The document presents three case studies of aortic dissection, highlighting the critical importance of early recognition, diagnosis, and management to improve survival rates. It discusses the various clinical presentations and complications associated with aortic dissection, as well as the diagnostic imaging options and surgical versus medical management approaches. It emphasizes that a high clinical suspicion is essential due to the high mortality rates associated with untreated cases and underscores the need for immediate action in cases of suspected aortic dissection.

1. AORTIC DISSECTION SYED RAZA

2. 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 .

3. Case 1 contd: ECG- Ischemic changes Inferior leads. CXR – Normal Troponin – Negative Routine blood tests - normal

4. 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

5. 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

6. 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

7. 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.

8. 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

9. ECG-non specific T wave changes. Trop I – normal Hb 10.1 Discharged as Musculo skeletal chest pain. Anaemia for Inv.

10. 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

11. 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

12. 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

13. OBJECTIVES 1.Recognition of Aortic Dissection 2.Prevalance 3.Clinical features 4.Investigation and Management

14. 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

15. Most important factor leading to a correct diagnosis is a high clinical suspicion!

16. 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)

17. 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

22. CLINICAL FEATURES Sudden Onset Severe Pain (90%) More severe at onset Never experienced before Restless Anterior Pain: Proximal Dissection Posterior Pain: Distal Dissection

23. 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)

29. 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

30. 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

31. 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.

34. 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

36. TRANSTHORACIC ECHO

37. 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

40. 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

42. 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

44. 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

46. TREATMENT

47. Surgical Management – Stanford Type A Medical Management – Stanford Type B

48. 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)

49. SURGERY

50. 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

51. 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.

52. 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

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