Aortography in Acute Aortic Dissection: An Undervalued Gold Standard
A 65-year-old male with no significant medical history complained of acute onset chest pain, right eye vision loss and lightheadedness. Shortly after, he collapsed and bystanders initiated cardiopulmonary resuscitation. Upon arrival, Emergency Medical Services (EMS) found the patient unresponsive with a systolic blood pressure in the 60's. He had palpable pulses, was in a normal sinus rhythm and EMS placed an emergent central venous line and intravenous saline was initiated in the field.
Upon arrival to the emergency department (ED), the patient was in respiratory distress, was intubated and placed on mechanical ventilation. Examination was notable for anisocoria with a dilated right pupil. Patient had a regular rate and rhythm with equal pulses and blood pressure readings bilaterally. Scattered crackles were noted on auscultation of the lungs bilaterally with no murmurs, extra heart sounds, jugular venous distention, or edema. Portable chest x-ray was without of evidence of mediastinal widening. Electrocardiogram demonstrated ST segment elevations anteriorly and in aVR with reciprocal depressions inferolaterally (Figure 1).
An ED bedside echocardiogram demonstrated a dilated aortic root with moderate aortic regurgitation without aortic intimal flap or regional wall motion abnormalities which were suggestive of acute aortic dissection (AAD). The patient was not hemodynamically stable enough to perform a computerized tomography scan (CT), so the decision was made to proceed directly with emergent aortography and potential angiography. An aortogram revealed a prolapsing proximal aortic dissection flap with aortic root dilatation and severe aortic regurgitation (Figure 2).
The patient was taken directly to the operating room, and underwent a successful type A aortic dissection repair with replacement of the ascending aorta and hemi-arch and re-suspension of the aortic valve. He was discharged to cardiac rehabilitation and had an uneventful post-operative course.
What percentage of patients with Type A acute aortic dissection present with ST segment elevation on their electrocardiogram (ECG)?