- Email: [email protected]
Aortic dissection in women <40 years of age and the unimportance of pregnancy
4. Thomas JD, Weyman AE. Doppler mitral pressure half-time: a clinical tool in search of theoretical justification. J Am Co/l Cardiol 1987;10:923-929. 5. Hatle L, Angelsen BA, Techn DR. Tramsdal A. Noninvasive assessment of at+ oventricular pressure half-time by Doppler ultrasound. Circulation 1979;60: 1096-I 104. 6. Hatle L. Doppler echocardiographic evaluation of mitral stenosis. Cardiol Clin 1990;8:233-247. 7. Sagar KB, Wann S, Paulson WJH, Lewis S. Role of exercise Doppler echocardiography in isolated mitral stenosis. Chest 1987;92:27-30. 8. Voelker W, Regele B, Dittmann H, Mauser M. lckrath 0, Schmid KM, Karsch KR. Effect of heart rate on transmitral flow velocity profile and Doppler measurements of mitral valve area in patients with mitral stenosis. Eur Hem-r J l992;13: 152-159.
9. Gonzalez MA, Child JS, Krivokapich I. Comparison of two-dimensional and Doppler echocardiography and intracardiac hemodynamics for quantification of mitral stenosis. Am J Cardiol 1987;60:327-332. 10. Braverman AC, Thomas JD, Lee RT. Doppler echocardiographic estimation of mitral valve area during changing hemodynamic conditions. Am J Cardiol 1991;68: I4855 1490. 11. Smith MD, Handshoe R, Kwan OL, DeMaria AN. Comparative accuracy of two-dimensional echocardiography and Doppler pressure half-time methods in assessing severity of mitral stenosis in patients with and without prior commissurotomy. Circulation 1986;73: IOQ-I 10. 12. Chambers J, McLaughlin N, Rapson A, Jackson G. Effect of changes in heart rate on pressure half-time in normally functioning mitral valve prosthesis. Br Hearr J 1988;60:502-506.
Aortic Dissection in Women c 40 Years of Age and the Unimportance of Pregnancy R. Oskoui, MD, and Joseph Lindsay, Jr., MD
I
t has been stated that approximately 50% of aortic dissections in women <40 years of age occur in pregnancy or puerperium. 1,2It has been inferred that this putative relation reflects a contribution of pregnancy to the pathogenesis of dissection. Published series by Schnitker and Bayen Shennan4 Hirst et a1,5Pedowitz and Perel16 and Mandel et al7 are usually cited as evidence for this association. Each of these series consists of collections of previously published case reports to which investigators added 1 or 2 cases from their own experience. In the largest series, Schnitker and Bayer3 compiled 49 case reports (including 1 of their own) of women ~40 years old with aortic dissection. Twenty-four (approximately 50%) were pregnant. No consecutive series of patients from a single institution or affiliated institutions has examined this issue. This distinction is important, because series of patients derived from published case reports may over-represent patients with unusual presentations of a given disease. This report examines the association utilizing the experience of the Washington Hospital Center over the past decade and published series of patients with aortic dissection which include consecutive patients from a single or group of aIIiliated institutions. From a review of the medical records of the Washington Hospital Center, we obtained a list of 196 consecutive patients who had been coded as having acute aortic dissection in the 11.5 years from July 1, 1981, to January I, 1993. The median age of these 196 patients was 67 years; I31 were men and 65 women. Nine women were ~40 years of age. The medical files of these patients were thoroughly reviewed for possible inclusion in this study. Seven had autopsy surgical, radiographic or echocardiographic conjirmation of the diagnosis defined as a “splitting process that occurred in the aortic media. ‘18One woman ~40 years of age was excluded because chart review showed that she had a pseudoaneurysm (not a true dissecting aneurysm) as a late complication of a Potts’ procedure to correct a tetralogy of Fallot. A second was excluded since she had a pseuFrom the Division of Cardiology, Department of Internal Medicine, Washington Hospital Center, 110 Irving Street, N.W. Washington, D.C. 20010. Manuscript received May 10, 1993; revised manuscript received July 30, 1993.
doaneurysm secondary to a motor vehicle accident. Aortic dissection was designated as acute tf the patient presented and was diagnosed within 14 days after onset of symptoms. Peripartum was defined as the first 6-month period after delivery. Patients were subsequently contacted by telephone to ascertain late follow-up information. We selected from the literature 11 series”t9 consisting of consecutive patients from single or a$liated institutions each of which included 240 patients. These series consisted predominantly of patients with acute, not chronic, aortic dissections and contained some patients who were ~40 years. The clinical characteristics of the 7patients are listed in Table I. At diagnosis the mean and median age was 34 years. Three were white and 4 black. Three had DeBakey type I, 3 had DeBakey type III and 1 had type II aortic dissection. 2o Systemic hypertension was by far the most common riskfactorfor aortic dissection.5*‘0v20Four of our 7 patients had known hypertension, and its presence was presumed in a fifth who had cardiomegaly (heart weight >600 g) that could not be explained on the basis of infiltrative or valvular heart disease. The sixth patient had Matian’s syndrome. The seventh patient had annuloaortic ectasia, but did not meet other criteria for the Marhan syndrome.2’ She had no evidence of systemic hypertension or any congenital cardiovascular abnormality. At diagnosis, no woman was pregnant or within 6 months of delivery. TABLE
I Clinical
Case
Age (years)
1
2 3 4 5
6 7
27 30 33 34 37 38 39
Characteristics Aortic DIssectIon Risk Factor
DeBa key
Race White White Black Black Black Black White
Hypertension* Annuloaortic ectaslat Hypertension Hypertension Marfan syndrome Hypertension Hypertension
I II I III I Ill III
Type
*Heart weight on necropsy was 638 g. Patlent history and pathologic study did not show ewdence of infiltrative or valvular heart disease. tHlstology showed cystic medlal mecros~s. The patent did not havethe musculoskeleta1 or ophthalmologic stigmata of the Marfan syndrome. Also, she had no hIstory or wdenceof hypertension or predlsposlng congenltal cardlovascularabnormality.
BRIEFREPORTS 821
TABLE II Summary of Consecutive Single or Affiliated Institutions
Series Authors Masuda et all2 Wilson and Hutchins’s Larson and Edwards9 Pate et all4 Slater and DeSanctisls Nakashima et aI16 DesLauriers et alI7 Lindsay and HurstlO Strong et alla Neya et aIll Murday et all9 Total cases
Series
Number of Patients 228 204 161 126 124 111 80 62 59 58 40 1,253
of Patients
M/F Ratio 155173 133171 lOW56 99127 go/34 67144 60120 40122 46/13 44114 29/11 8681385
All 7 patients were treated conventionally/J2 with surgical therapy for acute proximal dissections or complicated acute distal dissections and medical therapy for uncomplicated distal dissections. The 30-day mortality was 2 of 7 (29%). All of the 5 survivors were alive at the time of follow-up, which ranged porn 10 months to 6 years and 2 months. There were a total of 1,253 patients in the II patients series 9-19that we selected for review. Table II indicates the total number of patients in each series, the male-tofemale ratio, the age range, and whether cases were derivedfiom autopsy records. No instances of associated pregnancy were cited. No consecutive series of patients presenting to an institution or group of affiliated institutions with acute aortic dissection has specifically examined the etiology of aortic dissection among women ~40 years. Many current patient series focus on diagnostic techniques or the short- and long-term outcome of various treatment methods. Other reviews include large numbers of chronic dissections and do not adequately represent the population that presents acutely. The fundamental argument for the association of pregnancy and aortic dissection is contradicted by the data herein reviewed. In our own consecutive group of 196 patients with aortic dissections, we found 7 women (3.5%) ~40 years. If one extrapolates to the 1,253 patients contained in the published series, one might anticipate 30 to 40 cases of women <40 years. If 50% of those cases had been associated with pregnancy, 15 to 20 instances of pregnancy-associated aortic dissection might have been included therein. However, not a single instance of aortic dissection was reported. Moreover, Pate et all4 reviewed 126 consecutive cases of acute aortic dissection. Although there were 91,282 deliveries during the study period in their group of afliliated hospitals, they found no pregnant women with acute aortic dissection. At the Washington Hospital Center between July 1, 1981 and January 1, 1993 there were 32,101 deliveries, an average of nearly 2,80O/year. As stated earlier, no pregnant women were among the nearly 200 instances of acute aortic dissection encountered in the same time period.
822
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
73
with
Acute
Aortic
Dissection
from
Age Range (years)
Autopsy Series
Number of Cases Associated With Pregnancy
Not given 14-94 18-91 Not given 19-81 17-88 27-80 31-83 26-86 26-85 17-74
0 + + 0 0 0 In part In part 0 0 0
0 0 0 0 0 0 0 0 0 0 0
14-94
0
The putative association of pregnancy and acute aortic dissection may largely be an artifact of selective reporting. Pregnancy is a very common medical condition. Coincidental occurrence is to be expected. Many such case reports simply do not include enough patient information to rule out other more well-established causes of aortic dissection. All 7 women ~40 years compiled from our experience with 196 consecutive patients with acute aortic dissection had other important risk factors for the disorder, including hypertension and the Mar-fan syndrome. Based on our review of our institution’s experience, as well as the pertinent literature, we believe the causal relation between pregnancy and acute aortic dissection to be markedly overestimated. 1. Braunwald E. Heart Disease. Philadelphia: WB Saunders, 1992~1536-1557. 2. Roberts WC. Aortic dissection: anatomy, consequences, and causes. Am Hearr J 1981;101:195-214. 3. Schnitker MA, Bayer CA. Dissecting aneurysm of the aorta in young individuals, particularly in association with report of a case. Ann Intern Med 1944.20: 486511. 4. Sherman T. Dissecting Aneurysms. London Medical Research Council Special Report Series. London: His Majesty’s Stationary Office, 1934. 1. H&t AE, Johns VJ, Kime SW. Dissecting aneurysm of the aorta. A review of 505 cases. Medicine 1958;37:217-279. 6. Pedowitz P, Perell A. Aneurysms complicated by pregnancy. Part 1. Aneurysms of the aorta and its major branches. Am J Ohstet Gynecol 1957;73:72&735. 7. Mandel W, Evans EW, Walford RL. Dissecting aortic aneurysm during pregnancy. N En@ J Med 1954;251:1059-1061. 8. Crawford ES. The diagnosis and management of aottic dissection. JAMA 199D; 264:2537-2541. 9. Larson EW, Edwards WD. Risk factors for aortic dissection: a necropsy study of 161 cases. Am J Cardiol 1984;53:84%855, 10. Lindsay Jr J, Hurst JW. Clinical features and prognosis in dissecting aneurysm of the aorta. A reappraisal. Circulation 1967;35:88&888. 11. Neya K, Omoto R, Kyo S, Kimura S, Yokote Y, Takamoto S, Adachi H. Outcome of Stanford type B acute aortic dissection. Circulation 1992;86(suppl II):IIl-11-7. 12. Masuda Y, Yamada Z, Morooka N, Watanabe S, Inagaki Y. Prognosis of patients with medically treated aottic dissections. Circulation 1991;84(Suppl III):III7-111-13. 19. Wilson SK, Hutchins GM. Aortic dissecting aneurysms: causative factors in 204 subjects. Arch Parhol Lab Med 1982;106:175-180. 14. Pate JW, Richardson RL, Eastridge CE. Acute aortic dissections. Am Surg 1976;42:395xM, IS. Slater EE, DeSanctis RW. The clinical recognition of dissecting aortic aneurysm. Am J Med 1976;60:625-633. 19. Nakashima Y, Kurorumi T, Sueishi K, Tanaka K. Dissecting aneurysm: a clinicopathologic and histopathologic study of 111 autopsied cases. Hum Pathol 1990;21:291-296. 17. DesLauiers I, MacGregor DC, Goldman BS. Current management of dissect-
APRIL 15,1994
ing aneurysm of the aorta. Can J Surg 1973;16: 1-7. 19. Strong WW, Moggio RA, Stansel HC. Acute aoItic dissection. J Thorac Cardiovasc Surg 1974;68:815-821. 19. Murday Al, Pillai R, Magee PG, Walesby RK, Wright JEC, Stunidge MF. Results of surgical repair for dissection of the ascending aorta. Br Heart J 1987;57: 548-551. 29. DeBakey ME, McCollum CH, Crawford ES, Morris CC Jr, Howell I, Noon GP, Lawrie G. Dissection and dissecting aneurysms of the aorta: twenty-year follow-up of five hundred twenty-seven patients treated surgically. Surgery 1992;92: 1118-1134.
Transesophageal Echocardiographic Prosthetic Hip Replacement
21. Beighton P, de Paepe A, Dar&s D, Finidori G, Gedde-Dahl T, Goodman R, Hall JG, Hollister DW, Horton W, McKusick VA, Opitz JM, Pope FM, Pyeritz RE, Rimoin DL, Sillence D, Spranger JW, Thompson E, Tsipouras P, Viljoen D, Winship I, Young I. International nosology of heritable disorders of connective tissue, Berlin, 1986. Am J Med Genet 1988;29:581-594. 22. Doroghazi RM, Slater EE, DeSanctis RW, Buckley MJ, Austen WG, Rosenthal S. Long-term survival of patients treated with aortic dissection. JAm Coil Cardial 1984;3:1026--1034. 23. Gore I. Dissecting aneurysms of the aorta in persons under forty years of age. AMA Arch Path01 1953;55:1-13.
Right Atrial Findings During
Jose Luis Rodrigo, MD, Fernando Alfonso, MD, Ada Aubele, MD, Luis Mataix, MD, Jesus Hurtado, MD, Lourdes Duran, MD, Antonio Sanchez-Barba, MD, Luis Lopez Duran, MD, and Pedro Zarco, MD
T
wo-dimensional echocardiography is a well-estabEight consecutive patients (2 men and 6 women) unlished technique for the detection of cardiac masses. derwent orthopedic surgery with prosthetic hip reRecently, transesophageal echocardiography (TEE) has placement because of osteoarthrosis. Mean age of the proven to be of even greater value in the diagnosis of group was 68 + 12 years. Before the procedure, all paatria1 masses. TEE provides accurate anatomic infortients underwent a complete transthoracic echocardiomation of both atria, interatrial septum and atrial ap- graphic study. Associated diseases included chronic obpendages. Is2TEE is currently considered the diagnostic structive pulmonary disease in I patient, Rendu-Osler procedure of choice for the precise recognition of atria1 syndrome in 1 patient, and mild rheumatic mitral stenomasses and the delineation of their spatial relationship sis with mild aortic regurgitation (conjirmed during with surrounding cardiac structures.1,2 In this prospec- TEE) in another patient. Hip arthroplasties were pertive study we present the TEE right atria1 findings oc- formed in the standard manner under general anesthecurring during prosthetic hip replacement in a consecu- sia. Four patients received a cemented prosthesis and tive series of patients. the remaining 4 patients underwent a noncemented procedure. Hemodynamic monitorization including heart rate, blood pressure and arterial oxygen content was From the Departments of Cardiopulmonary, Anaesthesiology, and Orper$ormed throughout the intervention. TEE using a bithopaedic Surgery, Hospital Universitzuio San Carlos, Plaza de Cristo Rey, Madrid 28040, Spain. Manuscript received May 10, 1993; revised plane probe (Ultramark 9, 5 MHz) was obtained in every patient to monitor the procedure. After a convenmanuscript received July 29, 1993, and accepted August 3.
FlRURE 1. Transesophageal echocardiographic study in ths longitudinal right atrial view. A, before prosthetic hip CB placement a normal-appearing left atrium (La), right atrium (Ra) and interatrial septum (includiw the site of the fossa ovalis) are visualized. 6, at the beginni~ of the procedure, spontaneous contrast (smoke) enters the right atrium throub the inferior vena cava. Note the washout phenomenon induced by the blood coming from the superior vena cava (arrowheads). C, a free moving serpiglnous right atria1 mass is readily visualized (arrow), clearly dire& ated fnrm the smoke that is filling the caudal part of the left atrium. D, another mass of a more complex morphology was seen later, randomly swirling within the right atrium for some seconds before disappearing.
BRIEFREPORTS 823
9. Gonzalez MA, Child JS, Krivokapich I. Comparison of two-dimensional and Doppler echocardiography and intracardiac hemodynamics for quantification of mitral stenosis. Am J Cardiol 1987;60:327-332. 10. Braverman AC, Thomas JD, Lee RT. Doppler echocardiographic estimation of mitral valve area during changing hemodynamic conditions. Am J Cardiol 1991;68: I4855 1490. 11. Smith MD, Handshoe R, Kwan OL, DeMaria AN. Comparative accuracy of two-dimensional echocardiography and Doppler pressure half-time methods in assessing severity of mitral stenosis in patients with and without prior commissurotomy. Circulation 1986;73: IOQ-I 10. 12. Chambers J, McLaughlin N, Rapson A, Jackson G. Effect of changes in heart rate on pressure half-time in normally functioning mitral valve prosthesis. Br Hearr J 1988;60:502-506.
Aortic Dissection in Women c 40 Years of Age and the Unimportance of Pregnancy R. Oskoui, MD, and Joseph Lindsay, Jr., MD
I
t has been stated that approximately 50% of aortic dissections in women <40 years of age occur in pregnancy or puerperium. 1,2It has been inferred that this putative relation reflects a contribution of pregnancy to the pathogenesis of dissection. Published series by Schnitker and Bayen Shennan4 Hirst et a1,5Pedowitz and Perel16 and Mandel et al7 are usually cited as evidence for this association. Each of these series consists of collections of previously published case reports to which investigators added 1 or 2 cases from their own experience. In the largest series, Schnitker and Bayer3 compiled 49 case reports (including 1 of their own) of women ~40 years old with aortic dissection. Twenty-four (approximately 50%) were pregnant. No consecutive series of patients from a single institution or affiliated institutions has examined this issue. This distinction is important, because series of patients derived from published case reports may over-represent patients with unusual presentations of a given disease. This report examines the association utilizing the experience of the Washington Hospital Center over the past decade and published series of patients with aortic dissection which include consecutive patients from a single or group of aIIiliated institutions. From a review of the medical records of the Washington Hospital Center, we obtained a list of 196 consecutive patients who had been coded as having acute aortic dissection in the 11.5 years from July 1, 1981, to January I, 1993. The median age of these 196 patients was 67 years; I31 were men and 65 women. Nine women were ~40 years of age. The medical files of these patients were thoroughly reviewed for possible inclusion in this study. Seven had autopsy surgical, radiographic or echocardiographic conjirmation of the diagnosis defined as a “splitting process that occurred in the aortic media. ‘18One woman ~40 years of age was excluded because chart review showed that she had a pseudoaneurysm (not a true dissecting aneurysm) as a late complication of a Potts’ procedure to correct a tetralogy of Fallot. A second was excluded since she had a pseuFrom the Division of Cardiology, Department of Internal Medicine, Washington Hospital Center, 110 Irving Street, N.W. Washington, D.C. 20010. Manuscript received May 10, 1993; revised manuscript received July 30, 1993.
doaneurysm secondary to a motor vehicle accident. Aortic dissection was designated as acute tf the patient presented and was diagnosed within 14 days after onset of symptoms. Peripartum was defined as the first 6-month period after delivery. Patients were subsequently contacted by telephone to ascertain late follow-up information. We selected from the literature 11 series”t9 consisting of consecutive patients from single or a$liated institutions each of which included 240 patients. These series consisted predominantly of patients with acute, not chronic, aortic dissections and contained some patients who were ~40 years. The clinical characteristics of the 7patients are listed in Table I. At diagnosis the mean and median age was 34 years. Three were white and 4 black. Three had DeBakey type I, 3 had DeBakey type III and 1 had type II aortic dissection. 2o Systemic hypertension was by far the most common riskfactorfor aortic dissection.5*‘0v20Four of our 7 patients had known hypertension, and its presence was presumed in a fifth who had cardiomegaly (heart weight >600 g) that could not be explained on the basis of infiltrative or valvular heart disease. The sixth patient had Matian’s syndrome. The seventh patient had annuloaortic ectasia, but did not meet other criteria for the Marhan syndrome.2’ She had no evidence of systemic hypertension or any congenital cardiovascular abnormality. At diagnosis, no woman was pregnant or within 6 months of delivery. TABLE
I Clinical
Case
Age (years)
1
2 3 4 5
6 7
27 30 33 34 37 38 39
Characteristics Aortic DIssectIon Risk Factor
DeBa key
Race White White Black Black Black Black White
Hypertension* Annuloaortic ectaslat Hypertension Hypertension Marfan syndrome Hypertension Hypertension
I II I III I Ill III
Type
*Heart weight on necropsy was 638 g. Patlent history and pathologic study did not show ewdence of infiltrative or valvular heart disease. tHlstology showed cystic medlal mecros~s. The patent did not havethe musculoskeleta1 or ophthalmologic stigmata of the Marfan syndrome. Also, she had no hIstory or wdenceof hypertension or predlsposlng congenltal cardlovascularabnormality.
BRIEFREPORTS 821
TABLE II Summary of Consecutive Single or Affiliated Institutions
Series Authors Masuda et all2 Wilson and Hutchins’s Larson and Edwards9 Pate et all4 Slater and DeSanctisls Nakashima et aI16 DesLauriers et alI7 Lindsay and HurstlO Strong et alla Neya et aIll Murday et all9 Total cases
Series
Number of Patients 228 204 161 126 124 111 80 62 59 58 40 1,253
of Patients
M/F Ratio 155173 133171 lOW56 99127 go/34 67144 60120 40122 46/13 44114 29/11 8681385
All 7 patients were treated conventionally/J2 with surgical therapy for acute proximal dissections or complicated acute distal dissections and medical therapy for uncomplicated distal dissections. The 30-day mortality was 2 of 7 (29%). All of the 5 survivors were alive at the time of follow-up, which ranged porn 10 months to 6 years and 2 months. There were a total of 1,253 patients in the II patients series 9-19that we selected for review. Table II indicates the total number of patients in each series, the male-tofemale ratio, the age range, and whether cases were derivedfiom autopsy records. No instances of associated pregnancy were cited. No consecutive series of patients presenting to an institution or group of affiliated institutions with acute aortic dissection has specifically examined the etiology of aortic dissection among women ~40 years. Many current patient series focus on diagnostic techniques or the short- and long-term outcome of various treatment methods. Other reviews include large numbers of chronic dissections and do not adequately represent the population that presents acutely. The fundamental argument for the association of pregnancy and aortic dissection is contradicted by the data herein reviewed. In our own consecutive group of 196 patients with aortic dissections, we found 7 women (3.5%) ~40 years. If one extrapolates to the 1,253 patients contained in the published series, one might anticipate 30 to 40 cases of women <40 years. If 50% of those cases had been associated with pregnancy, 15 to 20 instances of pregnancy-associated aortic dissection might have been included therein. However, not a single instance of aortic dissection was reported. Moreover, Pate et all4 reviewed 126 consecutive cases of acute aortic dissection. Although there were 91,282 deliveries during the study period in their group of afliliated hospitals, they found no pregnant women with acute aortic dissection. At the Washington Hospital Center between July 1, 1981 and January 1, 1993 there were 32,101 deliveries, an average of nearly 2,80O/year. As stated earlier, no pregnant women were among the nearly 200 instances of acute aortic dissection encountered in the same time period.
822
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
73
with
Acute
Aortic
Dissection
from
Age Range (years)
Autopsy Series
Number of Cases Associated With Pregnancy
Not given 14-94 18-91 Not given 19-81 17-88 27-80 31-83 26-86 26-85 17-74
0 + + 0 0 0 In part In part 0 0 0
0 0 0 0 0 0 0 0 0 0 0
14-94
0
The putative association of pregnancy and acute aortic dissection may largely be an artifact of selective reporting. Pregnancy is a very common medical condition. Coincidental occurrence is to be expected. Many such case reports simply do not include enough patient information to rule out other more well-established causes of aortic dissection. All 7 women ~40 years compiled from our experience with 196 consecutive patients with acute aortic dissection had other important risk factors for the disorder, including hypertension and the Mar-fan syndrome. Based on our review of our institution’s experience, as well as the pertinent literature, we believe the causal relation between pregnancy and acute aortic dissection to be markedly overestimated. 1. Braunwald E. Heart Disease. Philadelphia: WB Saunders, 1992~1536-1557. 2. Roberts WC. Aortic dissection: anatomy, consequences, and causes. Am Hearr J 1981;101:195-214. 3. Schnitker MA, Bayer CA. Dissecting aneurysm of the aorta in young individuals, particularly in association with report of a case. Ann Intern Med 1944.20: 486511. 4. Sherman T. Dissecting Aneurysms. London Medical Research Council Special Report Series. London: His Majesty’s Stationary Office, 1934. 1. H&t AE, Johns VJ, Kime SW. Dissecting aneurysm of the aorta. A review of 505 cases. Medicine 1958;37:217-279. 6. Pedowitz P, Perell A. Aneurysms complicated by pregnancy. Part 1. Aneurysms of the aorta and its major branches. Am J Ohstet Gynecol 1957;73:72&735. 7. Mandel W, Evans EW, Walford RL. Dissecting aortic aneurysm during pregnancy. N En@ J Med 1954;251:1059-1061. 8. Crawford ES. The diagnosis and management of aottic dissection. JAMA 199D; 264:2537-2541. 9. Larson EW, Edwards WD. Risk factors for aortic dissection: a necropsy study of 161 cases. Am J Cardiol 1984;53:84%855, 10. Lindsay Jr J, Hurst JW. Clinical features and prognosis in dissecting aneurysm of the aorta. A reappraisal. Circulation 1967;35:88&888. 11. Neya K, Omoto R, Kyo S, Kimura S, Yokote Y, Takamoto S, Adachi H. Outcome of Stanford type B acute aortic dissection. Circulation 1992;86(suppl II):IIl-11-7. 12. Masuda Y, Yamada Z, Morooka N, Watanabe S, Inagaki Y. Prognosis of patients with medically treated aottic dissections. Circulation 1991;84(Suppl III):III7-111-13. 19. Wilson SK, Hutchins GM. Aortic dissecting aneurysms: causative factors in 204 subjects. Arch Parhol Lab Med 1982;106:175-180. 14. Pate JW, Richardson RL, Eastridge CE. Acute aortic dissections. Am Surg 1976;42:395xM, IS. Slater EE, DeSanctis RW. The clinical recognition of dissecting aortic aneurysm. Am J Med 1976;60:625-633. 19. Nakashima Y, Kurorumi T, Sueishi K, Tanaka K. Dissecting aneurysm: a clinicopathologic and histopathologic study of 111 autopsied cases. Hum Pathol 1990;21:291-296. 17. DesLauiers I, MacGregor DC, Goldman BS. Current management of dissect-
APRIL 15,1994
ing aneurysm of the aorta. Can J Surg 1973;16: 1-7. 19. Strong WW, Moggio RA, Stansel HC. Acute aoItic dissection. J Thorac Cardiovasc Surg 1974;68:815-821. 19. Murday Al, Pillai R, Magee PG, Walesby RK, Wright JEC, Stunidge MF. Results of surgical repair for dissection of the ascending aorta. Br Heart J 1987;57: 548-551. 29. DeBakey ME, McCollum CH, Crawford ES, Morris CC Jr, Howell I, Noon GP, Lawrie G. Dissection and dissecting aneurysms of the aorta: twenty-year follow-up of five hundred twenty-seven patients treated surgically. Surgery 1992;92: 1118-1134.
Transesophageal Echocardiographic Prosthetic Hip Replacement
21. Beighton P, de Paepe A, Dar&s D, Finidori G, Gedde-Dahl T, Goodman R, Hall JG, Hollister DW, Horton W, McKusick VA, Opitz JM, Pope FM, Pyeritz RE, Rimoin DL, Sillence D, Spranger JW, Thompson E, Tsipouras P, Viljoen D, Winship I, Young I. International nosology of heritable disorders of connective tissue, Berlin, 1986. Am J Med Genet 1988;29:581-594. 22. Doroghazi RM, Slater EE, DeSanctis RW, Buckley MJ, Austen WG, Rosenthal S. Long-term survival of patients treated with aortic dissection. JAm Coil Cardial 1984;3:1026--1034. 23. Gore I. Dissecting aneurysms of the aorta in persons under forty years of age. AMA Arch Path01 1953;55:1-13.
Right Atrial Findings During
Jose Luis Rodrigo, MD, Fernando Alfonso, MD, Ada Aubele, MD, Luis Mataix, MD, Jesus Hurtado, MD, Lourdes Duran, MD, Antonio Sanchez-Barba, MD, Luis Lopez Duran, MD, and Pedro Zarco, MD
T
wo-dimensional echocardiography is a well-estabEight consecutive patients (2 men and 6 women) unlished technique for the detection of cardiac masses. derwent orthopedic surgery with prosthetic hip reRecently, transesophageal echocardiography (TEE) has placement because of osteoarthrosis. Mean age of the proven to be of even greater value in the diagnosis of group was 68 + 12 years. Before the procedure, all paatria1 masses. TEE provides accurate anatomic infortients underwent a complete transthoracic echocardiomation of both atria, interatrial septum and atrial ap- graphic study. Associated diseases included chronic obpendages. Is2TEE is currently considered the diagnostic structive pulmonary disease in I patient, Rendu-Osler procedure of choice for the precise recognition of atria1 syndrome in 1 patient, and mild rheumatic mitral stenomasses and the delineation of their spatial relationship sis with mild aortic regurgitation (conjirmed during with surrounding cardiac structures.1,2 In this prospec- TEE) in another patient. Hip arthroplasties were pertive study we present the TEE right atria1 findings oc- formed in the standard manner under general anesthecurring during prosthetic hip replacement in a consecu- sia. Four patients received a cemented prosthesis and tive series of patients. the remaining 4 patients underwent a noncemented procedure. Hemodynamic monitorization including heart rate, blood pressure and arterial oxygen content was From the Departments of Cardiopulmonary, Anaesthesiology, and Orper$ormed throughout the intervention. TEE using a bithopaedic Surgery, Hospital Universitzuio San Carlos, Plaza de Cristo Rey, Madrid 28040, Spain. Manuscript received May 10, 1993; revised plane probe (Ultramark 9, 5 MHz) was obtained in every patient to monitor the procedure. After a convenmanuscript received July 29, 1993, and accepted August 3.
FlRURE 1. Transesophageal echocardiographic study in ths longitudinal right atrial view. A, before prosthetic hip CB placement a normal-appearing left atrium (La), right atrium (Ra) and interatrial septum (includiw the site of the fossa ovalis) are visualized. 6, at the beginni~ of the procedure, spontaneous contrast (smoke) enters the right atrium throub the inferior vena cava. Note the washout phenomenon induced by the blood coming from the superior vena cava (arrowheads). C, a free moving serpiglnous right atria1 mass is readily visualized (arrow), clearly dire& ated fnrm the smoke that is filling the caudal part of the left atrium. D, another mass of a more complex morphology was seen later, randomly swirling within the right atrium for some seconds before disappearing.
BRIEFREPORTS 823