present except in the right arm. Physical examination showed a mild, reactive, isochoric mydriasis, loud systodiastolic murmur, systemic severe desaturation (Sao2=50%), signs of pulmonary edema, and myocardial ischemia with ST-segment depression. The patient was transferred to the operating room, and a transesophageal echocardiography was performed. It showed a 360° aortic tear located at the sinotubular junction of the ascending aorta; the intimal flap (Figure, A) fell down the ventricle through the aortic valve during diastole (Figure, B), covering the coronary ostia, enveloping the aortic valve, and causing a massive aortic regurgitation. Coronary flow and aortic valve function were severely impaired by this mechanism (Movie I and Movie II). The aortic root was enlarged. The patient was operated on with aortic root replacement (Freestyle 25-mm bioprosthesis; Medtronic) and ascending aorta replacement (28-mm tubular graft) in deep hypothermia and circulatory arrest (22 minutes) with retrograde venous cerebral perfusion (21 minutes). The postoperative course was uneventful. Histological examination showed mixoid degeneration of the aortic valve cusps and of the ascending aorta.
The online-only Data Supplement, which contains Movie I, Movie II, and Movie III, can be found with this article at http://circ.ahajournals.org/cgi/content/full/112/25/e366/DC1.