Aortic Dissection Involving the Ostium of Left Main Coronary Artery

Abstract

Α 58-year-old hypertensive man was referred from another hospital with diagnosis of myocardial infraction. He presented with a two hour sudden onset of severe chest pain radiating to his interscapular region. Pain did not respond to IV administration of nitrates and morphine. His blood pressure was 110/70 mmHg and physical examination revealed no murmurs The ECG showed extensive ST-segment elevation in the anterior and lateral leads suggesting acute anterior myocardial infarction. A transthoracic echocardiogram (TTE) demonstrated a dilated ascending aorta with an intimal flap that extended from the aortic valve to the mid-ascending aorta, (Figure 1) consistent with a Stanford type A acute aortic dissection (AAD). A multiplane transoesophageal echocardiogram (TOE) was then performed showed AAD extending into the aortic arch, the take-off of the left subclavian artery (Figure 2) and the descending aorta (Figure 3). The intimal flap was thin, smooth showed a pulsatile mobility with systolic convexity towards the false lumen (Figure 4). Flow was present in the false lumen which was larger than the true lumen (Figure 5). The left coronary ostium seemed to be obstructed by prolapse of the intimal flap during diastole (Figure 6). The aortic valve was normal and mild aortic regurgitation was noted caused by the aortic dilatation. Regional and global left ventricular function was normal.There were no periaortic or pericardial fluids. The patient was transferred for emergency surgery and the ascending aorta was successfully replaced by a supracoronary interposition prosthetic graft.