1. Dissecting Aortic Aneurysm

2. Case I  23 y American male visiting his girlfriend  Seen in ER because of chest pain few hours duration  Sudden central, severe radiating to back  No realtion to exertion  Associated mild SOB

3. History  No cough,hemoptysis, orthopnea, PND  No fever, leg pain  No similar episode in the past  SR : 1-2 minutes loss of vision Rt eye

4. Examination  BP 245 / 140 HR 95 SR afebrile RR 18 Sat 95% RA RR 18 Sat 95% RA  Chest : clear, good BS  CVS : S1+ S2 +? S4  Abd & LL : NAD  CNS N

5. Investigation  CBC, PTT, INR N  BUN, Creat & Lytes N  EKG borderline LVH  CXR

6. Hospital Course  Initially patient was discharged from ER  Called back because of radiologist report  When reevaluated  chest pain minimal Still BP 240/140 Still BP 240/140  CT chest oredered

7. Hospital Course  Patient was admitted under CVT  Labetalol for HTN  Repair of Type A Aortic dissection  Uneventful OR  Recovering inhospital  flying back to Hawaii

8. Pathophysiology  Tear in aortic intima  Degeneration of aortic media {cystic medial necrosis} {cystic medial necrosis}  Blood pass through intimal tear  separation of intima from surrounding layers  false lumen creation  separation of intima from surrounding layers  false lumen creation

9. Incidence  464 pt 12 centers 1996  1998 International registry of aortic dissection IRAD International registry of aortic dissection IRAD  Incidence 2-3 /100,000  Male with age 68-80  HTN major risk factor Jama Feb 2000 Jama Feb 2000

10. Predisposition  Congenital : preexisting aneurysm, coarctation & Bicuspid aortic valve & Bicuspid aortic valve  Collagen disorders Marfan syndrome & Ehlers- Danols Syndrome & Ehlers- Danols Syndrome  Vasculitis : Takayasu & Giant cell arteritis  Cocaine  Trauma : Cardiac cath, blunt chest injury

11. Classification  Daily or Stanford system Type A  involving the ascending aorta Type A  involving the ascending aorta Type B  all other dissections Type B  all other dissections  DeBakey system Type I dissection  ascending & descending Type I dissection  ascending & descending Type II  confined to the ascending aorta Type II  confined to the ascending aorta Type III  confined to the descending aorta Type III  confined to the descending aorta

12. Presentation  Pain : chest, back or abdomen  Hypertension  Organ related : CVS  AR, tamponade, MI CVS  AR, tamponade, MI CNS  neurological deficits CNS  neurological deficits Gut, renal or limb ischemia Gut, renal or limb ischemia

13. Diagnosis  250 pt  prediction model  Multivariate analysis  3 predictors Pain immediate tearing Pain immediate tearing Pulse or BP differentials Pulse or BP differentials Mediastinal or aortic widening Mediastinal or aortic widening All 3 –ve  probability of having dissection 7% All 3 –ve  probability of having dissection 7% All 3 +ve  84% All 3 +ve  84% Arch Intern Med 2000 Oct Arch Intern Med 2000 Oct

14. Diagnosis  CXR 464 pt IRAD Mediastinal widening  63% Ttype A 56% Type B 56% Type B CXR N  11% Type A 16% Type B 16% Type B Jama Feb 2000 Jama Feb 2000

15. Diagnosis  Smooth muscle myosin heavy chain 30 minute serum assay 95 aortic dissection, 48 MI, 131 control Aortic dissection Vs control  sensitivity 91% & specificity 98%  sensitivity 91% & specificity 98% Aortic dissection Vs MI  specificity 85%  specificity 85% Ann Intern Med 2000 Oct Ann Intern Med 2000 Oct

16. Diagnosis  MRI Vs TEE 35 pt with clinically suspected dissection TTE Vs TEE Vs MRI Gold standard  autopsy, Angiography intraoperative findings intraoperative findings TTE less reliable for type B TEE & MRI sensitivity > 93% Int Jr Card Imaging Mar 1994 Int Jr Card Imaging Mar 1994

17. Management  Type A  surgical Rx Type B  medical Rx Type B  medical Rx surgical if dissection continued surgical if dissection continued or impair organ perfusion or impair organ perfusion  Pain & BP control decrease DP/DT  B blocker decrease DP/DT  B blocker

18. Management  35 pt type A with tamponade  shock 17 pt standard Rx (IVF +pressors +Sx) 17 pt standard Rx (IVF +pressors +Sx) Vs 18 standard Rx +ACTH 10 mg upon ER arrival (20-40 from emergency call) arrival (20-40 from emergency call) Higher MAP in ACTH 30 day survival 87% ACTH Vs 48% P<0.02 Lancet 2001 Mar Lancet 2001 Mar