Emergency Ultrasound Diagnosis of Type A Aortic Dissection and Apical Pleural Cap
Article first published online: 24 MAR 2010
© 2010 by the Society for Academic Emergency Medicine
Academic Emergency Medicine
Volume 17, Issue 4, pages e23–e24, April 2010
How to Cite
Barrett, C. and Stone, M. B. (2010), Emergency Ultrasound Diagnosis of Type A Aortic Dissection and Apical Pleural Cap. Academic Emergency Medicine, 17: e23–e24. doi: 10.1111/j.1553-2712.2010.00709.x
- Issue published online: 2 APR 2010
- Article first published online: 24 MAR 2010
A 70-year-old man with a medical history significant for hypertension, permanent pacemaker placement, and a remote repair of a type A aortic dissection presented to the emergency department with sudden onset of sharp anterior chest pain and hemoptysis. He was in no respiratory distress, but appeared markedly uncomfortable and had a cough productive of small quantities of bright red blood. His initial heart rate was 85 beats/min, his respiratory rate was 24 breaths/min, his oxygen saturation was 97% while breathing room air, and his blood pressure was 113/76 mm Hg.
After initial stabilization, a bedside cardiac ultrasound was performed by the emergency physician using a 5–1 MHz phased array transducer (Philips HD11XE, Andover, MA), which demonstrated a large aneurysm of his descending thoracic aorta, with a visible intimal flap (Figure 1 and Video Clip S1). Given the patient’s hemoptysis, a focused lung examination was then performed using a 5–2 MHz curvilinear array transducer (Philips, Andover, MA). This demonstrated a left anteroapical pleural fluid collection with internal echoes, consistent with hemorrhagic fluid (Video Clip S2). Chest radiography confirmed a widened mediastinum with a left-sided apical cap (Figure 2). The cardiothoracic surgery service was called to evaluate the patient, and computed tomography angiography of his thoracic aorta confirmed a large thoracic aortic aneurysm with a type A aortic dissection and an associated left-sided apical hemothorax (Figure 3). The patient was taken emergently to the operating room where these findings were confirmed. Although the aortic arch was successfully repaired, continued bleeding and extension of the dissection throughout the distal aorta led to intraoperative hemodynamic collapse, and the patient expired.
Recurrence of type A aortic dissection occurs in up to 35% of patients with Marfan’s syndrome who undergo repair of the ascending aorta and/or aortic arch. In patients without Marfan’s syndrome, recurrence of type A aortic dissection has been reported in up to 12.5% of cases.1
Video Clip S1. Large aneurysm of his descending thoracic aorta, with a visible intimal flap.
Video Clip S2. Left anteroapical pleural fluid collection with internal echoes, consistent with hemorrhagic fluid.
The video clips are in QuickTime.
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