An aortic dissection is a tear within the layers of the aortic wall. It can cause severe chest or back pain and risks damage to organs if blood flow is blocked. Prompt diagnosis through imaging tests and treatment are critical to survival. While type A dissections involving the ascending aorta require emergency surgery, type B dissections of the descending aorta can often be treated through intensive blood pressure control and medication to prevent expansion of the tear. Risk factors include hypertension, genetics, trauma, and certain medical conditions.
An aortic dissection occurs when blood tears the inner layer of the aorta, separating it from the middle layer. It is classified by location and timing of symptoms. Risk factors include hypertension, connective tissue disorders, and family history. Treatment depends on location but may include surgery, endovascular stent grafting, or medical management of blood pressure. Prognosis depends on type and treatment, with mortality rates declining with advances in surgical and endovascular techniques.
This document provides information about a seminar on aortic dissection presented by Monika Devi. It discusses the introduction, types, causes, symptoms, risk factors, diagnosis, treatment, complications and prevention of aortic dissection. The two main types are Type A, which involves the ascending aorta, and Type B, which only involves the descending aorta. Causes include high blood pressure, genetic conditions like Marfan syndrome, and traumatic injury. Symptoms can include chest pain and symptoms of a stroke. Treatment depends on the type but may involve medications to lower blood pressure or surgery to repair the tear in the aorta. Complications can include death, organ damage or stroke if not properly treated.
This document discusses pressure changes that can occur during coronary angiography, specifically damping and ventricularization. Damping is defined as a significant decrease in pressure at the coronary ostium when the catheter is placed, accompanied by the disappearance of pressure waveforms, suggesting no antegrade flow. Ventricularization occurs when blood circulates within a coronary artery like a closed system, deforming the aortic pressure waveform. The document emphasizes the importance of the operator recognizing abnormal pressure changes to avoid complications, and provides solutions like catheter replacement or intracoronary nitroglycerin to address issues.
The document discusses various diseases of the aorta including aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, aortic aneurysm, atherosclerotic disease, coarctation, and aortic trauma. It provides an overview of the anatomy, clinical presentation, diagnostic imaging, complications, and treatment options for each condition. Key imaging modalities for diagnosis include transthoracic echocardiography, transesophageal echocardiography, CT, and MRI. Mortality rates and predictors of outcome are also reviewed.
This document provides information about percutaneous transvenous mitral commissurotomy (PTMC), a procedure used to treat mitral stenosis. It discusses the stages and severity of mitral stenosis, indications and contraindications for PTMC, assessment of valve morphology, the PTMC procedure technique, instruments used, balloon size selection, post-procedure evaluation, complications, follow-up care, and long-term prognosis. PTMC is performed to improve the opening of a stenosed mitral valve by splitting the fused commissures using a balloon catheter, and is an important therapeutic option for treating symptomatic mitral stenosis.
This document discusses acute aortic syndrome, including a case presentation of a 55-year-old female with chest pain. Key details include:
1. The patient presented with sudden onset chest pain and was found to have hypertension on examination.
2. Initial workup including ECG, labs and chest x-ray were non-diagnostic but showed a widened mediastinum.
3. Echocardiogram and CT angiogram revealed an aortic dissection involving the aortic arch and descending thoracic aorta.
4. She was referred urgently for cardiovascular surgery to treat this life-threatening condition within 24 hours of presentation.
Contrast echocardiography uses microbubble ultrasound contrast agents to improve image quality. These microbubbles remain in the intravascular space and allow for assessment of cardiac structure, function, and perfusion. Second generation contrast agents use an inert gas encapsulated by albumin or phospholipid shells. They interact with ultrasound by reflecting at fundamental frequencies and resonating to produce harmonic frequencies. Continuous infusion provides steady contrast levels needed for perfusion assessment. Contrast echocardiography is a non-invasive technique that improves evaluation of the heart.
An aortic dissection occurs when blood tears the inner layer of the aorta, separating it from the middle layer. It is classified by location and timing of symptoms. Risk factors include hypertension, connective tissue disorders, and family history. Treatment depends on location but may include surgery, endovascular stent grafting, or medical management of blood pressure. Prognosis depends on type and treatment, with mortality rates declining with advances in surgical and endovascular techniques.
This document provides information about a seminar on aortic dissection presented by Monika Devi. It discusses the introduction, types, causes, symptoms, risk factors, diagnosis, treatment, complications and prevention of aortic dissection. The two main types are Type A, which involves the ascending aorta, and Type B, which only involves the descending aorta. Causes include high blood pressure, genetic conditions like Marfan syndrome, and traumatic injury. Symptoms can include chest pain and symptoms of a stroke. Treatment depends on the type but may involve medications to lower blood pressure or surgery to repair the tear in the aorta. Complications can include death, organ damage or stroke if not properly treated.
This document discusses pressure changes that can occur during coronary angiography, specifically damping and ventricularization. Damping is defined as a significant decrease in pressure at the coronary ostium when the catheter is placed, accompanied by the disappearance of pressure waveforms, suggesting no antegrade flow. Ventricularization occurs when blood circulates within a coronary artery like a closed system, deforming the aortic pressure waveform. The document emphasizes the importance of the operator recognizing abnormal pressure changes to avoid complications, and provides solutions like catheter replacement or intracoronary nitroglycerin to address issues.
The document discusses various diseases of the aorta including aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, aortic aneurysm, atherosclerotic disease, coarctation, and aortic trauma. It provides an overview of the anatomy, clinical presentation, diagnostic imaging, complications, and treatment options for each condition. Key imaging modalities for diagnosis include transthoracic echocardiography, transesophageal echocardiography, CT, and MRI. Mortality rates and predictors of outcome are also reviewed.
This document provides information about percutaneous transvenous mitral commissurotomy (PTMC), a procedure used to treat mitral stenosis. It discusses the stages and severity of mitral stenosis, indications and contraindications for PTMC, assessment of valve morphology, the PTMC procedure technique, instruments used, balloon size selection, post-procedure evaluation, complications, follow-up care, and long-term prognosis. PTMC is performed to improve the opening of a stenosed mitral valve by splitting the fused commissures using a balloon catheter, and is an important therapeutic option for treating symptomatic mitral stenosis.
This document discusses acute aortic syndrome, including a case presentation of a 55-year-old female with chest pain. Key details include:
1. The patient presented with sudden onset chest pain and was found to have hypertension on examination.
2. Initial workup including ECG, labs and chest x-ray were non-diagnostic but showed a widened mediastinum.
3. Echocardiogram and CT angiogram revealed an aortic dissection involving the aortic arch and descending thoracic aorta.
4. She was referred urgently for cardiovascular surgery to treat this life-threatening condition within 24 hours of presentation.
Contrast echocardiography uses microbubble ultrasound contrast agents to improve image quality. These microbubbles remain in the intravascular space and allow for assessment of cardiac structure, function, and perfusion. Second generation contrast agents use an inert gas encapsulated by albumin or phospholipid shells. They interact with ultrasound by reflecting at fundamental frequencies and resonating to produce harmonic frequencies. Continuous infusion provides steady contrast levels needed for perfusion assessment. Contrast echocardiography is a non-invasive technique that improves evaluation of the heart.
determining the suitability of the mitral valve for repair most likely in patients with mitral regurgitation due to myxomatous degeneration and is least likely in patients with regurgitation due to endocarditis most likely with posterior prolapse or flail, whereas ileaflet involvement and isolated anterior leaflet prolapse reduce the likelihood of successful repair substantially.
Coronary artery dissection and perforationFuad Farooq
Coronary artery dissection and perforation are serious potential complications of percutaneous coronary intervention (PCI) that can be life-threatening. Up to 30% of conventional balloon angioplasties result in angiographically significant coronary artery dissection. Perforation occurs in 0.3-0.6% of all PCI cases. The development of devices to remove or ablate tissue has increased the risk of these complications. Types C through F dissections according to the NHLBI classification portend significant morbidity and mortality if untreated, as they can lead to total coronary occlusion without blood flow. Acute vessel closure was the most feared complication before stents but now occurs in less than 1% of elective PCI due to stenting
An aortic aneurysm is a localized sac or dilation formed at a weak point in the aortic wall. They most commonly occur in the abdominal aorta and can be caused by conditions like hypertension, atherosclerosis, and smoking. Aortic aneurysms are classified as either saccular or fusiform based on their shape and size. Untreated aneurysms risk rupture, which can cause massive hemorrhage and death. Surgical treatment involves replacing the diseased aortic segment with a synthetic graft to prevent rupture.
This document provides an overview of acute aortic syndrome (AAS), including aortic dissection, intramural hematoma, penetrating aortic ulcer, and ruptured aortic aneurysm. It discusses the pathophysiology, imaging appearance and protocols, classification systems, and reporting considerations for each condition. CT and MRI are highlighted as the primary imaging modalities. The radiologist plays an important role in diagnosing AAS, determining treatment approaches such as endovascular intervention, and evaluating outcomes through follow up imaging. Proper technique and systematic reporting of anatomic details are essential for clinical management of these life-threatening aortic emergencies.
The document discusses thoracic aortic aneurysms (TAAs), including:
1. TAAs can be true aneurysms involving all vessel layers, or pseudoaneurysms where the intimal and medial layers are disrupted. Common types are fusiform and saccular.
2. Etiologies include atherosclerosis, cystic medial necrosis from conditions like Marfan syndrome, infections, vasculitides, trauma, and congenital factors.
3. Imaging plays a key role in evaluating TAAs to characterize morphology, size, relationships to other structures, and signs of rupture risk. Management depends on aneurysm location and size.
This document discusses aortic aneurysms, including their anatomy, physiology, risk factors, diagnosis, and management. It provides details on:
1) The layers of the aortic wall and how they give the aorta elasticity and strength.
2) Factors that cause the aortic wall to stiffen with age like increases in collagen and calcification of elastic fibers.
3) Definitions of aortic aneurysm and classifications based on location and shape. Thoracic aortic aneurysms involve the ascending aorta while abdominal aortic aneurysms are infrarenal.
4) Screening recommendations, diagnosis using imaging like ultrasound, CT and echocardiography, and considerations for open surgical repair
Single ventricle physiology refers to congenital heart defects where the entire atrioventricular junction connects to a single ventricular chamber. This includes conditions like double inlet left ventricle (DILV), tricuspid atresia, and unbalanced atrioventricular septal defects. The underlying embryology is not fully understood but is thought to involve limitations on inflow or outflow of the left ventricle. Initial management focuses on optimizing pulmonary and systemic blood flow without overloading the single ventricle. Surgical options have evolved from supportive care to staged reconstruction like the Norwood procedure and subsequent Fontan operations.
This document discusses fractional flow reserve (FFR), a technique used during coronary catheterization to measure pressure differences across a coronary stenosis and determine if it is causing myocardial ischemia. An FFR value below 0.75 is considered functionally significant while a value above 0.80 rules out ischemia. FFR is useful for evaluating single-vessel disease, left main stenosis, tandem lesions, diffuse disease, grafts, and ostial lesions. Limitations include inability to assess plaque morphology.
- Aortic dissection involves separation of the aortic media from the adventitia, creating a true and false lumen. It can be acute or chronic.
- Risk factors include hypertension, connective tissue disorders, congenital issues, trauma, pregnancy, and certain drugs or syndromes.
- It is classified using the Stanford or De Bakey system and usually affects those 50-70 years old, though it can occur in younger people with conditions like Marfan syndrome. Left untreated, it has a high mortality rate within weeks.
Aortic dissection occurs when blood tears the inner layer of the aorta, splitting it into two channels. It can be classified by location and timing as either Type A or B. Type A involves the ascending aorta and requires emergency surgery, while Type B spares the ascending aorta and is usually treated medically to control blood pressure. Risk factors include age, hypertension, genetic conditions. Diagnosis involves imaging like CT, MRI or echocardiogram to identify the intimal flap between the true and false lumens. Without treatment, aortic dissection can lead to complications like rupture or organ malperfusion.
Ischaemic cardiomyopathy revascularisation how when and whycardiositeindia
This document discusses ischemic cardiomyopathy and revascularization. It begins with an overview of ischemic cardiomyopathy and discusses factors that contribute to left ventricular remodeling and heart failure progression. It then reviews data from studies such as the Duke CVD Data Bank and STITCH trial on the outcomes of coronary artery bypass grafting versus medical therapy for patients with ischemic cardiomyopathy. The document discusses the role of myocardial viability and hibernation in identifying patients most likely to benefit from revascularization. It reviews various modalities for assessing myocardial viability and hibernation such as cardiac MRI, PET, and echocardiography. Overall, the document provides an overview of ischemic cardiomyopathy and the evidence regarding revascularization outcomes based on viability assessment.
This document discusses the natural history of ventricular septal defects (VSDs). It covers the incidence, classification, factors influencing outcomes, and potential complications of VSDs over time, including:
1. Cardiac failure in large VSDs due to left-to-right shunting.
2. Spontaneous closure or diminution, which is more common in smaller defects and those under 10 years of age.
3. Complications such as right ventricular outflow tract obstruction, aortic valve prolapse, pulmonary vascular disease, infective endocarditis, and arrhythmias.
The classification, mechanisms of closure, and guidelines for antibiotic prophylaxis for infective endocard
This document discusses fractional flow reserve (FFR), which is a technique used to functionally assess the significance of coronary artery stenosis. FFR is defined as the ratio of maximum blood flow in a stenotic artery to maximum blood flow if there was no stenosis. It is calculated as the ratio of mean distal coronary pressure (Pd) to mean aortic pressure (Pa) during maximal hyperemia induced by pharmacological agents. An FFR value below 0.75 is associated with inducible ischemia, while a value above 0.80 indicates an insignificant stenosis in most cases. FFR has advantages over angiography alone in evaluating stenosis as it accounts for vessel characteristics like length and takes collateral flow into consideration.
Echocardiographic Evaluation of LV Diastolic FunctionJunhao Koh
The document discusses methods for evaluating left ventricular diastolic function using echocardiography. It describes the four phases of diastole, parameters used to assess diastolic function including mitral inflow patterns, mitral annular tissue Doppler, pulmonary vein flow, left atrial size and the Tei index. Grades of diastolic dysfunction and approaches from ASE/EAE and Mayo Clinic are summarized. Continuous wave Doppler of aortic regurgitation is also presented as a noninvasive method to evaluate left ventricular relaxation.
The document discusses non-surgical interventions for atrial septal defects (ASDs) and ventricular septal defects (VSDs). It describes the anatomy, causes, symptoms, and types of ASDs and VSDs. It provides indications for intervention such as large defect size, heart failure, or failure to thrive. The main non-surgical interventions discussed are percutaneous device closure of ASDs and VSDs, which are preferred to surgery when the anatomy is suitable. The future of interventions may include improved 3D imaging, contrast agents, and stents to repair more complex congenital heart defects.
This document discusses contrast echocardiography, including the mechanism by which microbubble contrast agents improve echocardiographic imaging. Ideal contrast agents are described as being safe, metabolically inert, long-lasting, strong sound reflectors that are small enough to pass through capillaries. Several FDA-approved second generation contrast agents are mentioned along with their shell materials and gases. Optimal echocardiographic settings for contrast imaging are outlined. Clinical applications of contrast echocardiography include assessing shunts, venous anomalies, and leaks. Examples of its use in specific cases are provided.
This document summarizes dobutamine stress echocardiography (DSE). Key points include:
- DSE uses the drug dobutamine to simulate exercise and increase heart rate, contractility, and myocardial oxygen demand to detect ischemia.
- It is useful for evaluating ischemia, viability, and valvular dysfunction in patients unable to exercise.
- The document reviews the DSE protocol, interpretation of wall motion abnormalities, indications, side effects, and applications for assessing ischemic heart disease, viability, valvular stenosis like mitral and aortic stenosis, and pulmonary hypertension.
1) Cardiogenic shock is defined as hypotension, hypoperfusion, and elevated filling pressures caused by depressed left ventricular function following myocardial injury. Mortality from cardiogenic shock remains high at 50-70%.
2) Risk factors for cardiogenic shock include age over 65, female gender, large myocardial infarction, anterior infarction location, prior infarction history, diabetes, and hypertension. Post-mortem studies show extensive myocardial damage in patients who die from cardiogenic shock.
3) Early revascularization through percutaneous coronary intervention or coronary artery bypass grafting may improve survival outcomes for cardiogenic shock, especially in patients under age 75, according to the landmark SHOCK trial. Adjunctive therapies including intra
The document summarizes various potential complications that can occur during or after cardiac catheterization. The major complications discussed include death, myocardial infarction, stroke, bleeding, vascular injury, and contrast induced nephrotoxicity. Risk factors for complications include patient demographics, cardiovascular anatomy, clinical situation, and operator experience. Local vascular complications like hematoma, pseudoaneurysm, arterial thrombosis are also described. Strategies to prevent complications involve careful technique, minimizing contrast and anticoagulation.
An aortic dissection is a tear in the inner layer of the aorta that allows blood to flow between the layers of the aortic wall, creating a false passageway. It is a medical emergency that requires prompt diagnosis and treatment. Type A dissections, which involve the ascending aorta, require emergency surgery while type B dissections, involving only the descending aorta, are generally treated medically with blood pressure control. Surgical treatment of type A dissections aims to remove the damaged aortic segment and restore blood flow through the aorta using a graft.
Acute aortic dissection is a potentially life-threatening condition where blood flows into the layers of the aortic wall, splitting it apart. It occurs in approximately 2.9 per 100,000 people per year in the US. There are several classification systems, but the most important distinguishes between type A dissections, which involve the ascending aorta and require surgery, and type B dissections, which do not involve the ascending aorta and can be treated medically. Risk factors include hypertension, connective tissue disorders like Marfan syndrome, bicuspid aortic valves, pregnancy, and trauma. Prompt diagnosis and treatment are crucial as the risk of death is approximately 1% per hour without treatment.
determining the suitability of the mitral valve for repair most likely in patients with mitral regurgitation due to myxomatous degeneration and is least likely in patients with regurgitation due to endocarditis most likely with posterior prolapse or flail, whereas ileaflet involvement and isolated anterior leaflet prolapse reduce the likelihood of successful repair substantially.
Coronary artery dissection and perforationFuad Farooq
Coronary artery dissection and perforation are serious potential complications of percutaneous coronary intervention (PCI) that can be life-threatening. Up to 30% of conventional balloon angioplasties result in angiographically significant coronary artery dissection. Perforation occurs in 0.3-0.6% of all PCI cases. The development of devices to remove or ablate tissue has increased the risk of these complications. Types C through F dissections according to the NHLBI classification portend significant morbidity and mortality if untreated, as they can lead to total coronary occlusion without blood flow. Acute vessel closure was the most feared complication before stents but now occurs in less than 1% of elective PCI due to stenting
An aortic aneurysm is a localized sac or dilation formed at a weak point in the aortic wall. They most commonly occur in the abdominal aorta and can be caused by conditions like hypertension, atherosclerosis, and smoking. Aortic aneurysms are classified as either saccular or fusiform based on their shape and size. Untreated aneurysms risk rupture, which can cause massive hemorrhage and death. Surgical treatment involves replacing the diseased aortic segment with a synthetic graft to prevent rupture.
This document provides an overview of acute aortic syndrome (AAS), including aortic dissection, intramural hematoma, penetrating aortic ulcer, and ruptured aortic aneurysm. It discusses the pathophysiology, imaging appearance and protocols, classification systems, and reporting considerations for each condition. CT and MRI are highlighted as the primary imaging modalities. The radiologist plays an important role in diagnosing AAS, determining treatment approaches such as endovascular intervention, and evaluating outcomes through follow up imaging. Proper technique and systematic reporting of anatomic details are essential for clinical management of these life-threatening aortic emergencies.
The document discusses thoracic aortic aneurysms (TAAs), including:
1. TAAs can be true aneurysms involving all vessel layers, or pseudoaneurysms where the intimal and medial layers are disrupted. Common types are fusiform and saccular.
2. Etiologies include atherosclerosis, cystic medial necrosis from conditions like Marfan syndrome, infections, vasculitides, trauma, and congenital factors.
3. Imaging plays a key role in evaluating TAAs to characterize morphology, size, relationships to other structures, and signs of rupture risk. Management depends on aneurysm location and size.
This document discusses aortic aneurysms, including their anatomy, physiology, risk factors, diagnosis, and management. It provides details on:
1) The layers of the aortic wall and how they give the aorta elasticity and strength.
2) Factors that cause the aortic wall to stiffen with age like increases in collagen and calcification of elastic fibers.
3) Definitions of aortic aneurysm and classifications based on location and shape. Thoracic aortic aneurysms involve the ascending aorta while abdominal aortic aneurysms are infrarenal.
4) Screening recommendations, diagnosis using imaging like ultrasound, CT and echocardiography, and considerations for open surgical repair
Single ventricle physiology refers to congenital heart defects where the entire atrioventricular junction connects to a single ventricular chamber. This includes conditions like double inlet left ventricle (DILV), tricuspid atresia, and unbalanced atrioventricular septal defects. The underlying embryology is not fully understood but is thought to involve limitations on inflow or outflow of the left ventricle. Initial management focuses on optimizing pulmonary and systemic blood flow without overloading the single ventricle. Surgical options have evolved from supportive care to staged reconstruction like the Norwood procedure and subsequent Fontan operations.
This document discusses fractional flow reserve (FFR), a technique used during coronary catheterization to measure pressure differences across a coronary stenosis and determine if it is causing myocardial ischemia. An FFR value below 0.75 is considered functionally significant while a value above 0.80 rules out ischemia. FFR is useful for evaluating single-vessel disease, left main stenosis, tandem lesions, diffuse disease, grafts, and ostial lesions. Limitations include inability to assess plaque morphology.
- Aortic dissection involves separation of the aortic media from the adventitia, creating a true and false lumen. It can be acute or chronic.
- Risk factors include hypertension, connective tissue disorders, congenital issues, trauma, pregnancy, and certain drugs or syndromes.
- It is classified using the Stanford or De Bakey system and usually affects those 50-70 years old, though it can occur in younger people with conditions like Marfan syndrome. Left untreated, it has a high mortality rate within weeks.
Aortic dissection occurs when blood tears the inner layer of the aorta, splitting it into two channels. It can be classified by location and timing as either Type A or B. Type A involves the ascending aorta and requires emergency surgery, while Type B spares the ascending aorta and is usually treated medically to control blood pressure. Risk factors include age, hypertension, genetic conditions. Diagnosis involves imaging like CT, MRI or echocardiogram to identify the intimal flap between the true and false lumens. Without treatment, aortic dissection can lead to complications like rupture or organ malperfusion.
Ischaemic cardiomyopathy revascularisation how when and whycardiositeindia
This document discusses ischemic cardiomyopathy and revascularization. It begins with an overview of ischemic cardiomyopathy and discusses factors that contribute to left ventricular remodeling and heart failure progression. It then reviews data from studies such as the Duke CVD Data Bank and STITCH trial on the outcomes of coronary artery bypass grafting versus medical therapy for patients with ischemic cardiomyopathy. The document discusses the role of myocardial viability and hibernation in identifying patients most likely to benefit from revascularization. It reviews various modalities for assessing myocardial viability and hibernation such as cardiac MRI, PET, and echocardiography. Overall, the document provides an overview of ischemic cardiomyopathy and the evidence regarding revascularization outcomes based on viability assessment.
This document discusses the natural history of ventricular septal defects (VSDs). It covers the incidence, classification, factors influencing outcomes, and potential complications of VSDs over time, including:
1. Cardiac failure in large VSDs due to left-to-right shunting.
2. Spontaneous closure or diminution, which is more common in smaller defects and those under 10 years of age.
3. Complications such as right ventricular outflow tract obstruction, aortic valve prolapse, pulmonary vascular disease, infective endocarditis, and arrhythmias.
The classification, mechanisms of closure, and guidelines for antibiotic prophylaxis for infective endocard
This document discusses fractional flow reserve (FFR), which is a technique used to functionally assess the significance of coronary artery stenosis. FFR is defined as the ratio of maximum blood flow in a stenotic artery to maximum blood flow if there was no stenosis. It is calculated as the ratio of mean distal coronary pressure (Pd) to mean aortic pressure (Pa) during maximal hyperemia induced by pharmacological agents. An FFR value below 0.75 is associated with inducible ischemia, while a value above 0.80 indicates an insignificant stenosis in most cases. FFR has advantages over angiography alone in evaluating stenosis as it accounts for vessel characteristics like length and takes collateral flow into consideration.
Echocardiographic Evaluation of LV Diastolic FunctionJunhao Koh
The document discusses methods for evaluating left ventricular diastolic function using echocardiography. It describes the four phases of diastole, parameters used to assess diastolic function including mitral inflow patterns, mitral annular tissue Doppler, pulmonary vein flow, left atrial size and the Tei index. Grades of diastolic dysfunction and approaches from ASE/EAE and Mayo Clinic are summarized. Continuous wave Doppler of aortic regurgitation is also presented as a noninvasive method to evaluate left ventricular relaxation.
The document discusses non-surgical interventions for atrial septal defects (ASDs) and ventricular septal defects (VSDs). It describes the anatomy, causes, symptoms, and types of ASDs and VSDs. It provides indications for intervention such as large defect size, heart failure, or failure to thrive. The main non-surgical interventions discussed are percutaneous device closure of ASDs and VSDs, which are preferred to surgery when the anatomy is suitable. The future of interventions may include improved 3D imaging, contrast agents, and stents to repair more complex congenital heart defects.
This document discusses contrast echocardiography, including the mechanism by which microbubble contrast agents improve echocardiographic imaging. Ideal contrast agents are described as being safe, metabolically inert, long-lasting, strong sound reflectors that are small enough to pass through capillaries. Several FDA-approved second generation contrast agents are mentioned along with their shell materials and gases. Optimal echocardiographic settings for contrast imaging are outlined. Clinical applications of contrast echocardiography include assessing shunts, venous anomalies, and leaks. Examples of its use in specific cases are provided.
This document summarizes dobutamine stress echocardiography (DSE). Key points include:
- DSE uses the drug dobutamine to simulate exercise and increase heart rate, contractility, and myocardial oxygen demand to detect ischemia.
- It is useful for evaluating ischemia, viability, and valvular dysfunction in patients unable to exercise.
- The document reviews the DSE protocol, interpretation of wall motion abnormalities, indications, side effects, and applications for assessing ischemic heart disease, viability, valvular stenosis like mitral and aortic stenosis, and pulmonary hypertension.
1) Cardiogenic shock is defined as hypotension, hypoperfusion, and elevated filling pressures caused by depressed left ventricular function following myocardial injury. Mortality from cardiogenic shock remains high at 50-70%.
2) Risk factors for cardiogenic shock include age over 65, female gender, large myocardial infarction, anterior infarction location, prior infarction history, diabetes, and hypertension. Post-mortem studies show extensive myocardial damage in patients who die from cardiogenic shock.
3) Early revascularization through percutaneous coronary intervention or coronary artery bypass grafting may improve survival outcomes for cardiogenic shock, especially in patients under age 75, according to the landmark SHOCK trial. Adjunctive therapies including intra
The document summarizes various potential complications that can occur during or after cardiac catheterization. The major complications discussed include death, myocardial infarction, stroke, bleeding, vascular injury, and contrast induced nephrotoxicity. Risk factors for complications include patient demographics, cardiovascular anatomy, clinical situation, and operator experience. Local vascular complications like hematoma, pseudoaneurysm, arterial thrombosis are also described. Strategies to prevent complications involve careful technique, minimizing contrast and anticoagulation.
An aortic dissection is a tear in the inner layer of the aorta that allows blood to flow between the layers of the aortic wall, creating a false passageway. It is a medical emergency that requires prompt diagnosis and treatment. Type A dissections, which involve the ascending aorta, require emergency surgery while type B dissections, involving only the descending aorta, are generally treated medically with blood pressure control. Surgical treatment of type A dissections aims to remove the damaged aortic segment and restore blood flow through the aorta using a graft.
Acute aortic dissection is a potentially life-threatening condition where blood flows into the layers of the aortic wall, splitting it apart. It occurs in approximately 2.9 per 100,000 people per year in the US. There are several classification systems, but the most important distinguishes between type A dissections, which involve the ascending aorta and require surgery, and type B dissections, which do not involve the ascending aorta and can be treated medically. Risk factors include hypertension, connective tissue disorders like Marfan syndrome, bicuspid aortic valves, pregnancy, and trauma. Prompt diagnosis and treatment are crucial as the risk of death is approximately 1% per hour without treatment.
Aortic dissection, pathophysiology, risk, incidence, types and treatment, Moh...Moh'd sharshir
This document presents a case of a 55-year-old man with a history of diabetes, hypertension, and prior stroke who was transferred for endovascular aortic repair after a motor vehicle accident caused multiple injuries including head trauma, chest trauma, cardiac contusion, aortic injury, and bone fractures. On examination, he was intubated and sedated. Imaging showed aortic pseudoaneurysm, lung effusions, and subcutaneous emphysema. The document then reviews aortic dissection including types, risk factors, clinical manifestations, diagnosis, and involvement of the ascending versus descending aorta.
Fatal Condition of Aortic Dissection Produces Symptoms of Sudden and Tearing ...semualkaira
Aortic dissection is a very difficult condition in which the inner
sheath of the aortic wall is torn without tearing the outer sheath.
This causes blood to enter the aortic wall through the tear, which
further splits the mediastinum and creates a new channel in the
aortic wall. The serious and often fatal condition of aortic dissection produces symptoms of sudden and tearing chest pain. Although aortic dissection mostly occurs in people around the age of
60, the peak incidence in people with Marfan syndrome is between
20 and 40 years of age.
Fatal Condition of Aortic Dissection Produces Symptoms of Sudden and Tearing ...semualkaira
Aortic dissection is a very difficult condition in which the inner
sheath of the aortic wall is torn without tearing the outer sheath.
This causes blood to enter the aortic wall through the tear, which
further splits the mediastinum and creates a new channel in the
aortic wall. The serious and often fatal condition of aortic dissection produces symptoms of sudden and tearing chest pain. Although aortic dissection mostly occurs in people around the age of
60, the peak incidence in people with Marfan syndrome is between
20 and 40 years of age.
1. Aortic dissection is a tear in the inner layer of the aorta that allows blood to flow between the layers, causing severe chest pain. It is a medical emergency with high mortality if left untreated.
2. Diagnosis is based on symptoms of sudden, severe chest pain and imaging tests like CT scan or MRI that can detect the tear and blood flow between the layers of the aorta.
3. Risk factors include high blood pressure, genetic connective tissue disorders, injuries to the chest, and pregnancy. Prompt diagnosis and treatment are needed to prevent death.
Stanford Type A Aortic Dissection: a Complex Disease for Patients and Cardiot...Crimsonpublisherssmoaj
Acute type A aortic dissection is a catastrophic event in which blood exits the vascular lumen and dissects the media, creating a false lumen. Surgery is the best possible treatment but it is complex. The surgical team needs to understand the anatomy and physiopathology before dealing with the repair. While there are just a few surgical solutions for the repair of the dissected ascending aorta, debate is still ongoing about the best surgical option for the disease involving the arch and the descending aorta. Late reoperations are relatively common on the aortic valve and/or the distal aorta after primary repair. Results are excellent in specialized centers with high volume and complexity. Lifelong follow-up is required in survivors.
This document discusses cardioembolic stroke caused by atrial fibrillation. It notes that up to 3 million strokes per year worldwide are caused by AFib. AFib is the most common sustained heart rhythm disorder and increases the risk of stroke 5-fold. The document outlines the prevalence and sources of cardioembolic stroke, how AFib can lead to clots and stroke, and clinical features that help identify potential cardioembolic strokes. It also discusses various cardiac conditions that can cause emboli and stroke like ventricular thrombi, valvular heart disease, congenital heart defects, and arrhythmias.
This document discusses various types of arrhythmias and heart conditions including their causes, characteristics, and clinical presentations. It covers topics such as:
- Arrhythmias which can be initiated anywhere in the heart's conduction system and may present as tachycardia, bradycardia, or other irregular rhythms.
- Hypertension can lead to hypertensive heart disease over time due to increased pressure on the heart.
- Valvular heart diseases like rheumatic heart disease and degenerative valve diseases can cause stenosis or insufficiency of the heart valves.
- Infective endocarditis is a bacterial infection of the heart valves that forms vegetations and can cause embol
A short update on aortic regurgitation drmohitmathur
Aortic regurgitation can be caused by primary valve disease or primary aortic root disease. In the initial stages, increased blood flow to the left ventricle maintains cardiac output but causes increased pressure over time. Eventually, the left ventricle's function deteriorates as blood flows backward, leading to further enlargement and heart failure if untreated. Surgical replacement of the aortic valve is often needed to treat severe chronic aortic regurgitation before left ventricular dysfunction progresses. Homoeopathic treatment may help prevent immune-mediated valve damage in some cases.
Valvular heart disease accounts for 10-20% of cardiac surgery procedures in the US. The document discusses the causes, symptoms, diagnosis and treatment of two common types: mitral stenosis and mitral regurgitation. Mitral stenosis is usually caused by rheumatic fever and results in obstruction of blood flow from the left atrium to ventricle. Symptoms range from mild shortness of breath to pulmonary edema. Diagnosis involves echocardiography and treatment may involve medications, balloon valvuloplasty or valve replacement surgery. Mitral regurgitation occurs when the mitral valve does not close properly, allowing blood to flow back into the left atrium. It can be acute or chronic, with symptoms
This document provides an overview of carotid artery stenosis. It discusses the anatomy of the carotid arteries and how stenosis can increase the risk of stroke by reducing blood flow to the brain. Symptoms of stenosis range from transient ischemic attacks to full strokes, depending on the location and severity of the blockage. Imaging plays a key role in detecting and evaluating carotid artery stenosis. Treatment may involve medications, lifestyle changes, or carotid endarterectomy surgery to remove plaque buildup.
Congenital heart disease (CHD) describes abnormalities present at birth that affect the structure and function of the heart. The most common CHDs are ventricular septal defects, atrial septal defects, tetralogy of Fallot, transposition of the great arteries, coarctation of the aorta, and patent ductus arteriosus. CHDs can cause cyanosis, heart failure, or no symptoms depending on the specific defect and severity of shunting.
This document discusses the prevention and treatment of stroke. It defines stroke and describes the main types. It then discusses risk factors such as hypertension, cardiac diseases, diabetes, and infections. It also covers transient ischemic attacks, the causes of ischemic stroke, recommendations for stroke prevention, and clinical manifestations of stroke. The high-level goal is to provide an overview of stroke including definition, classification, risk factors, prevention strategies, and signs/symptoms.
Neha diwan presentation on aortic aneurysmNEHAADIWAN
The document discusses aneurysms and aortic dissections. It defines an aneurysm as an abnormal dilatation of a blood vessel wall due to weakening. Aortic dissections occur when the inner layer of the aorta tears, allowing blood to surge between the layers. Risk factors include hypertension, smoking, genetics. Symptoms include chest pain. Diagnosis involves imaging tests like ultrasound, CT, or MRI. Treatment depends on location but may include open or endovascular surgery to repair or replace the damaged vessel.
intracranial hemorrhage- by KEMISA HASSEN ZAINABU IIHS_jinjaUGANDA (2).pptxHASSENZAINABUKEMISA
By the end of this we shall be able to know the following
definition.of intracranial hemorriage
Classification of intracranial hemorriage
Types of intracranial hemorriage.
Causes of intracranial hemorriage.
Signs and symptoms of intracranial hemorriage
Investigations specific management.
Complication.
Ongoing nursing care.
This document discusses acute aortic syndrome (AAS), which includes acute aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer. AAS is caused by disruption of the aortic wall layers from tears or ulcers, allowing blood to track within the layers. The most common type is aortic dissection, where blood passes through a tear separating the vessel layers. Presenting symptoms typically include sudden severe chest or back pain. Diagnosis involves imaging like CECT, MRI, or TEE to identify abnormalities. Prognosis depends on factors like involvement of the ascending aorta and complications. Classification systems differentiate type A dissections involving the ascending aorta from type B.
This document discusses cardioembolic stroke, which occurs when heart issues cause materials to enter the brain's blood vessels. Common causes include atrial fibrillation, heart failure, and mechanical heart valves. Diagnosis involves echocardiography and monitoring for embolic signals. Treatment depends on the specific heart condition but often includes anticoagulants to prevent clots. Anticoagulation reduces stroke risk from atrial fibrillation by 60-90% compared to placebo. Managing cardioembolic stroke risk requires identifying the underlying heart condition and addressing it with medications, surgery, or lifestyle changes.
This document discusses delirium, which is an acute disturbance of consciousness and cognition. It defines delirium and describes its subtypes. Delirium is associated with increased mortality, longer hospital stays, and permanent cognitive impairment in some patients. Risk factors include infection, withdrawal, metabolic abnormalities, trauma, and various medical conditions. Delirium results from neurotransmitter imbalances and inflammation in the brain. It should be monitored using scales like the Richmond Agitation Sedation Scale and Confusion Assessment Method. Treatment involves managing the underlying causes, minimizing sedation, promoting mobility, and in some cases using antipsychotics or dexmedetomidine. Delirium usually develops within the first 48 hours and can last up to two weeks.
Colistin is a polymyxin antibiotic produced by Bacillus polymyxa that is effective against most gram-negative bacteria. It fell out of favor due to nephrotoxicity but remains a treatment of last resort for multidrug-resistant infections. There are two forms, colistin sulfate and colistimethate sodium, which are dosed differently and have different mechanisms of action, pharmacokinetics, and toxicity profiles. Resistance can develop with use but remains relatively rare currently.
This document discusses various methods for monitoring the central nervous system (CNS) during and after surgery. It describes cerebral perfusion monitoring techniques like cerebral blood flow measurements, transcranial Doppler ultrasonography, near-infrared spectroscopy, and jugular bulb oximetry. Regional perfusion is also monitored using brain tissue partial oxygen tension. Cerebral metabolism is assessed using cerebral microdialysis. Cerebral function is evaluated with the bispectral index, approximate entropy, and auditory evoked potentials. The document provides details on how each technique is performed and what clinical information it provides about CNS oxygenation, blood flow, and function.
This document discusses ventricular tachycardia (VT) clusters and incessant VT. It defines a VT cluster as 3 or more sustained VTs within 24 hours. Treatment options discussed include antiarrhythmic drugs, ablation, anesthesia, and LVAD. Amiodarone, lidocaine, and procainamide dosages are provided. Left stellate ganglion blockade is suggested as superior to antiarrhythmic drugs for electrical storms. The document also discusses therapies for VT including ablation and digitalis toxicity management.
This document discusses various calculations used to diagnose and distinguish between different types of acid-base disorders, including anion gap, delta gap, urine anion gap, and osmolar gap. It provides detailed explanations of how to calculate each value and what they indicate. The anion gap is useful for determining the cause of metabolic acidosis. The delta gap can identify mixed acid-base disorders. A negative urine anion gap suggests GI bicarbonate loss while a positive value suggests renal tubular acidosis. An increased osmolar gap may indicate ethylene glycol or methanol poisoning in the setting of an unexplained metabolic acidosis.
Chest x. ray interpretation and teachingsamirelansary
1. The document discusses various radiological signs seen on chest x-rays related to different disease processes and conditions. It provides descriptions of abnormalities indicative of conditions like pneumonia, lung cancer, tuberculosis, pulmonary edema and others.
2. Examples and descriptions are given for interpreting findings related to mediastinal masses, pleural effusions, atelectasis, pneumothorax and other lung abnormalities. Signs related to vascular structures like aneurysms are also outlined.
3. The document serves as a teaching guide for radiological interpretation and diagnosis, summarizing key signs and patterns seen for different diseases on chest x-rays.
Colistin is a polymyxin antibiotic produced by Bacillus polymyxa that is effective against most gram-negative bacteria. It fell out of favor due to nephrotoxicity but remains a treatment of last resort for multidrug-resistant infections. There are two forms, colistin sulfate and colistimethate sodium, which are not interchangeable. Dosing is complicated due to lack of standardization. Colistin works by disrupting bacterial membranes. While resistance is still rare, its increased use has led to some resistant strains emerging.
Chest x. ray interpretation and teachingsamirelansary
1. The document discusses various radiological signs seen on chest x-rays related to different disease processes and conditions. It provides descriptions of findings related to lung lesions, pleural diseases, pulmonary vascular abnormalities and other pathologies.
2. Examples of signs described include the appearance of mediastinal lesions, pleural effusions, lung opacities, findings associated with lobar collapse, and distributions of opacities related to specific conditions.
3. The document aims to aid in the interpretation of chest x-rays and teaching of radiological findings for different diseases. It covers topics such as cavitary lung lesions, mediastinal abnormalities, signs of pneumonia, and characteristics of vascular anomalies amongst other pathologies.
This document discusses various methods for monitoring the central nervous system (CNS) during and after surgery. It describes cerebral perfusion monitoring techniques like cerebral blood flow measurements, transcranial Doppler ultrasonography, near-infrared spectroscopy, and jugular bulb oximetry. Regional perfusion is also monitored using brain tissue partial oxygen tension. Cerebral metabolism is assessed using cerebral microdialysis. Cerebral function is evaluated with the bispectral index, approximate entropy, and auditory evoked potentials. The document provides details on how each technique is performed and what insights it provides about CNS oxygenation, blood flow, and electrical activity.
1) An arterial line allows continuous monitoring of a patient's blood pressure by connecting an arterial catheter to a pressure transducer. The transducer converts pressure oscillations into an electrical waveform displayed on a monitor.
2) The arterial waveform provides information about cardiovascular physiology and hemodynamics. An accurate waveform depends on proper catheter placement, monitoring equipment setup, and avoiding issues like dampening or resonance.
3) Key portions of the arterial waveform include the anacrotic limb, anacrotic notch, dicrotic limb, and dicrotic notch, which reflect events in the cardiac cycle and can be affected by conditions like vascular resistance.
1) The document presents several radiographic signs seen on chest x-rays and CT scans related to various pulmonary and mediastinal abnormalities.
2) Examples include the deep sulcus sign indicating pleural free air, the air crescent sign seen in invasive aspergillosis, the silhouette sign depicting a pericardial cyst, and the CT halo sign associated with various conditions including invasive aspergillosis.
3) Accompanying each sign is an illustration and example chest x-ray or CT image, with a brief explanation of the clinical significance of each radiographic finding.
The document provides updates on infectious diseases from Clostridium difficile infection to new vaccines and antimicrobial agents. It discusses the increasing severity and prevalence of C. difficile, new diagnostic tests and treatment options including fidaxomicin and stool transplants. New antimicrobial agents for gram-positive infections like daptomycin, linezolid and ceftaroline are mentioned. Vaccine recommendations are updated for herpes zoster, pertussis and pneumococcus.
1. Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space between the brain's outermost layers caused by a ruptured aneurysm in 70% of cases.
2. Presentation includes sudden severe headache, reduced consciousness, vomiting, neck stiffness, and seizures. Investigations include CT scan and lumbar puncture to detect blood.
3. Treatment aims to prevent rebleeding through securing the aneurysm via coiling or clipping, and managing complications like hydrocephalus, vasospasm, seizures, and hyponatremia which can occur in the weeks following SAH.
SYSTEMIC LUPUS ERYTHEMATOSUS Sle pathophysiology and managementsamirelansary
This document provides an overview and update on systemic lupus erythematosus (SLE). It discusses the definition and classification criteria for SLE, including revisions to the criteria. Genetic factors contributing to SLE susceptibility are described. Increased levels of interferon alpha are implicated in the disease pathogenesis. Clinical manifestations and leading causes of mortality in SLE patients are summarized. Current therapeutic approaches for SLE, including hydroxychloroquine, belimumab, and targeted therapies in development are outlined.
This case describes a 45-year-old male presenting with agitation, fever, hypertension, tachycardia, and other signs consistent with serotonin syndrome after ingesting Paxil, Gravol, ibuprofen, and smoking crack cocaine. The document discusses the diagnostic criteria and causes of serotonin syndrome and recommends supportive care and medications like cyproheptadine, benzodiazepines, beta-blockers, chlorpromazine, and dantrolene for treatment. Cyproheptadine appears to be an effective and safe treatment option for mild to moderate cases based on case reports and series.
This document defines key terms and concepts related to mechanical ventilation and interprets blood gas results to guide ventilator adjustments. It describes various ventilator modes, appropriate initial settings, priorities for weaning, and criteria for extubation. Volume control delivers a set tidal volume while pressure control uses a fixed pressure. Pressure-regulated volume control aims for a target minute ventilation. Complications include barotrauma, pneumonia, and cardiac/GI issues. Physical exams and pressure patterns can localize causes of acute deterioration. Neurologic, cardiovascular, and pulmonary status must be optimized before extubation.
This document discusses new insights into treatment strategies for critically ill patients, including optimal antibiotic dosing and the potential benefits of extended infusion of antibiotics. It also reviews evidence on the use of aerosolized colistin, inhalation antibiotics, statins, probiotics, and prophylactic antibiotics in preventing infections like ventilator-associated pneumonia in ICU patients. While some studies found decreased infection rates, ICU stay, or ventilation time with these approaches, larger trials are still needed to determine clear effects on mortality or define best practices. The document emphasizes individualizing care based on pharmacokinetic factors and calls for more research on optimization of antibiotic use in critical illness.
Mixed connective tissue disease (MCTD) is a rare autoimmune disorder with features of lupus, scleroderma, rheumatoid arthritis, and polymyositis. It is characterized by high levels of antibodies against ribonucleic proteins. Diagnostic criteria require 3 of 5 clinical features plus positive serology. Over time, many patients evolve symptoms meeting criteria for other connective tissue diseases. Pulmonary, renal, and cardiac involvement are common complications. Prognosis depends on degree of organ involvement, with 5-year mortality of 8-19% reported.
This document discusses normal and increased intracranial pressure (ICP). It begins by defining normal ICP ranges in adults and babies. ICP is influenced by several factors and shows pressure fluctuations with cardiac systole and respiration. Increased ICP can be caused by factors that increase brain volume such as tumors or hematomas. Treatment aims to reduce ICP through general measures, induced cerebral vasoconstriction using techniques like hyperventilation, and osmotherapy using agents like mannitol. Careful monitoring of ICP is important for guiding therapy to prevent secondary brain injury.
This document contains summaries of several research points related to critical care. It discusses findings that propofol may limit recovery after brain injury in adults, that cardiac dysfunction is associated with mortality after traumatic brain injury, that vitamin D deficiency predicts sepsis in critically ill patients, and that neuromuscular blocking agents are associated with lower mortality in mechanically ventilated sepsis patients. It also summarizes research showing that a bundle of measures was effective at reducing ventriculitis associated with external cerebral ventricular drainage. Finally, it finds that critical illness is characterized by reduced intestinal absorption of glucose and lower expression of glucose transporters and taste receptors.
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- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
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3. Aortic dissection
An aortic dissection is a tearing of the layers
within the aortic wall, classically associated
with sudden-onset chest or back pain, a pulse
deficit, and mediastinal widening on a chest
radiograph.
Depending on size and degree of aortic
involvement, it may result in marked
hemodynamic instability and, often, a rapid
death.
4. Aortic dissection.
Prompt diagnosis and appropriate treatment
are critical to maximize the possibility of
survival.
Significant dissections are often fatal and
rarely survive to clinical attention; the majority
of dissections seen in the critical care
environment are either
Subacute, contained, or sparing the
major aortic vessels.
5. Anatomy of injury in aortic
dissection
The tear usually originates in the intima.
It then propagates into the media creating a
false channel for blood to flow and hematoma
to form.
The dissection process may alternatively
originate with hemorrhage
in the media that secondarily causes
disruption of the intima.
6. In approximately 70% of patients, the intimal
tear, which is the beginning of the dissection,
occurs in the ascending aorta.
In 20% of patients it occurs in the descending
thoracic aorta, and in 10% of patients it occurs
in the aortic arch.
Only rarely is an intimal tear identified in the
abdominal aorta.
7. DeBakey classifications of aortic
dissection
The two classification systems most
commonly used both have anatomic
as well as management
implications.
8. The DeBakey classification describes three
types of dissection :
Type I: extends from aortic root to beyond the
ascending aorta
Type 11: involves only the ascending aorta
Type Ill: Begins distal to the takeoff of the left
subclavian artery and has two subtypes
Type III A: limited to the thoracic aorta
Type 111 B: extends below the diaphragm
9. The Stanford classification has
two types of dissection
Type A: involves the ascending
aorta
Type B: involves the descending
aorta, distal to the left subclavian
artery
10. Approximately 75% of patients with ruptured
aortic aneurysm will reach an emergency
department alive.
Whereas for aortic dissection 40% die
immediately.
Furthermore, only 50% to 70% will be alive 5
years after surgery depending on age and
underlying cause.
11. For untreated acute dissection of the
ascending aorta the mortality rate is 1 % to 2%
per hour after onset.
For type A dissections treated medically it is
approximately 20% within the first 24 hours and
50% by 1 month after presentation.
Even with surgical intervention
the mortality rate for type A dissection may be
as high as 10% after 24 hours and nearly 20%
1 month after repair.
12. Although type B dissection is less dangerous
than type A, it is still associated with an
extremely high mortality.
The 30-day mortality rate for an uncomplicated
type B dissection approaches 10%.
However, patients with type B dissection who
have complications such as limb ischemia,
renal failure, or visceral ischemia have a 2-day
mortality upwards of 20% and may prompt the
need for surgical intervention.
14. Hypertension: Present in 70% to 90% of
patients with acute dissection.
Advanced age: Mean of 63 years in the
International Registry of Acute Aortic
Dissection (IRAD).
Male sex: Represented by 65% of patients in
the IRAD.
Family history: Recently recognized is a
genetic, nonsyndromic familial form of thoracic
aortic dissection.
16. Other associated congenital disorders
include
Ehlers-Danlos syndrome, Loeys-Dietz
syndrome, bicuspid aortic valve, aortic
coarctation, Turner syndrome, Takayasu
and giant-cell aortitis, relapsing
polychondritis (Behcet disease,
spondyloarthropathies), or confirmed
genetic mutations known to predispose
.to dissections (TGFBRI, TGFBRP, FBNI,
ACTAP, or MYHI I ) .
17. Pregnancy
Associated with 50% of dissections in
women under age 40 and most
frequently occurring in the third
trimester.
This might be attributable to
elevations in cardiac output during
pregnancy that cause increased
wall stress.
18. Circadian and seasonal
variations
Producing a higher frequency of dissection
in the morning hours and in the winter
months.
Iatrogenic
Occurring as a consequence of invasive
procedures or surgery, especially when the
aorta has been entered or its main
branches have been cannulated, such as
for cardiopulmonary bypass.
20. Pain
The most common presenting symptom is
chest pain, occurring in up to 90% of
patients with acute dissection.
Classically, for type A dissections, sudden
onset of severe anterior chest pain with
extension to the back occurs that is
described as ripping or tearing in nature.
21. The pain is usually of maximal intensity
from its inception and is frequently
unremitting.
It may migrate along the path of the
dissection.
The pain of aortic dissection may mimic
that of myocardial ischemia.
Patients with type B dissections are more
likely to be seen with back pain ( 64%)
alone.
22. Syncope
Syncope is a well-recognized clinical
feature of dissection, occurring in up to
13% of cases.
Impairments of cerebral blood flow can
be due to
Acute hypovolemia, low cardiac output,
or dissection-involvement of the cerebral
vessels.
23. Syncope
Patients with a presenting syncope were
significantly more likely to die than were
those without syncope (34% vs. 23%),
likely because of
the frequent correlation with associated
cardiac tamponade, stroke,
decreased consciousness, and
spinal cord ischemia.
25. Neurologic symptoms
17% of patients were seen initially with neurologic
symptoms, 53% of which represented
ischemic stroke.
Neurologic complications may result from
hypotension, malperfusion, distal thromboembolism,
or nerve compression.
Acute paraplegia as a result of spinal cord
malperfusion has been described as a primary
manifestation in 1% to 3% of patients.
Up to 50% of neurologic symptoms may be
transient.
26. Cardiovascular manifestations
The heart is the most frequently involved end-organ
in acute proximal aortic dissections.
Acute aortic regurgitation
may be present in 41 % to 76% of patients with
proximal dissection and may be caused by widening
of the aortic annulus resulting in incomplete valve
closure or actual disruption of the aortic valve
leaflets from the dissection flap.
27. Clinical manifestations of dissection-
related aortic regurgitation span from
mere diastolic murmurs without clinical
significance to overt congestive heart
failure and cardiogenic shock.
28. Myocardial ischemia or infarction
May result from compromised coronary artery flow
by an expanding false lumen that compresses the
proximal coronary or by extension of the dissection
flap into the coronary artery ostium.
This occurs in 7% to 19% of patients with proximal
aortic dissections.
Clinically, these present as electrocardiographic
changes consistent with primary myocardial
ischemia and/or infarction.
29. Cardiac tamponade is diagnosed in 8% to
10% of patients seen with acute type A
dissections.
It is associated with a high mortality and
should prompt consideration for emergent
drainage and aortic repair.
Hypertension occurs in greater than 50% of
patients with dissection, more commonly with
distal disease.
Ongoing renal ischemia can produce severe
hypertension.
30. Hypotension/shock may present in up to 20% of
patients with dissection.
This may be a result of cardiac tamponade from aortic
rupture into the pericardium, dissection, or
compression of the coronary arteries, acute aortic
regurgitation, acute blood loss, true lumen
compression by distended false lumen, or an intra-
abdominal catastrophe.
Cardiogenic shock
In approximately 6% of cases.
This can be due to acute aortic
regurgitation or ongoing myocardial
ischemia.
31. Peripheral vascular complications
Can manifest as pulse and/or blood pressure
differentials or deficits and occur in
approximately one third to one half of patients
with proximal dissection.
Etiology is partial compression, obstruction,
thrombosis, or embolism of
the aortic branch vessels, resulting in
cerebral, renal, visceral, or limb ischemia.
Peripheral pulse deficits should alert the clinician to
possible ongoing renal or visceral ischemia unable to
be detected from physical examination or laboratory
values alone.
32. Pulmonary complications
May manifest as pleural effusions, which
occur most frequently on the left.
Causes include rupture of the dissection
into the pleural space or weeping of fluid
from the aorta as an inflammatory
response to the dissection.
33. Laboratory abnormalities
associated with aortic dissection
Laboratory data are usually unrevealing, but
anemia from blood loss into the false lumen
can occur.
A moderate leukocytosis (10,000-14,000
white cells per mL) is sometimes seen.
Lactic acid dehydrogenase and bilirubin
levels may be elevated because of hemolysis
within the false lumen.
34. Laboratory abnormalities
associated with aortic dissection
Disseminated intravascular coagulation has
been reported.
Currently, randomized controlled data do not
support the use of D-dimers or experimental
serum markers (plasma smooth muscle
myosin heavy chain protein, high-sensitivity
C-reactive protein).
35. Imaging modalities
used to diagnose aortic
dissection
On the basis of clinical risk factors and
conditions, presentation, and associated
examination findings, patients are
stratified into
Low- intermediate- or high-
risk categories.
36. Further work-up is dictated by this pretest
probability index.
Some patients with acute dissection initially
have no high-risk features, creating a
diagnostic dilemma.
According to most recent guidelines, if a
clear alternative diagnosis is not established
after the initial evaluation, then obtaining a
diagnostic aortic imaging study should be
considered.
37. Although lacking specificity, a chest
radiograph should be obtained as part
of the initial diagnostic evaluation.
A radiograph abnormality is seen in up
to 90% of patients with aortic
dissection; most frequent is widening
of the aorta and mediastinum.
38. Other findings may include a localized hump on
the aortic arch, displacement of calcification in
the aortic knob, and pleural effusions.
However, approximately 40% of radiographs in
acute dissection lack a widened mediastinum,
and as many as 16% are normal.
Thus a negative radiograph must not delay
definitive aortic imaging in patients deemed at
high risk for aortic dissection by initial
screening.
39. Computed tomography (CT) scanning,
magnetic resonance imaging (MRI), and
Transesophageal
echocardiography (TEE)
Are all highly accurate imaging modalities that
may be used to make the diagnosis; all can
provide acceptable diagnostic accuracy.
Transthoracic echocardiography has
limited diagnostic accuracy.
40. Aortography
Which was once the test of choice, is no
longer used routinely because it is invasive and
time-consuming and involves exposure to
intravenous contrast dye.
The most recent comparative study with
nonhelical CT, MRI, and TEE showed 100%
sensitivity for all modalities, with better
specificity of CT (100%) as compared with TEE
or MRI.
41. A recent metaanalysis found that all three
imaging techniques provided equally
reliable results.
Although each imaging modality offers
advantages and disadvantages, the
choice among CT, MRI, and TEE is
probably best based on which is most
readily available.
42. It should be noted, however, that the diagnosis
of acute aortic dissection can be difficult and
occasionally cannot be absolutely excluded by
a single imaging study.
If a high clinical suspicion exists despite initially
negative imaging, then consideration should be
given to a second imaging modality.
Regardless, prompt surgical consultation
should be initiated in any patient with a
suspected dissection.
45. Differentiate between the
management of Stanford type A
and type B dissections
An acute type A dissection is a surgical
emergency
However, medical management is critical to
halt the progression of the dissection while the
diagnostic work-up takes place and while
preparations are made to bring the patient to
the operating room for definitive treatment.
46. While the diagnosis work-up proceeds and a
cardiothoracic surgeon is consulted, the
patient's condition should be carefully
monitored and stabilized in an intensive care
unit.
Pain management and gradual down-titration of
blood pressure are critical to prevent extension
of the dissection.
47. Sufficient blood products and intravascular
access should be available in the event of
aortic rupture.
Patients with uncomplicated type B dissection
are preferably managed medically with p-
blockers and other antihypertensive agents.
Surgical intervention has no demonstrable
superiority except in cases of failed medical
management manifesting as malperfusion,
aortic expansion with potential for imminent
rupture, or intractable pain.
48. Ongoing advances with less
invasive interventions
(endovascular stent grafts and
endovascular fenestration
procedures) suggest an expanded
role for interventional management
in the treatment of acute type B
dissection, especially in experienced
centers.
49. The strategies for medical
management of dissection and
commonly used medications
The goals of medical therapy are to treat
pain, to aggressively control blood
pressure, and to determine need for
surgical or endovascular intervention.
50. Patients who are seen with hypotension
should receive the following:
Prompt but judicious volume resuscitation and
hemodynamic support with intravenous
vasopressors to maintain a goal mean
arterial pressure of 70 mm Hg .
Rapid search for underlying etiology
(tamponade, myocardial dysfunction, acute
hemorrhage)
Emergent surgical consultation for operative
management
51. In those who are seen initially with
hypertension, the blood pressure should
generally be lowered to a systolic of 100 to
120 mm Hg, to a mean of 60 to 65 mm Hg,
or to the lowest level that is compatible with
perfusion of the vital organs.
The aortic wall stress is affected by the
heart rate, blood pressure, and velocity of
ventricular contraction (dP/dt).
52. The ideal antihypertensive regimen must
decrease blood pressure
without increasing
cardiac output
through peripheral vasodilatation.
This is because an increased cardiac output
can increase flow rates producing higher
aortic wall stress and thus propagating the
dissection.
53. Intravenous p-blockers (commonly esmolol,
labetalol, propranolol, or metoprolol) are
considered the first-line medical stabilization
regimen because they affect all three parameters
without increases
in cardiac output and aortic wall stress.
In patients who are unable to tolerate B- blockade,
nondihydropyridine calcium channel antagonists
(verapamil, diltiazem) offer an acceptable
alternative.
54. Often, single-drug therapy alone is
inadequate to optimize blood pressure
management.
Adequate pain control is essential not only
for patient comfort but also to decrease
sympathetic mediated increases in heart rate
and blood pressure.
This may be accomplished with intravenous
opioid analgesics.
55. .
If p-blockade and adequate pain control
are ineffective to control blood pressure,
the addition of a rapidly acting, easily
titratable intravenous vasodilator, such
as
nitroprusside
should be considered.
56. Other agents, such as
Nicardipine, nitroglycerin, and
fenoldopam
are also acceptable.
Vasodilator therapy without prior p-blockade
may cause reflex tachycardia and increased
force of ventricular contraction leading to
greater wall stress and potentially causing
false lumen propagation; therefore adequate
p-blockade must be established first, before
the vasodilator is initiated.
57. The surgical approach for repair of Stanford
type A dissection.
The purpose of surgery is to resect the aortic
segment containing the proximal intimal tear, to
obliterate the false channel, and to restore aortic
continuity with a graft or by reapproximating the
transected ends of the aorta.
For patients with aortic insufficiency, it may be
possible to resuspend the aortic valve, but in
some cases replacement of the aortic valve is
necessary.
.
58. In some cases of proximal dissection,
reimplantation of the coronary arteries is
required.
If a DeBakey type II dissection is present,
the entire dissected aorta should be
replaced.
Surgery to repair an aortic dissection
generally requires cardiopulmonary bypass
and, often, deep hypothermic circulatory
arrest.
59. Recent alternatives to surgical repair of
aortic dissection
An endovascular technique of stent-grafting
and/or balloon fenestration may be used for
initial surgical treatment of some dissections.
Indications for open or endograft treatment are
based on the anatomic features of the lesion,
clinical presentation and course, patient
comorbidities, and anatomic constraints
related to endograft technology.
60. Dissections pose a complex situation because
the branches of the aorta may be perfused
from either the true or false lumen.
Often, both the true and false lumens are
patent and some of the visceral, renal, or lower
extremity vessels are fed by one channel and
the remainder by the other.
Consideration must be given to how blood flow
reaches vital organs before considering
treatment of a dissection with an endovascular
stent-graft.
61. For type B dissection, an increasing
number of reports show better results
with endovascular repair versus open
surgical repair.
The role of endovascular stent-graft
versus optimal medical therapy was
recently examined in the literature, but
no difference was noted in survival or
number of adverse events.
62. However, longer-term (5 year)
data are needed to fully assess
the potential impact of stent-
grafting for acute dissection,
including
Effects on survival, clinical
outcomes, and long-term
aortic remodeling.
63. The use of fenestrated endografts
A new era in the treatment of aortic
dissections.
Unsuitable anatomy is a significant barrier
to the use of endovascular stent-grafts for
most forms of aortic disease, where the
ostia of major vessels would otherwise be
partially or completed covered with the
deployment of a stent-graft.
.
64. The use of fenestrated endografts
Using preoperative
Three-dimensional CT aortic
reconstruction
customized stents can be constructed,
featuring holes (fenestrations) or side-
branches matched to patient-specific
anatomy to ensure perfusion to major
aortic branch vessels.
65. The use of fenestrated endografts
Current trials are underway in
Europe and the United States for
their use for
complex aneurysmal disease, and
expectations are high for similar
application to aortic dissection.
66. SAMIR EL ANSARY
ICU PROFESSOR
AIN SHAMS
CAIRO
elansarysamir@yahoo.com
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Global Critical Care
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