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Acute Aortic Dissection With ST Segment Myocardial Infarction Following Masturbation
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–4, 2020 Ó 2020 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter
https://doi.org/10.1016/j.jemermed.2020.01.007
Clinical Communications: Adult ACUTE AORTIC DISSECTION WITH ST SEGMENT MYOCARDIAL INFARCTION FOLLOWING MASTURBATION Brian D. McBeth, MD, CPE* and Daniel I. Rosenstein, MD† *Department of Emergency Medicine, O’Connor Hospital, San Jose, California and †Department of Urology, Kaiser Permanente Medical Group, San Jose, California Reprint Address: Brian D. McBeth, MD, CPE, Department of Emergency Medicine, O’Connor Hospital, 2105 Forest Avenue, San Jose, CA 95128
, Abstract—Background: Acute aortic dissection is the most common life-threatening disorder affecting the aorta, and can mimic other disease processes. We describe an unusual presentation of a critically ill patient with initial hematospermia diagnosed with a type A acute aortic dissection. Case Report: A 68 year old man presented to a community ED after masturbation and report of blood in his ejaculate, followed by rapid development of severe low back, chest and hip pain with shock. ECG showed evidence of ST segment elevation, but suspicion remained high for thoracic or abdominal aortic catastrophe. Bedside ultrasound demonstrated no pericardial effusion, a severely hypokinetic myocardium and a question of fluid in the left perinephric space. Attempts were made to resuscitate the patient, and an ED chest/abdomen/pelvis CT showed a type A acute thoracic aortic dissection. Unfortunately, the patient remained profoundly unstable, with multiple arrests. He was transferred to a tertiary care facility, but expired shortly after arrival. Why Should an Emergency Physician Be Aware of This?: An emergency physician needs to be aware of the myriad of presentations of acute aortic dissection. Although hematospermia was felt ultimately to be an incidental symptom, sexual activity may bring about a significant transient increase in blood pressure, which could contribute to sheer force causing aortic injury. Awareness of this trigger and a careful sensitive history may aid the clinician in early diagnosis. Ó 2020 Elsevier Inc. All rights reserved.
INTRODUCTION Acute aortic dissection is the most common lifethreatening disorder affecting the aorta, and can mimic other disease processes—most notably myocardial ischemia or infarct. Symptoms at presentation can vary significantly, depending on location of the dissection and resulting complications. We describe an unusual presentation of a critically ill patient with a type A acute aortic dissection (AAD) following masturbation. CASE REPORT A 68-year-old man with history of hypertension and coronary artery disease with prior coronary stenting, presented to a community emergency department with severe low back pain and chest pain, starting 30 min prior to arrival. He reported that he had been masturbating just prior to the onset of his symptoms, and noticed blood in the ejaculate, and then began having the pain. Pain was sharp and severe in the left chest and diffusely in the abdomen, although worst in the left lower back and left hip. Brought in by ambulance, his initial vital signs showed a blood pressure of 88/68 mm Hg, heart rate 69 beats/min, respiratory rate 15 breaths/min, temperature 98.8 F and 100% oxygen saturation on 4 L nasal cannula. Electrocardiogram (ECG) was rapidly obtained, which showed ST segment elevation in the lateral and
, Keywords—acute aortic dissection; hematospermia
RECEIVED: 18 October 2019; FINAL SUBMISSION RECEIVED: 4 December 2019; ACCEPTED: 12 January 2020 1
2
B. D. McBeth and D. I. Rosenstein
Figure 1. Electrocardiogram demonstrating ST elevation in anterior and lateral leads with reciprocal depression.
anterior leads, with reciprocal depression (Figure 1). Interventional cardiology was consulted to assist in evaluation, as resuscitation was initiated with laboratory tests sent, type and cross-ordered, and large-bore i.v. Bedside
ultrasound was performed, which demonstrated what appeared to be free fluid in the abdomen, small-to-moderate quantity in the left spleno-renal gutter. Bedside cardiac ultrasound was also performed, which demonstrated no
Figure 2. Type A acute aortic dissection demonstrating (A) central true lumen and (B) peripheral false lumen.
Acute Aortic Dissection After Masturbation
pericardial effusion, but a severely hypokinetic myocardium. No abdominal aneurysm was seen, although images were obscured by bowel gas. The patient was resuscitated with unmatched blood (a total of 4 units), fresh-frozen plasma, and platelets, but remained hypotensive. During resuscitation, his left lower extremity became noticeably pale and cool with nonpalpable distal pulses. The patient received multiple doses of i.v. fentanyl, but continued to have severe pain, and was intubated to facilitate resuscitation and diagnosis. Computed tomography (CT) of the chest/abdomen/pelvis was obtained, which showed a type A acute thoracic aortic dissection beginning at the level of the aortic valve leaflets. There was aneurysmal dilatation of the thoracic aorta, measuring up to 5.2 cm and dissection into the coronary arteries, and extension distally into the abdominal aorta, likely also involving the superior mesenteric artery (Figure 2). There was no evidence of abdominal free fluid, but there was an incidental large left-sided inferior renal cystic mass. The patient remained hypotensive despite blood products, and a norepinephrine drip was initiated, as efforts were made to locate specialists and a tertiary care facility to accept this patient. After the accepting facility and specialist were confirmed, the patient had a pulseless electrical activity arrest (PEA), was resuscitated with cardiopulmonary resuscitation and multiple doses of epinephrine with return of circulation. Transfer was made with 15-min ambulance time, but the patient expired shortly after arrival at the receiving facility after a repeat PEA arrest. DISCUSSION AAD is a relatively uncommon condition, but one that continues to be a challenge to diagnose and treat, with a variable but high mortality (26–58%), depending on location of the lesion, complications, treatment strategy, and patient-specific factors (1). Well-established risk factors include hypertension, known atherosclerosis, known aortic aneurysm, previous cardiac surgery, Marfan syndrome, and cocaine use (2). Diagnosis can be a challenge, in part due to patient instability and need for resuscitation precluding immediate CT evaluation, but also complications of the dissection can lead clinicians down alternative diagnostic and treatment pathways, such as a myocardial infarction (catheterization laboratory activation), acute stroke (thrombolytics), and acute limb ischemia, as well as consideration of alternative aortic pathology, such as an abdominal aortic aneurysm (AAA) rupture. Hypotension and shock, limb ischemia, tamponade, and history of aortic valve replacement are all independent risk factors for mortality in patients presenting with type A AAD (2).
3
We presented a case of a relatively healthy patient with acute onset of symptoms and notable hematospermia following sexual activity with precipitous decompensation and hemodynamic collapse. Sexual activity as a cause of AAD has been reported previously, with the hypothesis that acute surges in blood pressure and stress could cause increased sheer force leading to aortic injury (3). Retrospective review of AAD patients suggested that a subset of male patients (12.9%) with AAD mention sexual activity as a trigger prior to onset of their symptoms, although this is a single paper and, given the sensitive nature of the history, this could be significantly underreported (3). One source mentions that sexual activity at orgasm can result in an increase of systolic blood pressure of 40 mm Hg, although this normalizes within 2 min (4). Other rare acute vascular dissection syndromes following sexual activity include coronary, carotid, and vertebral arteries (5–7). There is a single case report of AAD following masturbation in the literature (8). This patient had a prominent presenting complaint of hematospermia along with his pain. Hematospermia has never been reported as a symptom of AAD, nor has dissection of the testicular artery. Anatomically, the testicular arteries originate directly off the abdominal aorta, typically anteriorly and just distally to the origins of the renal arteries. On later review, we had considered a hypothesis that the aortic dissection flap could have extended beyond the renal arteries to involve one or both of the testicular arteries, with resulting testicular ischemia. Radiographically, we were not able to distinguish the extent of the distal extension of this patient’s dissection, largely due to his profound ongoing compromise of cardiac function at the time of imaging. Contrast enhancement was not ideal, and the patient was not stable for additional delayed imaging, nor was this a priority in his ongoing resuscitation and management. However, the timing was also inconsistent with this explanation, as the patient reported the hematospermia immediately before the onset of his pain. Even hypothesizing complete ischemia to the bilateral testes, this would not be an explanation for hematospermia. Hematospermia typically arises from prostate inflammation, urethritis, or inflammatory change to the other ejaculatory accessory structures (eg, seminal vesicles and ejaculatory ducts), and not from the testes themselves (9). Hematospermia is also unlikely to be caused by direct trauma during sexual activity; first, there was no overt evidence of this on genitourinary examination, such as ecchymosis or abrasion. But even if there had been local trauma to the testes during sexual activity, this would not cause hematospermia without significant injury to the prostate or ejaculatory ducts, which is inconsistent with his presentation.
4
Management of this case was also complicated by evidence of ST segment elevation on anterior and lateral leads of initial ECG. Type A AAD involvement of the coronaries is well reported and, given this patient’s severe ongoing back pain, there was strong consideration from his initial presentation of AAD as well as a ruptured AAA. Interventional cardiology assisted in evaluation and management at the bedside, with interpretation of bedside echocardiogram, and agreement that activation of the cardiac catheterization laboratory was not immediately indicated until aortic pathology could be evaluated and excluded. Echocardiogram showed no suggestion of cardiac tamponade or effusion, but a profoundly hypokinetic myocardium was evident, consistent with cardiogenic shock. Appearance of hypoechoic fluid in the left perinephric space also complicated diagnosis, with concern for hemoperitoneum from AAA rupture. CT was able to clarify this lucency as an incidental cyst and establish the correct diagnosis, although ultimately the patient could not be saved. Open surgical management of type A AAD is the recommended therapy when a patient is deemed survivable, including excision of the intimal tear, obliteration of the entry into the false lumen, reconstitution of the aorta with synthetic graft, and repair/replacement of the aortic valve, if needed (10). Endovascular stent grafting, more commonly used in type B AAD, and hybrid procedures combining endovascular and open repair, have been explored but experience is limited, and discussion is beyond the scope of this report (11). Unfortunately for our patient, although we attempted to involve cardiac surgery and interventional radiology, intractable cardiogenic shock—related to his myocardial infarction secondary to dissection extension into his coronary arteries—did not allow him to undergo surgical repair. In the final analysis, it was felt that the reported hematospermia was likely an incidental symptom, unrelated to this patient’s AAD and rapid decompensation and cardiovascular collapse. However, it is possible that sexual activity in his case may have caused an increase in systolic blood pressure and sheer forces that contributed to an AAD. Although not exactly an analogous clinical context, consensus recommendations from cardiac surgeons after surgical repair of AAD suggest that patients do not need to abstain from sexual intercourse, and a ‘‘common sense approach to sexual activity, avoiding straining or maximal exertion, may be safe.’’ (4). The Thoracic Aortic Disease Coalition suggests that sexual activity that ‘‘avoids straining, maximum exertion or
B. D. McBeth and D. I. Rosenstein
shortness of breath may be permitted’’ (12). These guidelines seem intentionally equivocal, and emergency physicians should be aware of reported sexual activity, including masturbation, as a potential trigger for AAD among patients with risk factors for this disease. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? An emergency physician needs to be aware of the myriad of presentations of AAD. Although less common than myocardial ischemia, it can mimic this and other acute chest pathology, and distract a clinician if one anchors early in the diagnostic process—potentially misdirecting to treatment with thrombolytics or cardiac catheterization. An emergency physician should keep in mind that blood pressure fluctuations, such as seen with masturbation and other sexual activity, may be a risk factor that should increase suspicion for AAD, and patients might not volunteer this sensitive historical information. REFERENCES 1. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897. 2. Evangelista A, Isselbacher EM, Bossone E, et al. Insights from the Internal Registry of Acute Aortic Dissection: a 20-year experience of collaborative clinical research. Circulation 2018;137:1846–60. 3. Ganser L, Deutsch O, Szameitat L, et al. Aortic dissections type A during sexual intercourse in male patients: accident or systematic coincidence? Examination of 365 patients with acute aortic dissection within 20 years. Thorac Cardiovasc Surg 2016;64:133–6. 4. Chaddha A, Klin-Rogers E, Woznicki EM. Activity recommendations for postaortic dissection patients. Circulation 2014;13(16): e140–2. 5. Schifferdecker B, Pacifico L, Ramsaran EK, et al. Spontaneous coronary artery dissection associated with sexual intercourse. Am J Cardiol 2004;93:1323–4. 6. Li AH, Chan L, Jao T, et al. Postcoital carotid artery dissection associated with acute cerebral infarction: a case report. Acta Neurol Taiwan 2009;18:267–71. 7. Chank GY, Ahn PC. Postcoital vertebral artery dissection. Am Fam Physician 1996;54:2195–6. 8. Ridha A, Safiullah S, Al-Abayechi S. A rare presentation of a lifethreatening condition secondary to masturbatory activity: a case report. J Cardiovasc Disord 2015;2:1012. 9. Ahmad I, Krishna NS. Hemospermia. J Urol 2007;177:1613. 10. Moon MR. Approach to the treatment of aortic dissection. Surg Clin North Am 2009;89:869–93. 11. Murzi M, Tiwari KK, Farneti PA, et al. Might type A acute dissection repair with the addition of a frozen elephant trunk improve long-term survival compared to standard repair? Interact Cardiovasc Thorac Surg 2010;11:98. 12. The Thoracic Aortic Dissection Coalition. After dissection: postop care. http://www.tadcoalition.org/patients-and-caregivers/afterdissection-post-op-care. Accessed June 26, 2019.
https://doi.org/10.1016/j.jemermed.2020.01.007
Clinical Communications: Adult ACUTE AORTIC DISSECTION WITH ST SEGMENT MYOCARDIAL INFARCTION FOLLOWING MASTURBATION Brian D. McBeth, MD, CPE* and Daniel I. Rosenstein, MD† *Department of Emergency Medicine, O’Connor Hospital, San Jose, California and †Department of Urology, Kaiser Permanente Medical Group, San Jose, California Reprint Address: Brian D. McBeth, MD, CPE, Department of Emergency Medicine, O’Connor Hospital, 2105 Forest Avenue, San Jose, CA 95128
, Abstract—Background: Acute aortic dissection is the most common life-threatening disorder affecting the aorta, and can mimic other disease processes. We describe an unusual presentation of a critically ill patient with initial hematospermia diagnosed with a type A acute aortic dissection. Case Report: A 68 year old man presented to a community ED after masturbation and report of blood in his ejaculate, followed by rapid development of severe low back, chest and hip pain with shock. ECG showed evidence of ST segment elevation, but suspicion remained high for thoracic or abdominal aortic catastrophe. Bedside ultrasound demonstrated no pericardial effusion, a severely hypokinetic myocardium and a question of fluid in the left perinephric space. Attempts were made to resuscitate the patient, and an ED chest/abdomen/pelvis CT showed a type A acute thoracic aortic dissection. Unfortunately, the patient remained profoundly unstable, with multiple arrests. He was transferred to a tertiary care facility, but expired shortly after arrival. Why Should an Emergency Physician Be Aware of This?: An emergency physician needs to be aware of the myriad of presentations of acute aortic dissection. Although hematospermia was felt ultimately to be an incidental symptom, sexual activity may bring about a significant transient increase in blood pressure, which could contribute to sheer force causing aortic injury. Awareness of this trigger and a careful sensitive history may aid the clinician in early diagnosis. Ó 2020 Elsevier Inc. All rights reserved.
INTRODUCTION Acute aortic dissection is the most common lifethreatening disorder affecting the aorta, and can mimic other disease processes—most notably myocardial ischemia or infarct. Symptoms at presentation can vary significantly, depending on location of the dissection and resulting complications. We describe an unusual presentation of a critically ill patient with a type A acute aortic dissection (AAD) following masturbation. CASE REPORT A 68-year-old man with history of hypertension and coronary artery disease with prior coronary stenting, presented to a community emergency department with severe low back pain and chest pain, starting 30 min prior to arrival. He reported that he had been masturbating just prior to the onset of his symptoms, and noticed blood in the ejaculate, and then began having the pain. Pain was sharp and severe in the left chest and diffusely in the abdomen, although worst in the left lower back and left hip. Brought in by ambulance, his initial vital signs showed a blood pressure of 88/68 mm Hg, heart rate 69 beats/min, respiratory rate 15 breaths/min, temperature 98.8 F and 100% oxygen saturation on 4 L nasal cannula. Electrocardiogram (ECG) was rapidly obtained, which showed ST segment elevation in the lateral and
, Keywords—acute aortic dissection; hematospermia
RECEIVED: 18 October 2019; FINAL SUBMISSION RECEIVED: 4 December 2019; ACCEPTED: 12 January 2020 1
2
B. D. McBeth and D. I. Rosenstein
Figure 1. Electrocardiogram demonstrating ST elevation in anterior and lateral leads with reciprocal depression.
anterior leads, with reciprocal depression (Figure 1). Interventional cardiology was consulted to assist in evaluation, as resuscitation was initiated with laboratory tests sent, type and cross-ordered, and large-bore i.v. Bedside
ultrasound was performed, which demonstrated what appeared to be free fluid in the abdomen, small-to-moderate quantity in the left spleno-renal gutter. Bedside cardiac ultrasound was also performed, which demonstrated no
Figure 2. Type A acute aortic dissection demonstrating (A) central true lumen and (B) peripheral false lumen.
Acute Aortic Dissection After Masturbation
pericardial effusion, but a severely hypokinetic myocardium. No abdominal aneurysm was seen, although images were obscured by bowel gas. The patient was resuscitated with unmatched blood (a total of 4 units), fresh-frozen plasma, and platelets, but remained hypotensive. During resuscitation, his left lower extremity became noticeably pale and cool with nonpalpable distal pulses. The patient received multiple doses of i.v. fentanyl, but continued to have severe pain, and was intubated to facilitate resuscitation and diagnosis. Computed tomography (CT) of the chest/abdomen/pelvis was obtained, which showed a type A acute thoracic aortic dissection beginning at the level of the aortic valve leaflets. There was aneurysmal dilatation of the thoracic aorta, measuring up to 5.2 cm and dissection into the coronary arteries, and extension distally into the abdominal aorta, likely also involving the superior mesenteric artery (Figure 2). There was no evidence of abdominal free fluid, but there was an incidental large left-sided inferior renal cystic mass. The patient remained hypotensive despite blood products, and a norepinephrine drip was initiated, as efforts were made to locate specialists and a tertiary care facility to accept this patient. After the accepting facility and specialist were confirmed, the patient had a pulseless electrical activity arrest (PEA), was resuscitated with cardiopulmonary resuscitation and multiple doses of epinephrine with return of circulation. Transfer was made with 15-min ambulance time, but the patient expired shortly after arrival at the receiving facility after a repeat PEA arrest. DISCUSSION AAD is a relatively uncommon condition, but one that continues to be a challenge to diagnose and treat, with a variable but high mortality (26–58%), depending on location of the lesion, complications, treatment strategy, and patient-specific factors (1). Well-established risk factors include hypertension, known atherosclerosis, known aortic aneurysm, previous cardiac surgery, Marfan syndrome, and cocaine use (2). Diagnosis can be a challenge, in part due to patient instability and need for resuscitation precluding immediate CT evaluation, but also complications of the dissection can lead clinicians down alternative diagnostic and treatment pathways, such as a myocardial infarction (catheterization laboratory activation), acute stroke (thrombolytics), and acute limb ischemia, as well as consideration of alternative aortic pathology, such as an abdominal aortic aneurysm (AAA) rupture. Hypotension and shock, limb ischemia, tamponade, and history of aortic valve replacement are all independent risk factors for mortality in patients presenting with type A AAD (2).
3
We presented a case of a relatively healthy patient with acute onset of symptoms and notable hematospermia following sexual activity with precipitous decompensation and hemodynamic collapse. Sexual activity as a cause of AAD has been reported previously, with the hypothesis that acute surges in blood pressure and stress could cause increased sheer force leading to aortic injury (3). Retrospective review of AAD patients suggested that a subset of male patients (12.9%) with AAD mention sexual activity as a trigger prior to onset of their symptoms, although this is a single paper and, given the sensitive nature of the history, this could be significantly underreported (3). One source mentions that sexual activity at orgasm can result in an increase of systolic blood pressure of 40 mm Hg, although this normalizes within 2 min (4). Other rare acute vascular dissection syndromes following sexual activity include coronary, carotid, and vertebral arteries (5–7). There is a single case report of AAD following masturbation in the literature (8). This patient had a prominent presenting complaint of hematospermia along with his pain. Hematospermia has never been reported as a symptom of AAD, nor has dissection of the testicular artery. Anatomically, the testicular arteries originate directly off the abdominal aorta, typically anteriorly and just distally to the origins of the renal arteries. On later review, we had considered a hypothesis that the aortic dissection flap could have extended beyond the renal arteries to involve one or both of the testicular arteries, with resulting testicular ischemia. Radiographically, we were not able to distinguish the extent of the distal extension of this patient’s dissection, largely due to his profound ongoing compromise of cardiac function at the time of imaging. Contrast enhancement was not ideal, and the patient was not stable for additional delayed imaging, nor was this a priority in his ongoing resuscitation and management. However, the timing was also inconsistent with this explanation, as the patient reported the hematospermia immediately before the onset of his pain. Even hypothesizing complete ischemia to the bilateral testes, this would not be an explanation for hematospermia. Hematospermia typically arises from prostate inflammation, urethritis, or inflammatory change to the other ejaculatory accessory structures (eg, seminal vesicles and ejaculatory ducts), and not from the testes themselves (9). Hematospermia is also unlikely to be caused by direct trauma during sexual activity; first, there was no overt evidence of this on genitourinary examination, such as ecchymosis or abrasion. But even if there had been local trauma to the testes during sexual activity, this would not cause hematospermia without significant injury to the prostate or ejaculatory ducts, which is inconsistent with his presentation.
4
Management of this case was also complicated by evidence of ST segment elevation on anterior and lateral leads of initial ECG. Type A AAD involvement of the coronaries is well reported and, given this patient’s severe ongoing back pain, there was strong consideration from his initial presentation of AAD as well as a ruptured AAA. Interventional cardiology assisted in evaluation and management at the bedside, with interpretation of bedside echocardiogram, and agreement that activation of the cardiac catheterization laboratory was not immediately indicated until aortic pathology could be evaluated and excluded. Echocardiogram showed no suggestion of cardiac tamponade or effusion, but a profoundly hypokinetic myocardium was evident, consistent with cardiogenic shock. Appearance of hypoechoic fluid in the left perinephric space also complicated diagnosis, with concern for hemoperitoneum from AAA rupture. CT was able to clarify this lucency as an incidental cyst and establish the correct diagnosis, although ultimately the patient could not be saved. Open surgical management of type A AAD is the recommended therapy when a patient is deemed survivable, including excision of the intimal tear, obliteration of the entry into the false lumen, reconstitution of the aorta with synthetic graft, and repair/replacement of the aortic valve, if needed (10). Endovascular stent grafting, more commonly used in type B AAD, and hybrid procedures combining endovascular and open repair, have been explored but experience is limited, and discussion is beyond the scope of this report (11). Unfortunately for our patient, although we attempted to involve cardiac surgery and interventional radiology, intractable cardiogenic shock—related to his myocardial infarction secondary to dissection extension into his coronary arteries—did not allow him to undergo surgical repair. In the final analysis, it was felt that the reported hematospermia was likely an incidental symptom, unrelated to this patient’s AAD and rapid decompensation and cardiovascular collapse. However, it is possible that sexual activity in his case may have caused an increase in systolic blood pressure and sheer forces that contributed to an AAD. Although not exactly an analogous clinical context, consensus recommendations from cardiac surgeons after surgical repair of AAD suggest that patients do not need to abstain from sexual intercourse, and a ‘‘common sense approach to sexual activity, avoiding straining or maximal exertion, may be safe.’’ (4). The Thoracic Aortic Disease Coalition suggests that sexual activity that ‘‘avoids straining, maximum exertion or
B. D. McBeth and D. I. Rosenstein
shortness of breath may be permitted’’ (12). These guidelines seem intentionally equivocal, and emergency physicians should be aware of reported sexual activity, including masturbation, as a potential trigger for AAD among patients with risk factors for this disease. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? An emergency physician needs to be aware of the myriad of presentations of AAD. Although less common than myocardial ischemia, it can mimic this and other acute chest pathology, and distract a clinician if one anchors early in the diagnostic process—potentially misdirecting to treatment with thrombolytics or cardiac catheterization. An emergency physician should keep in mind that blood pressure fluctuations, such as seen with masturbation and other sexual activity, may be a risk factor that should increase suspicion for AAD, and patients might not volunteer this sensitive historical information. REFERENCES 1. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897. 2. Evangelista A, Isselbacher EM, Bossone E, et al. Insights from the Internal Registry of Acute Aortic Dissection: a 20-year experience of collaborative clinical research. Circulation 2018;137:1846–60. 3. Ganser L, Deutsch O, Szameitat L, et al. Aortic dissections type A during sexual intercourse in male patients: accident or systematic coincidence? Examination of 365 patients with acute aortic dissection within 20 years. Thorac Cardiovasc Surg 2016;64:133–6. 4. Chaddha A, Klin-Rogers E, Woznicki EM. Activity recommendations for postaortic dissection patients. Circulation 2014;13(16): e140–2. 5. Schifferdecker B, Pacifico L, Ramsaran EK, et al. Spontaneous coronary artery dissection associated with sexual intercourse. Am J Cardiol 2004;93:1323–4. 6. Li AH, Chan L, Jao T, et al. Postcoital carotid artery dissection associated with acute cerebral infarction: a case report. Acta Neurol Taiwan 2009;18:267–71. 7. Chank GY, Ahn PC. Postcoital vertebral artery dissection. Am Fam Physician 1996;54:2195–6. 8. Ridha A, Safiullah S, Al-Abayechi S. A rare presentation of a lifethreatening condition secondary to masturbatory activity: a case report. J Cardiovasc Disord 2015;2:1012. 9. Ahmad I, Krishna NS. Hemospermia. J Urol 2007;177:1613. 10. Moon MR. Approach to the treatment of aortic dissection. Surg Clin North Am 2009;89:869–93. 11. Murzi M, Tiwari KK, Farneti PA, et al. Might type A acute dissection repair with the addition of a frozen elephant trunk improve long-term survival compared to standard repair? Interact Cardiovasc Thorac Surg 2010;11:98. 12. The Thoracic Aortic Dissection Coalition. After dissection: postop care. http://www.tadcoalition.org/patients-and-caregivers/afterdissection-post-op-care. Accessed June 26, 2019.