Atypical echocardiographic findings in traumatic aortic transection

Aortic rupture and transection are constituents of the acute aortic syndrome. Injury to the thoracic aorta during motor vehicle crashes is associated with blunt chest trauma and rapid deceleration mechanisms. Type A dissections and/or rupture of the aorta at the level of the aortic isthmus are the more common presentations of aortic injuries associated with motor vehicle crashes. We present the case of atypical echocardiographic findings of a nearly complete circumferential transection of the proximal ascending aorta injury after a motorcycle crash.     

Significance of symptoms and signs in patients with traumatic aortic rupture

The records of 50 patients with traumatic aortic rupture (Group I) and 50 patients with blunt chest trauma but negative aortograms (Group II) were reviewed retrospectively. Symptoms and signs referable to the chest and thoracic aorta were recorded and compared in Group I and Group II patients. Each patient's chart was evaluated for chest pain, respiratory distress, thoracic back pain, hypotension, hypertension, and decreased femoral pulses. None of the symptoms or signs attained statistical significance between Group I and Group II patients. The only significant difference between Group I and Group II patients was in the injury severity score (ISS). The mean ISS for aortic rupture patients was 42.1 +/- 11.6 (SD), but was only 19.9 +/- 11.4 (SD) (P less than .001) for patients without aortic rupture. We conclude that the diagnosis of aortic rupture in patients sustaining blunt chest trauma cannot be accurately predicted or excluded on the basis of the patients' presenting complaints or physical findings.     

Pathology of aortic valve stenosis and pure aortic regurgitation a clinical morphologic assessment—part I

This two-part article examines the histologic and morphologic basis for stenotic and purely regurgitant aortic valves. Part I discusses stenotic aortic valves and Part II will discuss causes of purely regurgitant aortic valves. In over 95% of stenotic aortic valves, the etiology is one of three types: congenital (primarily bicuspid), degenerative, or rheumatic. Other rare causes of stenotic aortic valves include active infective endocarditis, homozygous type II hyperlipoproteinemia, and systemic lupus erythematosis. The causes of pure aortic regurgitation are multiple but can be separated into diseases affecting the valve (normal aorta) (infective endocarditis, congenital bicuspid, rheumatic, floppy), diseases affecting the walls of aorta (normal valve) (syphilis, Marfan's, dissection), disease affecting both aorta and valve (abnormal aorta, abnormal valve) (ankylosing spondylitis), and diseases affecting neither aorta nor valve (normal aorta, normal valve) (ventricular septal detect, systemic hypertension). Diseases affecting the aortic valve alone are the most common subgroup of conditions producing pure aortic valve regurgitation.     

Stanford type A aortic dissection in a hypertensive patient with atherosclerosis of aorta and aortitis

Dissection of aorta is a serious condition; the main factors are hypertension and diseases of the connective tissue or of collagen. Aortitis syndrome in combination with hypertension and atherosclerosis in association with ascending aortic dissection is rarely seen. We present the case of a 53-year-old hypertensive patient whose ascending aortic dissection was associated with pericardial effusion without rupture of the aorta and with pleural effusion. Several unusual aspects of transesophageal echocardiography are described. The intraoperative biopsy revealed inflammatory aortitis with mural hematoma, without giant cells. The literature concerning aortic dissection and aortitis is reviewed.     

Thoracic Aortic Disease: Endovascular Stents

Aortic disease is a serious, often life-threatening condition. The keys to instituting appropriate therapy in diseases of the aorta include accurate and rapid diagnosis and anatomical assessment. Endovascular aortic repair is a new alternative to conventional surgical approaches. Because arterial rupture is a risk of this procedure, appropriate facilities for resuscitation must be present during the procedure. This paper reviews the important aspects of aortic anatomy, echocardiographic imaging of the thoracic aorta, aortic pathology, endovascular surgery, and the role of echocardiography in the evaluation of the surgical outcome.     

Nonneoplastic diseases of aorta and pulmonary trunk—Part III

This five-part review focuses on selected nonneoplastic diseases of the aorta and pulmonary trunk. Because many more diseases affect the aorta compared with the pulmonary trunk and right and left main pulmonary arteries, most of this review will be devoted to disorders of the aorta. Part III of this five-part series discusses the etiology of aortic aneurysms and aortitis.     

Spontaneous rupture and thrombotic effects in a swine model of untreated abdominal aortic aneurysms

Background In our previous canine model of abdominal aortic aneurysm, although aneurysm growth was observed, the aneurysms did not rupture. This prompted us to develop a swine model, which has the advantage of fibrinolytic and coagulation systems similar to those found in humans.Methods We simulated aneurysms by connecting fascia pouches to the aorta. In nine pigs, two pieces of fascia (5 × 8 cm each) were sutured to the posterior surface of the aorta. After the lateral edges of the aorta were sutured together, the aorta was clamped below the renal arteries and at the aortic bifurcation. We then resected a piece of aorta within the pouch, clamped the pouch below the open roof, and unclamped the aorta. When the entire pouch had been sutured, the last clamp was removed and blood flowed into the aneurysm. The total aortic cross clamp time was between 4 and 25 minutes.Results Aneurysm size ranged from 3.0 × 2.5 cm to 7.5 × 4.0 cm (length × width). Aneurysm rupture occurred in seven pigs between 4 and 43 days after initial surgery; however, rupture never occurred at a suture site. Aneurysm size at rupture was two to four times greater than that of the original pouch. We found thrombus in all of the aneurysms examined more than 2 days after surgery. Histology revealed aneurysm walls that were thicker than the fascia. Although fascia segments could be identified because of their characteristic trilayer of thick collagen fibers, most of the aneurysm wall contained thin collagen fibers. These observations are consistent with new collagen production.Conclusion We constructed a swine model of abdominal aortic aneurysm that possessed the features of growth and rupture necessary to simulate human aneurysms. Our method will allow techniques designed to isolate aneurysms from the circulation to be tested in a model with a fibrinolytic system similar to that of humans.     

Delivery balloon‐induced ascending aortic dissection: An unusual complication during transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is a relatively mature technique that is generally accepted as a promising treatment for inoperable patients and those who are high‐risk candidates for surgical aortic replacement. Although severe complications in the aortic valve complex, such as annular or aortic root rupture, are not frequently observed, these events could easily lead to catastrophic outcomes, and therefore remain major issues during TAVI. However, there remains a paucity of data describing these catastrophic complications because of their low incidence. We encountered the case of an 88‐year‐old woman complicated by a dissection of the ascending aorta during TAVI from an “unusual” cause: injury due to the delivery of a balloon‐expandable valve to a very narrow and heavily calcified sinotubular junction (STJ). This is the first report to demonstrate the mechanism of this complication; even a delivery balloon, not a stent frame, with low inflation pressure might injure a narrow STJ and lead to an aortic dissection. Therefore, the use of oversized delivery balloons should be avoided in patients with a narrow and calcified STJ. © 2015 Wiley Periodicals, Inc.     

急性降主动脉夹层致器官灌注不良的诊疗进展

急性降主动脉夹层是致死性的主动脉疾病。治疗急性主动脉夹层的目标不仅是阻止动脉瘤的形成和破裂,而且要阻止灌注不良综合征这一类并发症的发生。尽管主动脉夹层伴灌注不良综合征的诊断有所提高,手术方式的选择有所改进,但外科手术治疗的病死率仍有50%。血管内治疗技术不断发展为主动脉夹层的治疗提供了一个新的选择。现回顾主动脉夹层伴灌注不良综合征的发病机制,讨论目前脊髓、小肠、肢体末梢灌注不足的治疗模式和各种治疗方法的疗效。     

Complex atheromatosis of the aortic arch in cerebral infarction

In many stroke patients it is not possible to establish the etiology of stroke. However, in the last two decades, the use of transesophageal echocardiography in patients with stroke of uncertain etiology reveals atherosclerotic plaques in the aortic arch, which often protrude into the lumen and have mobile components in a high percentage of cases. Several autopsy series and retrospective studies of cases and controls have shown an association between aortic arch atheroma and arterial embolism, which was later confirmed by prospectively designed studies. The association with ischemic stroke was particularly strong when atheromas were located proximal to the ostium of the left subclavian artery, when the plaque was ≥ 4 mm thick and particularly when mobile components are present. In these cases, aspirin might not prevent adequately new arterial ischemic events especially stroke. Here we review the evidence of aortic arch atheroma as an independent risk factor for stroke and arterial embolism, including clinical and pathological data on atherosclerosis of the thoracic aorta as an embolic source. In addition, the impact of complex plaques (≥ 4 mm thick, or with mobile components) on increasing the risk of stroke is also reviewed. In non-randomized retrospective studies anticoagulation was superior to antiplatelet therapy in patients with stroke and aortic arch plaques with mobile components. In a retrospective case-control study, statins significantly reduced the relative risk of new vascular events. However, given the limited data available and its retrospective nature, randomized prospective studies are needed to establish the optimal secondary prevention therapeutic regimens in these high risk patients.     

Aortic rupture following a covered stent for coarctation: delayed recognition.

Primary stenting for aortic coarctation is frequently used in adult patients. Aortic rupture remains an infrequent complication. A number of strategies, including the use of covered stents, have been proposed to reduce the risk of this catastrophic complication. We describe a 51-year-old female who underwent stenting of aortic coarctation using a covered stent, which was complicated by aortic rupture. Treatment consisted of placement of an additional covered stent to seal the site of aortic disruption. The prevention and management of aortic rupture complicating aortic coarctation stenting are discussed.     

TEVAR for non‐aneurysmal thoracic aortic pathology

Objective : Management of penetrating atherosclerotic ulcers (PAU), intramural hematomas (IMH), and acute aortic dissections (AD) of the thoracic aorta remain controversial in the endovascular era. Methods : Between 2001 and 2007, patients with PAU (13 patients), and/or IMH (7 patients) were treated with thoracic endografts (TEVAR) in the endovascular suite under general anesthesia. Indications for intervention were intractable chest pain, expanding hematoma or contained rupture, or distal malperfusion. End‐points were early morbidity and mortality, incidence of endoleak, device‐related complications, and secondary interventions. Results : Of the 20 patients with a median age of 67 (25–83), 13 (65%) were men, 2 (10%) had contained aortic rupture, and 10 were symptomatic. One patient had carotid‐subclavian bypass debranching before endograft implantation. Ten patients had cerebrospinal fluid drainage. Mean length of aorta treated was 122.1 mm (range 36–300). All endografts were technically successful. Average blood loss was 50 mL. Thirty‐day mortality was 0%. Symptoms resolved in all patients; there were no neurologic complications. Average length of stay was 5 days. Mean follow‐up was 2.0 years (range 0.1–5.8). All patients remained asymptomatic. Three had early (<180 days) endoleaks: Two type II and 1 type I treated successfully with an additional cuff, which was the only patient requiring reintervention. Two patients had late (>180 days) endoleaks (type 2) observed with no aortic expansion. Two deaths at 5.4 and 5.8 years were due to severe aortic valve stenosis and metastatic lung cancer. Conclusion : TEVAR is a feasible option for repair of non‐aneurysmal thoracic aortic pathology with resolution of symptoms, no mortality, and no neurologic complications. © 2009 Wiley‐Liss, Inc.     

Traumatic rupture of an aortic ulcerative atherosclerotic plaque producing aortic dissection: A complication of interscapular back blows used to dislodge objects from the esophagus

Penetrating atherosclerotic ulcer of the aorta is a rare entity which usually occurs in the descending thoracic aorta. Herein, we report an unusual case of penetrating aortic ulcer which ruptured into the mediastinum. Interscapular back blows were performed on our patient in an attempt to dislodge an aspirin which she thought was lodged in her esophagus. Unlike previously reported cases of this entity, the penetrating aortic ulcer in our patient was located in the distal thoracic asending aorta. Diagnosis of penetrating aortic ulcer can be made by utilizing aortography, contiguous dynamic contrast-enhanced computed tomography or magnetic resonance imaging. Treatment consists of adjunctive medical therapy until surgery can be performed.     

Fragmentation hemolytic anemia 8 years after replacement of ascending aorta with a sutureless intraluminal graft

A 56-year-old man underwent replacement of the ascending aorta with a sutureless intraluminal graft, for a Stanford type A aortic dissection. Eight years after the operation, he developed gross hemoglobinuria, associated with an intravascular hemolytic anemia. Due to numerous schistocytes in the peripheral blood, the hemolysis was attributed to mechanical injury of the red blood cells at the site of the vascular graft. The patient's course was complicated by an infection of the aortic graft, which led to an urgent graft replacement. The hemolytic anemia resolved completely shortly after the reoperation. Physicians should consider this etiology in the differential diagnosis of fragmentation hemolytic anemia.     

Mitral annular calcification as a marker of complex aortic atheroma in patients with stroke of uncertain etiology

The aim of this study was to evaluate the presence of dense mitral annular calcification as a marker of complex aortic atherosclerosis in patients with stroke of uncertain etiology. One hundred twenty-one patients with stroke of uncertain etiology were evaluated for complex aortic atherosclerotic plaques; their presence and severity were correlated with transthoracic echocardiographic findings, demographic data, and cardiovascular risk factors. Complex plaques in the ascending aorta or aortic arch were found in 72 of the 121 patients (59.5%). The only difference seen in patients with or without plaques was the presence of dense mitral annular calcification (58.3 vs 16.3%; P < 0.001). Dense mitral annular calcification (n = 50) was associated with higher prevalence of complex aortic plaques (84.0% vs 42.3%; P < 0.001), mobile components (28.0% vs 9.9%; P < 0.01), and protruding (80.0% vs 36.6%; P < 0.001), ulcerated (16.0% vs 1.4%; P < 0.01), and multisite complex plaques (46.0% vs 9.0%; P < 0.001). Therefore, in patients with stroke of uncertain etiology dense mitral annular calcification is an important marker of aortic atherosclerosis with high risk of embolism, and this association may explain in part the high prevalence of stroke and peripheral embolism in patients with mitral annular calcification.     

Difficulty Diagnosing Retrograde Type A Aortic Dissection with Intramural Hematoma and Risk of Re-dissection and Rupture: A Report of Two Cases

Acute type A aortic dissection is a potentially fatal disease, and emergency surgery should be considered when it is diagnosed. We herein report two cases of retrograde type A aortic dissection with intramural hematoma, followed by re-dissection, rupture, and cardiac tamponade. The diagnoses in these cases had to be made carefully, as the false lumen of the ascending aorta was sometimes unclear on contrast-enhanced computed tomography.     

Aortic dilatation resulting in chronic aortic regurgitation and complicated by aortic dissection in a patient with Turner's syndrome

A patient with XO Turner's syndrome with a 12-year history of progressive aortic root dilatation resulting in chronic aortic regurgitation is presented. Her case is unique in that it occurred in the absence of coarctation of the aorta, bicuspid aortic valve, or hypertension. Idiopathic dilatation of the aorta may be an additional risk factor to the development of aortic dissection in the setting of Turner's syndrome.     

3D morphometric analysis of ascending aorta as an adjunctive tool to predict type A acute aortic dissection

BackgroundAcute type A aortic dissection (AAAD) is a pathological process that implicates the ascending aorta and represents a surgical emergency burdened by high mortality if not promptly treated in the first hours of onset. Despite best efforts, the annual incidence rates of aortic dissection has remained stable over the past decades. We measured aortic dimensions (aortic diameters, area, length and volume) using 3D multiplanar reconstruction imaging with the purpose of refining the risk- morphology for AAAD.MethodsComputerized tomography angiography studies of three groups were compared retrospectively: patients affected by AAAD (AAAD group; n=71), patients affected by aortic aneurysm and subsequently subjected to ascending aorta replacement (Aneurysm, n=77) and a healthy aorta’s group (Control, n=75).ResultsMean diameters of AAAD (4.9 cm) and Aneurysm (5.1 cm) aortas were significantly larger than those of the control group (3.4 cm). In AAAD patients, an ascending aorta diameter greater than 5.5 cm was observed in 18% of patients. Multiple comparisons showed statistically significant differences among mean of the ratio of aortic root area to height between the three groups (P<0.001). In frontal and sagittal planes, the length of the ascending aorta was significantly greater in patients affected by aortic pathology (AAAD and aneurysm) than in the control group (P<0.001). Significant differences were confirmed when indexing the aortic length to patient’s height and BSA, and the aortic volume to patient’s BSA.ConclusionsMaximum transverse diameter, considered separately, is not the best predictor of aortic dissection. In our opinion, the introduction into clinical practice of measurements of the area, length, and volume of the aorta, as absolute or indexed values, could improve the selection of patients who would benefit from preventive surgical aortic replacement.     

Native Aortic Valve Endocarditis Complicated by Pseudoaneurysm of Mitral‐Aortic Intervalvular Fibrosa

Pseudoaneurysm of mitral‐aortic intervalvular fibrosa (PA‐MAIVF) is a rare complication of native aortic valve endocarditis. This region is a relatively avascular area and prone to infection during endocarditis and subsequent aneurysm formation. The rupture into the pericardial cavity and left atrium or aorta, systemic embolism, myocardial infarction secondary to left coronary compression, and sudden death are the reported complications. Herein, we present a 9‐year‐old boy who was diagnosed with bicuspid aortic valve endocarditis complicated by PA‐MAIVF, cerebral embolism, and hemorrhage. PA‐MAIVF was visualized by both two‐ and three‐dimensional transthoracic echocardiography and ruptured into pericardial space causing a fatal outcome.     

升主动脉成形术治疗二叶式主动脉瓣患者升主动脉扩张的效果分析

目的:探讨升主动脉成形术(reduction ascending aortoplasty,RAA)治疗二叶式主动脉瓣(bicuspid aortic valve,BAV)患者升主动脉扩张的临床效果。方法:回顾性分析2006年1月至2015年12月长海医院208例因主动脉瓣病变合并升主动脉扩张行主动脉瓣置换术(aortic valve replacement,AVR)联合RAA治疗患者的临床资料。根据患者主动脉瓣情况,分为BAV组和三叶式主动脉瓣(tricuspid aortic valve,TAV)组;在BAV组中,根据术中升主动脉的目标直径,将患者分为30 mm组和≥30 mm组。结果:BAV组与TAV组的术后死亡率、并发症发生率、二次手术比例和随访升主动脉直径等指标差异无统计学意义(P均0.05);BAV组术中升主动脉目标直径30 mm组的随访升主动脉直径、术后5年和9年升主动脉扩张程度均明显小于术中升主动脉≥30 mm组(P均0.05)。结论:对于BAV合并升主动脉扩张的患者,BAV不是行RAA的不利因素,在RAA术中将升主动脉目标直径控制在30 mm以下,中远期疗效更好。