Ascending aortic tear with severe aortic regurgitation following rugby injury

Blunt ascending aortic injuries are rare in clinical practice. Aortic valve regurgitation is an uncommon consequence of closed chest injury. It is caused by either ruptured valve cusp or when subadventitial rupture of the ascending aorta causes prolapse of subjacent valve cusp. Most of the blunt aortic injuries are secondary to high speed motor vehicle accident or falls from significant height. We report on a 33-year-old man who sustained an injury during a rugby game and presented with severe aortic regurgitation secondary to subadventitial rupture of ascending aorta on a background of asymptomatic dilated aortic root. He underwent emergency operation for torrential aortic regurgitation and severe left ventricular failure.     

Respecting Symptoms in Thoracic Aortic Aneurysm Management: A Case of Symptomatic Necrotizing Granulomatous Aortitis

A 41-year-old woman presented with chest pain of unclear etiology in the setting of a mildly dilated ascending aorta. Computed tomography angiography showed an aorta with an irregular contour and an aneurysm of 4.5 cm. There was no radiographic evidence of rupture or dissection. The patient was taken to the operating room and was found to have severe aortitis with marked localized wall thinning at imminent risk of aortic rupture. Aortic pathology demonstrated necrotizing granulomas of noninfectious etiology. This case illustrates the importance of respecting symptoms in surgical decision making for thoracic aortic aneurysms that may not meet standard interventional criteria.     

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.     

Aortic atheromas: current knowledge and controversies: a brief review of the literature

Atheromatous disease of the aorta is a known marker of vascular disease and is associated with ischemic stroke, peripheral embolization, and coronary events. Transesophageal echocardiogram is routinely used to assess aortic atheromas. Discrepancies exist in the grading of aortic atheromas. Atheromas with >4 mm thickness or with plaque rupture and mobile fragments are more likely to be associated with peripheral embolic events. Antiplatelet agents, oral anticoagulants, and statins have been suggested in the management of atheromas but sufficiently powered, randomized, controlled trials are not available to guide medical management of atheromas.     

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.     

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.     

Bicuspid aortic valve morphology when associated with coarctation of the aorta

Thirteen children and young adults with coarctation of the aorta as their principal cardiovascular abnormality, 11 with bicuspid aortic valves, were evaluated by orifice-view aortography to evaluate their aortic valvular morphology. For comparison 30 individuals with aortic valvular deformities but without coarctation of the aorta were similarly studied. Two distinct forms of bicuspid valves could be identified characterized by either the appearance of gross inequality of size of the two valve leaflets or an appearance wherein each leaflet closely approximated the size of the other, thus equally bicuspid. Excepting two individuals with normal, tricuspid, aortic valves, all of the patients with coarctation of the aorta had equally bicuspid aortic valves which contrasted to the group without coarctation in which the unequally bicuspid type predominated. This difference in bicuspid aortic valve morphology associated with coarctation of the aorta suggests a different developmental process involving the aortic valve as opposed to the situation in individuals without coarctation.     

Early stabilization of traumatic aortic transection and mitral valve regurgitation with extracorporeal membrane oxygenation

We report a case of life-threatening aortic transection with concomitant mitral papillary muscle rupture and severe lung contusion caused by a failed parachute jump. This blunt thoracic injury was treated by early stabilization with extracorporeal membrane oxygenation followed by successful delayed graft repair of the descending aorta and mitral valve replacement with a mechanical prosthesis.     

Imaging in thoracic trauma: the trauma surgeon's perspective

Thoracic trauma is a common cause of significant disability and mortality. Most thoracic injury in developed countries results from motor vehicle crashes (MVC). Imaging of patients with thoracic trauma must be accurate and timely to avoid preventable death. Trauma surgeons prioritize imaging options based on the patient's hemodynamic status, associated injuries, and age. The screening test for the detection of life-threatening thoracic injury is the supine anteroposterior (AP) chest radiograph. Rib fractures are a marker for serious associated injuries, including abdominal injuries. Rib fractures are especially ominous in children and the elderly. Thoracic aortic injury is associated with high-speed mechanisms of injury and can occur in the absence of radiographic signs. Chest computed tomography (CT) can be used as a screening and diagnostic tool for suspected aortic injury. Aortography is reserved for patients with high suspicion of aortic injury or for confirmation of CT scan diagnosis.     

Endovascular stent-graft implantation in acute traumatic aortic dissection with contained rupture and hemorrhagic shock

BACKGROUND: Traumatic dissections of the thoracic aorta with consecutive organ ischemia are emergencies with an enormously high mortality despite immediate surgical therapy. Successful therapy of a thoracic aortic aneurysm by percutaneous implantation of a stent graft prosthesis was first reported in 1994. In recent years endovascular methods have been used increasingly for the treatment of acute aortic syndromes. CASE REPORT: After a traffic accident, a 33 year old motorcycle rider was admitted to our emergency unit conscious with clinical signs of hemorrhagic shock. His lower extremities were pulseless and paraplegia of the legs had already developed. An immediate angio-CT scan demonstrated a contained rupture of the aortic wall with mediastinal hematoma caused by a dissection beginning in the aortic arch. In the cathlab the right femoral artery was exposed and an angiography was performed showing a complete interruption of aortic blood flow caused by the transection. Under angiographic control an endovascular self-expanding nitinolstent (Talent Stent Graft, Medtronic) was implanted into the descending aorta. After moderate balloon inflation at the proximal entry, the rupture was completely closed and perfusion was restituted. The further clinical course was complicated by rhabdomyolysis necessitating additional subtotal arm amputation. Spinal ischemia resulted in persisting paraplegia of the legs. CONCLUSION: An urgent treatment of a contained rupture of the descending aorta with consecutive organ ischemia by endovascular implantation of stent graft prosthesis is technically possible. Advantages are a less invasive procedure and rapid restitution of blood flow.     

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.     

Risk factors for motor vehicle crashes in older women

BACKGROUND: Motor vehicle crash and fatality rates are higher per mile driven for elderly drivers, with an exponential increase above age 75. Identifying elderly drivers who are at risk for automobile crashes may help direct interventions to reduce their high rate of injuries and deaths. METHODS: Subjects were 1416 women aged 65 to 84 enrolled in the Portland, Ore. site of the Study of Osteoporotic Fractures. Motor vehicle crash information for the years 1986-1995 for each participant was obtained from the Oregon State Department of Transportation. Items from questionnaires, interviews, and physical examinations were tested prospectively for associations with the occurrence of motor vehicle crashes. RESULTS: About one third of participants (415 of 1416) had a motor vehicle crash during a mean follow-up time of 5.7 years. After adjustment for age and weekly driving mileage, risk factors significantly associated with motor vehicle crashes were a fall in the previous year [hazard ratio (HR) 1.53, 95% confidence interval (CI) 1.26-1.86], a greater orthostatic systolic blood pressure drop (HR 1.11 per 12.5 mm Hg, 95% CI 1.01-1.22), and increased foot reaction time (HR 1.10 per 0.06 second, 95% CI 1.00-1.22). Other neuromuscular tests, functional status, medical diagnoses, vision tests, and cognitive tests did not predict motor vehicle crashes in this study population. CONCLUSIONS: This prospective study with extended follow-up of a large cohort of elderly women has identified crash risk factors that can be measured in the clinical setting. Further study is needed to determine if interventions aimed at these risk factors can decrease the risk of motor vehicle crashes.     

Post-traumatic pseudoaneurysm of the ascending aorta—an incidental finding two decades later

Traumatic rupture of the aorta following blunt trauma is a wel 1 described entity. Rupture of the ascending aorta is frequently associated with concomitant cardiac damage and immediate death with few long-term survivors described in the literature. A case of traumatic pseudoaneurysm of the ascending aorta discovered two decades after the initial injury is reported.     

Endovascular treatment of thoracic aortic disease: mid-term follow-up.

OBJECTIVE: The aim of this study was to evaluate the mid-term follow-up in a cohort of patients with acute or chronic descending aortic disease treated by stent-graft repair. BACKGROUND: Since 1999, endovascular stent-graft placement has been reported as an alternative treatment to surgical approach for a variety of thoracic aortic diseases; however, results beyond initial short-term follow-up are not widely available for the broad range of applications. METHODS: From March 2001, 43 consecutive patients with traumatic aortic transection (group A = 16) and complicated type B aortic dissection or aneurysm (group B = 27) underwent stent-graft implantation. All patients underwent computed tomography (CT) scan as preoperative assessment and in 26 a transesophageal echo (TEE) exam was performed. RESULTS: Technically successful stent-graft deployment was achieved in all patients. No patient required surgical conversion and no cases of paraplegia occurred. The overall in-hospital mortality was 9.3%. A residual endoleak (type II) was detected in one group B patient who was managed conservatively. The mean follow-up was 29 +/- 8 months (range 10-48 months). No patient died during late follow-up after hospital discharge. At 12 months, one patient (2.5%) who had stent graft repair of an aortic dissection developed an asymptomatic type I endoleak. Three asymptomatic patients with chronic dissection had a persistent retrograde perfusion of the thoracic false lumen via a distal tear(s) in the dissection septum. CONCLUSION: Our results of stent-graft treatment of complicated and uncomplicated diseases of the descending aorta confirms that this alternative to open repair is a safe, less invasive, and relatively low risk approach. Medium-term follow-up results suggest that it is effective and durable therapy with low associated mortality and morbidity rates.     

Flail aortic valve and acute aortic regurgitation due to spontaneous localized intimal tear of ascending aorta

This report describes the transesophageal echocardiographic findings of acute severe aortic regurgitation resulting from localized transverse intimal tear of ascending thoracic aorta which could not be suspected as a cause of flail aortic valve preoperatively. In patients with chest pain and acute aortic regurgitation associated with flail aortic valve, localized intimal tear of aorta should be considered as a possible cause of flail aortic valve.     

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.     

Prediction of traumatic aortic rupture from plain chest film findings using stepwise logistic regression

We reviewed initial chest radiographs of 21 patients with, and 26 without, aortic rupture, and examined the presence or absence of individual signs previously cited to be associated with aortic rupture. Using stepwise logistic regression, the three most significant signs associated with rupture were loss of aortic contour, tracheal deviation, and mediastinal-to-chest ratio. A formula calculating the probability of aortic rupture (P) using these three variables was derived. Using a low cutoff point, this equation would approach 100% sensitivity in detecting aortic rupture while reducing the number of negative aortographs. The reliability of this equation and the optimal cutoff point must be determined in a prospective study before being used to make clinical decisions.     

Isolated supravalvular aortic stenosis with left ventricular diverticulum and cleft mitral valve: Surgical repair in adulthood

Supravalvular aortic stenosis is an uncommon but well characterized congenital narrowing of the ascending aorta above the level of the coronary arteries. It can be a familial disorder, can occur sporadically, or can be associated with Williams syndrome. We are reporting a very rare presentation of supravalvular aortic stenosis with associated left ventricular diverticulum and cleft mitral valve. Repair consisted of resection of the ascending aorta, patch augmentation of the aortic root, and mitral valve repair. Follow-up echocardiography demonstrated normal mitral and aortic valve function and a postoperative three-dimensional computed tomographic scan showed a normal shape of the reconstructed ascending aorta.