Aortic  dissection
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Aortic dissection

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Aortic dissection can can kill if not recognised and managed early. Chances of survival decreases by 10% per hour if left untreated.

Aortic dissection can can kill if not recognised and managed early. Chances of survival decreases by 10% per hour if left untreated.

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Aortic  dissection Aortic dissection Presentation Transcript

  • AORTIC DISSECTION
    • SYED RAZA
  • CASE 1
    • University Teaching Hospital
    • 53/f admitted to Heart Emergency Centre
    • Chest pain/discomfort – 1 hour
    • right leg numbness
    • PMH- Hypertension – not on medication
    • Smoker – 5 cigs/day
    • BP 170/80 mmHg
    • Power RLL 4/5 , Grade 2 AR murmur .
  • Case 1 contd:
    • ECG- Ischemic changes Inferior leads.
    • CXR – Normal
    • Troponin – Negative
    • Routine blood tests - normal
  • Case 1 contd:
    • MRA – Aortic aneurysm (6.5 cms).Aortic Dissection from aortic root, extending to ascending Aorta and arch involving the left common carotid artery.
    • Small area of infarct Left MCA territory .
    • Urgent Surgery – Patient did not survive
  • Case 2
    • University Teaching Hospital
    • 26/f , Univ. student
    • Chest pain after returning from holiday in USA
    • 2 pm Seen in ER , ECG and D-dimer - Normal
    • diagnosed- musculoskeletal chest pain, discharged on simple analgesics
    • 8 pm Patient returned to ER in 6 hrs
    • Seen by Med. Registrar on call – ‘ heard pericardial rub’ – admitted , NSAIDS
  • Case 2 contd:
    • 8 am Referred to Cardiology
    • Auscultation – not rub but AR murmur
    • 9 am TTE – Dissection flap , Moderate AR
    • Urgent referral to surgeon (wanted CT Angio while OR was being prepared)
    • CT scan – Extensive dissection from Aortic root till abdominal aorta involving renal arteries
  • Case 2 contd:
    • 10.30 am – Rushed to OR
    • Post operative course in ICU – Sepsis ,severe renal failure ,
    • Mechanical ventilator and maximum ionotropic support
    • Died after 5 days
    • Post Mortem genetic analysis : Heterozygous PC 1307Y of the FBN1 gene.
  • CASE 3
    • District General Hospital
    • 79 yrs old Chinese lady , did not speak English
    • Seen in ER with chest pain , anterior , on and off for more than 2 weeks
    • PMH- HPN,DM, End stage COPD
    • BP- 124/72 mmHg
    • CVS- NAD
    • ECG-non specific T wave changes. Trop I – normal Hb 10.1
    • Discharged as Musculo skeletal chest pain. Anaemia for Inv.
  • CASE 3 contd:
    • Returned to ER following day – continuing chest pain. Admitted as Atypical chest pain. CXR-unfolded aorta
    • Repeat Trop I-normal , D-dimer –elevated(>500 ng/dl)
    • CTPA – Requested .
    • Anticoagulant commenced.
    • ECG - <1 mm ST elevation in Inferior leads. Referred to Cardiology
  • Case 3 contd:
    • History from grand son
    • Admitted in hospital in China for 1 day just before coming to the UK.
    • EX- BP right arm 170/96 left arm 122/ 70
    • CXR- Widened mediastinum
  • CASE 3 contd:
    • CTPA – Dissection Asc. Aorta involving RCA , Arch of aorta involving left sub clavian artery extending just beyond the diaphragm. Small to moderate pericardial effusion.
    • Discussed with surgeon- High risk for surgery.
    • Patient and family not keen for intervention.
    • Medical management – aggressive BP control
    • Anticoagulant stopped
  • OBJECTIVES
    • 1.Recognition of Aortic Dissection
    • 2.Prevalance
    • 3.Clinical features
    • 4.Investigation and Management
    • Acute Aortic Dissection is a medical emergency
    • High mortality rate
    • Mortality rate rises at 1% per hour if left untreated.
    • Atypical presentations are very uncommon
    • Painless AAD have been reported
    • Most important factor
    • leading to a correct diagnosis is
    • a high clinical suspicion!
  • How Big Is The Problem?
    • Incidence and prevalence uncertain.
    • 5-30 cases per 1 million population per year.
    • Available information: 2000 cases/year in U.S.
    • Males 3 times more frequent than females
    • Descending dissections: 60-70 years old
    • Ascending dissections: 50-59 years old
    • (<40 years: Marfan, pregnancy, AV disease/Coarctation of Ao)
  • CLASSIFICATION
    • D E BAKEY
    • Type I
    • Ascending aorta extending beyond arch
    • Type II
    • Ascending aorta only
    • Type III a
    • Descending aorta distal to left subclavian (above diaphragm)
    • Type III b
    • Descending aorta distal to LSA extending below diaphragm
    • S TANFORD
    • A – Ascending aorta
    • B – Not involving Ascending Aorta
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  • CLINICAL FEATURES
    • Sudden Onset Severe Pain (90%)
        • More severe at onset
        • Never experienced before
        • Restless
    • Anterior Pain: Proximal Dissection
    • Posterior Pain: Distal Dissection
  • PHYSICAL EXAMINATION
    • May or may not look acutely ill.
    • Hypertension (moderate to severe)
    • Hypotension (20%): acute complications
    • Aortic insufficiency : (50-60% ascending dissections)
    • Pulse deficits : (if left subclavian artery involved)
    • Other
        • Look for signs of Connective Tissue Disease ( Marfans Syndrome)
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  • NATURAL HISTORY
    • Autopsy Series: >50% of people with untreated aortic dissections are dead within 48 hours .
    • 1934 Shennan: >300 cases reviewed.
      • 40% acute ascending dissections died suddenly.
      • None lived > 5 weeks
    • Anagnostopoulos et al. Am J Card 1972
      • 973 pts with untreated proximal and distal dissections
      • 50% died with 48 hours
      • 84% died within 1 month
  • DIAGNOSTIC EVALUATION
    • Chest radiograph
    • Tran thoracic echocardiogram
    • Tran esophageal echocardiogram*
    • Computed tomography*
    • Magnetic resonance imaging*
    • Aortography
    • * Choice based on rapid availability and quality of performance
  • CHEST X-RAY
      • 1. widened mediastinum, (sen: 44-80%)
      • 2. Calcium sign -Displaced intimal calcification (>10mm) from outer aortic wall– useful in older patients
      • 3.pleural effusion (involvement of descending aorta)
    • 4.Normal in 18%
      • A Normal CXR Should Not Deter Further Evaluatio n.
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  • TTE
    • Indicated as an initial test if patient is very unwell and other modalities of imaging not readily available
    • Can be performed bedside
    • Can detect intimal flap and AR
    • Limitation : No information beyond aortic root and early part of proximal aorta
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  • TRANSTHORACIC ECHO
  • TRANSESOPHAGEAL ECHO
    • Procedure of first choice for dissection, if readily available
    • Portability of equipment facilities in emergency to ER or ICU
    • High sensitivity (98%) and specificity(97%)
    • Limitations : Unable to visualize distal part of asc. Aorta
    • (beginning of aortic arch) and desc. Aorta below stomach
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  • CT SCAN WITH CONTRAST
    • Sensitivity 98-100% Specificity 98-100%
    • Limitations :
    • Use of contrast
    • Inability to identify site of tear
      • No evaluation of aortic regurgitation
      • Limited information on branch vessels
    • Useful for follow-up of dissections
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  • MRA
    • Good alternative to TEE or CT, if readily available
    • High sensitivity (98%) and specificity (98%)
    • Provides three dimensional reconstruction
    • Can detect site of intimal tear and involvement of branch vessels
    • Non-invasive; neither x-rays nor contrast needed
    • Limitation : claustrophobic, more costly, not readily available
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  • AORTOGRAPHY
    • Considered Gold standard in olden days
    • Sensitivity (88%) Specificity (94%)
    • Identify intimal flap, true and false lumen
    • Aortic insufficiency, branch vessel involvement
    • Limitations
    • Invasive
    • Use of contrast
    • Time delay in preparation
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  • TREATMENT
    • Surgical Management – Stanford Type A
    • Medical Management – Stanford Type B
  • Medical Treatment
    • ICU admission
    • Close observation of BP, urine output, neurology status
    • Prompt blood pressure control is critical
        • Can reduce propagation of dissection
        • Decrease BP and LV contractility
          • Sodium nitroprusside + Beta blocker
          •  and  – blocker (Labetalol)
          • Calcium channel blocker (rate limiting)
  • SURGERY
  • INDICATIONS FOR SURGERY
    • Stanford type A (DeBakey type I and II) ascending aortic dissection
    • Complicated Stanford type B (DeBakey type III ) aortic dissections with clinical or radiological evidence of the following conditions:
      • Propagation (increasing aortic diameter)
      • Increasing size of hematoma
      • Compromise of major branches of the aorta
      • Impending rupture
  • PROGNOSIS
    • Without treatment about 50% will die within 48 hours
    • Without treatment , about 75% will die within the first 2 weeks.
    • With treatment , about 70% who have Type A dissection and about 90% who have Type B dissection survive to leave the hospital.
    • About 60% of people who survive the first 2 weeks are still alive 5 years after treatment, and 40% live at least 10 years.
  • TAKE HOME MESSAGE
    • Medical emergency
    • Many misdiagnosed or undiagnosed
    • High clinical suspicion. Should consider as a differential diagnosis with all chest pain.
    • Thrombolytic ,Anticoagulants and anti platelet therapy may be catastrophic.
    • Early diagnosis + prompt action = SURVIVAL
  • THANK YOU FOR YOUR ATTENTION