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Acute aortic dissection detected by contrast echocardiography
International Journal of Cardiology 136 (2009) e72 – e73 www.elsevier.com/locate/ijcard
Letter to the Editor
Acute aortic dissection detected by contrast echocardiography Nicolas Mansencal a,⁎, Guillaume Belliard b , Stephen Binsse c , Antoine Vieillard-Baron b , Olivier Dubourg a a
Department of Cardiology, Université de Versailles-Saint Quentin (UVSQ), University Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris (AP-HP), Boulogne, France b Intensive Care Unit, Université de Versailles-Saint Quentin (UVSQ), University Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris (AP-HP), Boulogne, France c Department of Radiology, Université de Versailles-Saint Quentin (UVSQ), University Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris (AP-HP), Boulogne, France Received 27 January 2008; accepted 3 May 2008 Available online 24 July 2008
Abstract We describe the case of a man with acute aortic dissection detected by contrast transthoracic echocardiography. Conventional echocardiography was not contributory. To our knowledge, this is the first report of the usefulness of contrast echocardiography in ascending aortic dissection at bedside. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Aortic dissection; Echocardiography; Contrast
An 85-year-old man with a history of arterial hypertension was admitted to the intensive care unit for acute chest pain. Physical examination at admission showed a respiratory rate of 27, pulse of 128, and blood pressure of 111/57 mm Hg. No pulse deficit was detected. D-dimers were increased [1]. The ECG on presentation demonstrated an ST depression in D1, aVL. Chest roentgenogram detected a widening of the aortic silhouette (Fig. 1A). Conventional transthoracic echocardiography was not contributory (Fig. 1B), whereas in suprasternal view, contrast echocardiography (Sonovue, Bracco Altana Inc., Milan, Italy) [2] allowed to distinguish an intimal flap and the true lumen from the false lumen in the ascending aorta
⁎ Corresponding author. AP-HP, Hôpital Universitaire Ambroise Paré, Service de Cardiologie et des Maladies Vasculaires, 9 avenue Charles de Gaulle, 92100 Boulogne, France. Tel.: +33 149095619; fax: +33 149095344. E-mail address: [email protected] (N. Mansencal). 0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.05.027
(Fig. 1C and Data Supplement Movie 1). The diagnosis of acute ascending aortic dissection (Stanford type A) was confirmed by CT-scan (Fig. 1D). The patient was treated with intensive antihypertensive drug therapy. At 6-month followup, the patient was still alive with antihypertensive drug therapy. Acute aortic dissection requires urgent therapeutic management. Surgery is the treatment of choice of Stanford type A dissection. In our case, the patient was very old, had comorbidities and we decided to only perform an intensive antihypertensive drug therapy [3]. Conventional transthoracic echocardiography is not effective for the diagnosis of aortic dissection in routine practice, whereas transesophageal echocardiography allows to accurately study the aortic arch, but is invasive particularly in elderly patients [4,5]. To our knowledge, this is the first report highlighting the usefulness of contrast agent for the detection of aortic dissection. Contrast transthoracic echocardiography could be of interest for the
N. Mansencal et al. / International Journal of Cardiology 136 (2009) e72–e73
e73
Fig. 1. Acute ascending aortic dissection. (A) Widening of the aortic silhouette detected by chest roentgenogram. In suprasternal view, (B) noncontributory conventional transthoracic echocardiography, but (C) contrast echocardiography allows to visualize the intimal flap (arrow) and to distinguish the true lumen (TL) from the false lumen (FL). (D) Intimal flap (arrow) visualized by CT-scan.
diagnosis of aortic dissection at bedside in intensive care unit, allowing to perform an immediate appropriate diagnosis. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ijcard.2008.05.027. References [1] Kiernan TJ. Aortic dissection and elevated D-dimers—an important clinical link. Int J Cardiol 2007;114:E77–8. [2] Mansencal N, Abi Nasr I, Pillière R, et al. Usefulness of contrast echocardiography for assessment of left ventricular thrombus following acute myocardial infarction. Am J Cardiol 2007;99:1667–70.
[3] Mehta R, O'Gara P, Bossone E, et al. Acute type A aortic dissection in the elderly: clinical characteristics, management, and outcomes in the current era. J Am Coll Cardiol 2002;40:685–92. [4] Nienaber CA, von Kodolitsch Y, Nicolas V, et al. The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N Engl J Med 1993;328:1–9. [5] Movsowitz HD, Levine RA, Hilgenberg AD, Isselbacher EM. Transesophageal echocardiographic description of the mechanisms of aortic regurgitation in acute type A aortic dissection: implications for aortic valve repair. J Am Coll Cardiol 2000;36:884–90.
Letter to the Editor
Acute aortic dissection detected by contrast echocardiography Nicolas Mansencal a,⁎, Guillaume Belliard b , Stephen Binsse c , Antoine Vieillard-Baron b , Olivier Dubourg a a
Department of Cardiology, Université de Versailles-Saint Quentin (UVSQ), University Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris (AP-HP), Boulogne, France b Intensive Care Unit, Université de Versailles-Saint Quentin (UVSQ), University Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris (AP-HP), Boulogne, France c Department of Radiology, Université de Versailles-Saint Quentin (UVSQ), University Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris (AP-HP), Boulogne, France Received 27 January 2008; accepted 3 May 2008 Available online 24 July 2008
Abstract We describe the case of a man with acute aortic dissection detected by contrast transthoracic echocardiography. Conventional echocardiography was not contributory. To our knowledge, this is the first report of the usefulness of contrast echocardiography in ascending aortic dissection at bedside. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Aortic dissection; Echocardiography; Contrast
An 85-year-old man with a history of arterial hypertension was admitted to the intensive care unit for acute chest pain. Physical examination at admission showed a respiratory rate of 27, pulse of 128, and blood pressure of 111/57 mm Hg. No pulse deficit was detected. D-dimers were increased [1]. The ECG on presentation demonstrated an ST depression in D1, aVL. Chest roentgenogram detected a widening of the aortic silhouette (Fig. 1A). Conventional transthoracic echocardiography was not contributory (Fig. 1B), whereas in suprasternal view, contrast echocardiography (Sonovue, Bracco Altana Inc., Milan, Italy) [2] allowed to distinguish an intimal flap and the true lumen from the false lumen in the ascending aorta
⁎ Corresponding author. AP-HP, Hôpital Universitaire Ambroise Paré, Service de Cardiologie et des Maladies Vasculaires, 9 avenue Charles de Gaulle, 92100 Boulogne, France. Tel.: +33 149095619; fax: +33 149095344. E-mail address: [email protected] (N. Mansencal). 0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.05.027
(Fig. 1C and Data Supplement Movie 1). The diagnosis of acute ascending aortic dissection (Stanford type A) was confirmed by CT-scan (Fig. 1D). The patient was treated with intensive antihypertensive drug therapy. At 6-month followup, the patient was still alive with antihypertensive drug therapy. Acute aortic dissection requires urgent therapeutic management. Surgery is the treatment of choice of Stanford type A dissection. In our case, the patient was very old, had comorbidities and we decided to only perform an intensive antihypertensive drug therapy [3]. Conventional transthoracic echocardiography is not effective for the diagnosis of aortic dissection in routine practice, whereas transesophageal echocardiography allows to accurately study the aortic arch, but is invasive particularly in elderly patients [4,5]. To our knowledge, this is the first report highlighting the usefulness of contrast agent for the detection of aortic dissection. Contrast transthoracic echocardiography could be of interest for the
N. Mansencal et al. / International Journal of Cardiology 136 (2009) e72–e73
e73
Fig. 1. Acute ascending aortic dissection. (A) Widening of the aortic silhouette detected by chest roentgenogram. In suprasternal view, (B) noncontributory conventional transthoracic echocardiography, but (C) contrast echocardiography allows to visualize the intimal flap (arrow) and to distinguish the true lumen (TL) from the false lumen (FL). (D) Intimal flap (arrow) visualized by CT-scan.
diagnosis of aortic dissection at bedside in intensive care unit, allowing to perform an immediate appropriate diagnosis. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ijcard.2008.05.027. References [1] Kiernan TJ. Aortic dissection and elevated D-dimers—an important clinical link. Int J Cardiol 2007;114:E77–8. [2] Mansencal N, Abi Nasr I, Pillière R, et al. Usefulness of contrast echocardiography for assessment of left ventricular thrombus following acute myocardial infarction. Am J Cardiol 2007;99:1667–70.
[3] Mehta R, O'Gara P, Bossone E, et al. Acute type A aortic dissection in the elderly: clinical characteristics, management, and outcomes in the current era. J Am Coll Cardiol 2002;40:685–92. [4] Nienaber CA, von Kodolitsch Y, Nicolas V, et al. The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N Engl J Med 1993;328:1–9. [5] Movsowitz HD, Levine RA, Hilgenberg AD, Isselbacher EM. Transesophageal echocardiographic description of the mechanisms of aortic regurgitation in acute type A aortic dissection: implications for aortic valve repair. J Am Coll Cardiol 2000;36:884–90.