https://orcid.org/0009-0001-3039-1749
This Spot the Diagnosis article refers to ‘Answer: Diagnostic dilemma in a critical extracorporeal membrane oxygenation patient: a case of uncertain aortic pathology’, by C. Gregório et al., https://doi.org/10.1093/ehjacc/zuaf016.
Case description
A 56-year-old male experienced an episode of chest pain followed by cardiopulmonary arrest (CPA) upon arrival of the pre-hospital emergency team. Vigorous basic life support measures were initiated, and one shock was delivered according to the recommendation of the automatic external defibrillator, resulting on spontaneous circulation return. During pre-hospital transport, the patient experienced a second episode of CPA with a shockable rhythm. Advanced life support measures were initiated. The patient was admitted to our hospital after 56 min of appropriate cardiopulmonary resuscitation, on refractory cardiogenic shock. Brainstem reflexes were preserved, and we decided to implement short term circulatory support with femoro-femoral veno-arterial extracorporeal membrane oxygenation, as a bridge to potential recovery. The patient had no significant past medical history, although he was a heavy smoker.
At admission, the electrocardiogram showed sinus rhythm with intraventricular conduction disturbance characterized by widened QRS complexes, consistent with a complete right bundle branch block pattern (de novo). Laboratory results were consistent with mild lactic acidosis (lactic acid 2.1 mmol/L), acute kidney injury (creatinine 1.79 mg/dL), a slight increase in creatine kinase (570 U/L), in cardiac troponin T level (81 ng/mL), and in N-terminal pro-brain natriuretic peptide (20 pg/mL). A limited transthoracic echocardiogram revealed severe left ventricular dysfunction due to diffuse hypokinesia, no significant valvular lesions, normal ascending aorta, and no pericardial effusion.
The patient was transferred to the cardiac catheterization laboratory. During the attempt to right coronary artery catheterization and following the injection of intravenous contrast, contrast retention was observed in the aortic root. An aortography beyond the aortic arch also showed incomplete opacification of the aortic arch, consistent with type A aortic dissection (Figure 1A; see Supplementary material online, Video S1). The procedure was immediately stopped and a thoracic contrast-enhanced computed tomography was performed. Cross-sectional images of the arterial phase showed a clearly delineated contrast-blood layering in the ascending and descending aorta (Figure 1B–D).
CECT and coronary angiography in a patient on VA-ECMO. (A) Aortography showing contrast retention in the coronary sinuses, raising suspicion of type A aortic dissection. (B and C) CECT axial images reveal contrast layering in the ascending and descending aorta (white and yellow arrows, respectively) during the arterial phase. (D) CECT axial images demonstrate pseudo-layering in the descending aorta (yellow arrows) during the arterial phase, with the left ventricle appearing non-opacified. CECT, contrast-enhanced computed tomography; VA-ECMO, veno-arterial extracorporeal membrane oxygenation.
A bedside transoesophageal echocardiogram was also performed, showing a non-dilated ascending aorta, with no evidence of dissection flap, and a competent aortic valve. After a multidisciplinary discussion involving Cardiology, Cardiac Surgery and Intensive Care Medicine, open-heart surgery was performed.
Question:
What is the most likely diagnosis?
Aortic intramural haematoma
Aortic dissection
Flow artefact mimicking aortic dissection
Aortic aneurysm rupture
Supplementary material
Supplementary material is available at European Heart Journal: Acute Cardiovascular Care online.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Data availability
No new data were generated or analysed in support of this research.
Author notes
Conflict of interest: none declared.
Comments