Answer to the last #DiagnosticDilemma
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Perform transesophageal echocardiography
In the patient, results of non–ECG-gated computed tomography angiography were not conclusive for aortic pathology. The short-axis view of TTE at the aortic valve level revealed echogenic tissue in the aortic sinus, which was not considered an aortic valve leaflet given its malalignment with the commissure. This finding warranted further investigation and prompted us to perform transesophageal echocardiography, which confirmed the echogenic tissue as the intimal flap of a type A aortic dissection (TAAD), with limited extension beyond the aortic root.

Dyspnea and edema are common phenomena in late pregnancy; however, the sudden onset of chest pain with an associated heart murmur in the peripartum period should raise concerns for a cardiac event. Among the differential diagnoses, the index of suspicion for TAAD is high.

When the dissection is limited to a short segment of the aorta and creates subtle morphological changes, the selection of proper diagnostic modalities and adequate interpretation becomes critical to facilitate early diagnosis. Aortic dissection in women younger than 40 years is rare but more frequently seen in those who have bicuspid aortic valves, have connective tissue disorders, or are pregnant. Given the clinical presentation and TTE finding concerning for aortic dissection, this patient underwent transesophageal echocardiography and was diagnosed with TAAD. Surgical repair was performed promptly. The dissection was limited to the medial aspect of the sinotubular junction with extension into the aortic sinus. The coronary ostia were spared. The aortic root was repaired and the proximal ascending aorta was reconstructed with a short length of the polyester graft. The patient recovered well from the surgery. Pathological analysis showed granulation tissue of the adventitia consistent with subacute onset of aortic dissection. At the 6-month follow-up visit, TTE showed trace aortic regurgitation. Genetic testing did not reveal connective tissue disorders.


Dr. C●●●●●●●t K●●r
Dr. C●●●●●●●t K●●r Obstetrics and Gynaecology
Jun 5, 2020Like