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.

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Aortic dissection

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

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