Acute thoracic aortic dissection: can your nurses defuse a time bomb?

Sometimes, every second counts. Help your staff learn to differentiate between acute thoracic aortic dissection and myocardial infarction, how to confirm a dissection, and how to care for aortic dissection patients.     

Ultrasound evaluation of aortic valve anatomy in the fetus.

OBJECTIVE: To assess the feasibility of ultrasound identification of aortic valve anatomy in the fetus, with particular emphasis on the detection of bicuspid aortic valve. METHODS: This study was a prospective analysis of 21 fetuses with prenatally diagnosed congenital left heart obstructive lesions and 45 normal fetuses undergoing routine ultrasound evaluated at a tertiary referral center. These fetuses underwent detailed echocardiography, including the study of the aortic valve on a targeted short-axis view of the right ventricle. Necropsies or postnatal echocardiograms were available for confirmation of the diagnosis in all cases. RESULTS: Aortic cusps and commissures were satisfactorily visualized in 38/45 (84%) normal fetuses and in 18/21 (86%) fetuses with congenital heart disease. The aortic valve was correctly defined as bicuspid in one normal fetus and in six fetuses with congenital heart disease. In two fetuses with a positive family history, the bicuspid aortic valve was isolated. There was one incorrect diagnosis (a unicuspid unicommissural valve diagnosed prenatally as a bicuspid aortic valve in a fetus with severe aortic stenosis) and one false-positive diagnosis in a fetus diagnosed with a coarctation and a bicuspid aortic valve late in the third trimester of pregnancy and in which both anomalies were not confirmed at neonatal echocardiography. CONCLUSIONS: This study demonstrated that aortic valve anatomy can be satisfactorily assessed in fetuses with and without left heart obstructive lesions. We believe that a detailed search for a bicuspid aortic valve should be attempted in all patients referred for a positive family history of congenital heart disease, in general, and of left ventricle outflow tract obstruction or bicuspid aortic valve, in particular. In fact, the presence of an asymptomatic bicuspid aortic valve has been demonstrated to represent an important factor predisposing to the development of bacterial endocarditis and dissecting aortic aneurysm late in adult life. Therefore, an early detection of such an anomaly may contribute to ensure a longer symptom-free lifespan of individuals with the most common cardiac anomaly at birth.     

Acute Type A Aortic Dissection in a 37-Week Pregnant Patient: An Unusual Clinical Presentation

Background

Aortic dissection in pregnancy is relatively rare, but it is often fatal. The estimated incidence of aortic dissection in the general population is 2.9 per 100,000 person-years. Early recognition and treatment of aortic dissections are crucial for survival. Whereas the majority of patients who present with aortic dissection are older than 50 years of age and have a history of hypertension, younger patients with connective tissue disease, bicuspid aortic valves, or a family history of aortic dissection are also at increased risk for developing this condition.

Chronic aortic regurgitation: indications for operation--1988

Timing of operation in a patient with severe aortic regurgitation is a difficult and controversial decision, especially when the patient is asymptomatic or minimally symptomatic. A rational decision can be made when the pathophysiologic features of aortic regurgitation and the natural history of medically treated patients are understood and the benefits and risks associated with aortic valve replacement are known. Proper interpretation of the literature involving echocardiography and nuclear cardiology is essential, as is consideration of the constantly changing surgical techniques and results. Aortic valve replacement should be recommended for those patients with chronic aortic regurgitation who are severely symptomatic (New York Heart Association Functional Class III or IV), in order to ameliorate symptoms and increase longevity. In asymptomatic or minimally symptomatic patients, close continued serial follow-up is necessary in order to detect the onset of resting left ventricular dysfunction and to recommend the optimal timing for surgical intervention.     

经胸超声心动图诊断A型主动脉壁间血肿

目的 观察经胸超声心动图诊断A型主动脉壁间血肿的价值。方法 回顾性分析40例经CT血管成像（CTA）确诊的A型主动脉壁间血肿患者的临床资料及超声心动图表现,评价经胸超声心动图诊断A型主动脉壁间血肿的价值。结果 40例A型主动脉壁间血肿患者,男25例（25/40,62.50%）,女15例,发病中位年龄55岁;以胸背部疼痛（36/40,90.00%）为主要症状;其中30例有高血压病史、15例有吸烟史。主动脉壁间血肿超声主要表现为主动脉壁内-中膜与外膜间存在厚薄不均匀低回声;主动脉窦部增宽与年龄、高血压病史相关（r=0.51,P=0.01;r=0.34,P=0.03）。25例（25/40,62.50%）合并主动脉瓣反流,其中21例（21/25,84.00%）为轻度反流;12例合并心包积液,其中10例（10/12,83.33%）为少量积液。结论 经胸超声心动图对诊断A型主动脉壁间血肿有一定价值,并可用于患者随访。     

Cardiovascular evaluation of the child and adolescent before participation in sports

A thorough cardiovascular evaluation is necessary to detect potentially lethal abnormalities that may predispose children and adolescents to sports-related sudden death. Hypertrophic cardiomyopathy and anomalous origin of the left coronary artery from the right sinus of Valsalva are the two most common cardiac abnormalities associated with sudden death during childhood. Other conditions potentially associated with sudden death are Marfan's syndrome, aortic valve stenosis, primary pulmonary hypertension, and arrhythmias. A detailed medical evaluation is indicated for subjects who have a history of nonvasodepressor syncope, exercise-related syncope or presyncope, angina pectoris, or known congenital or acquired heart disease. In addition, a family history of premature sudden unexpected syncope or death, hypertrophic cardiomyopathy, premature atherosclerotic heart disease, severe arrhythmias, or Marfan's syndrome or premature aortic aneurysms is an indication for a thorough cardiovascular evaluation before participation in sports.     

Chronic Aortic Dissection in a Young Adult

Background: Acute aortic dissection is a life-threatening disease that is often a diagnostic challenge in the Emergency Department (ED). Patients with acute aortic dissection often have underlying hypertension and atherosclerotic disease, and commonly present with acute-onset severe chest or back pain in their sixth or seventh decades of life. Aortic dissection, however, can also be seen in patients < 40 years old and may present chronically, with symptom duration longer than 2 weeks. Objective: We present an unusual case of chronic aortic dissection in a young patient, followed by a review of the literature on chronic aortic dissections and aortic dissections in young patients. Case Report: We report a case of chronic aortic dissection in a 32-year-old man with a history of untreated hypertension who presented to the ED with palpitations and mild shortness of breath. Conclusion: Acute and chronic thoracic aortic dissections can occur in patients of all ages, as well as in patients with atypical signs and symptoms.     

The 1979 Presidential Address. American Physical Therapy Association.

As I close this address, I do so with a certain sense of sadness about leaving a leadership team in a very exciting time of our professional history. I retire from this office with great faith in the leadership that will follow and with the optimism that the future will hold numerous excitements for our profession. The motivation and interactions that you have provided have caused me to dream of physical therapy in a manner I could have never envisioned on my own. Oh, how I thank you for the pleasures I have derived! I hope my remarks of today will serve to stimulate your dreams, your goals, inasmuch as the combination of our dreams and goals will bring greater fulfillment to the profession of physical therapy in the years that lie ahead.     

Headache as the initial manifestation of acute aortic dissection type A

The most common initial symptom of aortic dissection is chest pain. Other initial symptoms include pain in the neck, throat, abdomen and lower back, syncope, paresis, and dyspnoea. Headache as the initial symptom of aortic dissection has not been described previously. A 61-year-old woman with a history of migraine and arterial hypertension developed continuous bifrontal headache. Two hours later, right-sided thoracic pain and a diastolic murmur were suggestive of aortic dissection that was confirmed by echocardiography and subsequent surgery. The dissection commenced in the ascending aorta and involved all cervical arteries until the base of the skull. Headache as the initial manifestation of aortic dissection was assumed due to either vessel distension or pericarotid plexus ischemia. Aortic dissection has to he considered as a rare differential diagnosis of frontal headache, especially in patients who develop aortic regurgitation or chest pain for the first time.     

MEDLINEing. Why and how to conduct a literature search

Have you ever proposed a new prehospital intervention at your local medical advisory committee only to be stopped dead in your tracks when another participant calmly asserts that your idea is not field appropriate, has too many risks or is simply ineffective, then cites medical literature that says so? If you haven't done your homework, you must fold up your notes and quietly return to your seat. To be sure you're prepared with the best, current research for such a proposal, you need the same research tool your physician colleagues use, and that's the ability to search the MEDLINE database. Read on to learn a free and easy way to access this very powerful research tool via the Internet.     

Repeat Pregnancy after Prior Aortic Valve-in-Valve Replacement: A Cautionary Tale

Transcatheter aortic valve replacement (TAVR) within a severely stenotic native aortic valve or previously placed surgical biologic aortic valve replacement (SAVR) is a rare occurrence in pregnant patients. The short- and long-term procedural outcomes for future pregnancies in these women or any woman of child bearing age who have received prior TAVR or TAVR in SAVR, are unknown. We describe the first result of a repeat pregnancy outcome in a woman with a history of prior TAVR in SAVR. Both maternal and fetal outcomes were favorable, but maternal cardiac complications observed in the third trimester emphasize our concerns regarding risk for cardiac complications in subsequent pregnancies in patients with a prior TAVR in SAVR. Despite the maternal complications that occurred during repeat pregnancy in this patient, a successful pregnancy outcome reaffirms our recommendation to utilize a multidisciplinary team for pregnancy management in patients with prior TAVR or TAVR in SAVR and to help in the management of any cardiac complications that may occur during or shortly after pregnancy.     

Abdominal aortic aneurysm.

Abdominal aortic aneurysm is a chronic dilation of the aorta with a natural history toward enlargement and rupture. Its pathogenesis is believed to be multifactorial and complex. Clinical presentation may be asymptomatic, symptomatic, or as rupture. Elective surgery by open transperitoneal or retroperitoneal approach is the most common repair intervention. However, placing an endoluminal stent graft within the aneurysm is currently being evaluated as an alternative to open repair. Nursing care of the patient with abdominal aortic aneurysm involves intensive care skills as well as a foundation in chronic illness management. This article presents information on pathogenesis, natural history, clinical presentation, surgical interventions, and postoperative complications.     

Documenting patient refusals

Patient morbidity and mortality, subsequent to either patient- or provider-initiated refusals, are noteworthy. It has been estimated that hospital admission is twice as likely after prehospital providers refuse a patient transportation to the hospital. In one particular study group, prehospital-provider refusal of transportation, as opposed to patient refusal of transportation, accounted for 73% of the post-refusal hospital admissions. Provider-initiated refusals are tantamount to a time bomb. There are very few justifiable provider-initiated refusals of treatment or transportation. If the call is of a non-emergency nature, the decision not to treat or transport should be a mutual agreement between the patient and provider. Consult with the online medical director for guidance as needed. Document the physician's name, consulting facility and medical direction. As with every patient encounter, a legally defensible runsheet should be completed. Should you write a report if your services are "not needed," or if you are canceled en route to the call? For your protection, a report archiving every run should be documented. If your services are canceled en route, note the canceling authority and time of cancellation. If your services are canceled at the scene, document the canceling authority, time of cancellation and the circumstance. It is important to specifically document that "no patient contacts were made." When patient contact is made, a patient-provider relationship is established, thereby redefining your duty to the patient. Protect yourself, your crew members, your chain of command, your jurisdiction and your agency by writing a legally defensible informed refusal report. According to one source, "Every negligence case in the last 30 years has been decided on its documentation." If it wasn't written down, it wasn't done. Be safe, and document safely.     

Securing your PC and protecting your privacy

Working in a networked information environment brings new opportunities for getting and sharing information. Regrettably, these benefits of the Internet are challenged by forces that would interfere to satisfy their own profit or malevolent motives. Your networked computer can be infected by viruses, worms, or Trojan horses or infiltrated by spyware, adware, or pop-ups. Without being aware of the dangers and taking precautionary steps, your PC is susceptible to being compromised and your privacy invaded. This column will highlight some of the dangers and offer basic steps for securing your computer and protecting your privacy.     

Abnormal Vascular Responses to Exercise in Patients with Aortic Stenosis

We tested the hypothesis that the normal forearm vasoconstrictor response to leg exercise is inhibited or reversed in patients with aortic stenosis, possibly because of activation of left ventricular baroreceptors. Forearm vascular responses to supine leg exercise were measured in 10 patients with aortic stenosis and in 2 control groups of 6 patients with mitral stenosis and 5 patients without valvular heart disease.Forearm vasoconstriction occurred during exercise in the control groups. In contrast, forearm blood flow increased and forearm vascular resistance did not change in patients with aortic stenosis. In six patients with aortic stenosis and a history of exertional syncope, forearm vasodilatation occurred during the second minute of leg exercise. Inhibition or reversal of forearm vasoconstrictor responses in aortic stenosis was asscociated with significant increases in left ventricular pressure.In three patients with aortic stenosis and exertional syncope, forearm vasodilator responses to exercise changed to vasoconstrictor responses after aortic valve replacement.The results indicate that forearm vasoconstrictor responses to leg exercise are inhibited or reversed in patients with aortic stenosis, possibly because of activation of left ventricular baroreceptors. The observations suggest that reflex vasodilatation resulting from activation of left ventricular baroreceptors may contribute to exertional syncope in patients with aortic stenosis.     

Painless dissection of the thoracic aorta

A 64-year-old man presented to an emergency department with a two-week history of intermittent, bilateral lower extremity paralysis without associated chest, abdominal, or back pain. He subsequently deteriorated and died as a result of a thoracic aortic dissection. This unusual case is reported, and the pathophysiology, diagnosis, and management of aortic dissection are discussed.     

Puzzles in practice. Platelet satellitism

A 68-year-old woman underwent a right total hip arthroplasty for severe osteoarthritis. The surgery was uneventful without excessive blood loss, but she was found to have a platelet count of 62 000 per cm on a routine postoperative complete blood count (CBC). There was no preoperative CBC available for comparison. Other than mild anemia (Hb, 11.2 g/dL), there were no abnormalities in the automated CBC. The patient had did not have a history of easy bruisability, abnormal mucosal bleeding, gastrointestinal bleeding, or genitourinary bleeding. Her family history was negative for any bleeding disorders. The patient's only medication was acetaminophen for hip pain. The peripheral smear was reviewed and showed rosetting of platelets about polymorphonuclear leukocytes. What is your diagnosis?     

Aortic dissection with extension to a patent ductus arteriosus

An 81-year-old woman presented with shortness of breath and fever of 3 days duration. An enhanced CT of the chest revealed a patent ductus arteriosus (PDA) communicating with the true lumen of an aortic arch dissection. Neither the aortic dissection nor the PDA was suspected. The patient had no history of a connective tissue abnormality or other condition which would predispose to dissection other than systemic hypertension. It is likely that propagation of the aortic dissection partially re-opened the ductus arteriosus.     

Infected abdominal aortic aneurysm caused by nontyphoid Salmonella in an immunocompromised patient with rheumatoid arthritis

Nontyphoid Salmonella strains are important pathogens commonly found worldwide, typically causing gastrointestinal illness. Here, we report a case of a 66-yearold man with an abdominal aortic infected (or so-called mycotic) aneurysm caused by Salmonella enterica subsp. enterica serovar Enteritidis (S. Enteritidis). He had multiple risk factors for atherosclerosis: age over 60, a long history of smoking, an 8-year history of diabetes mellitus, and a 10-year history of rheumatoid arthritis treated with low-dose corticosteroids. Although he had presented with no episode of diarrhea or abdominal pain, the abdominal aortic infected aneurysm was diagnosed by blood cultures and was carefully followed up by computed tomography. An abdominal aneurysmectomy and autogenous in situ reconstruction were successfully performed consequently. Alertness to the possibility of endovascular infection is important, even if there are no symptoms except for persistent fever, when treating Salmonella bacteremia in an immunocompromised patient, particularly when there are associated atherosclerotic risk factors.