Disorders of the Mediastinum |

When Routine Physical Exams Save Lives: A Case of Massive Thoracic Aneurysm With Dissection in a Healthy Young Active Male FREE TO VIEW

Yenal Harper, MD; Khalid Al-Khafaji, MD; Zaid Haddad, MD; George Sousanieh, MD; Marwan Odeesh, MD; Sneha Parmar, MD; Yazan Ghosheh, MD; Raul Gazmuri, MD; Amin Nadeem, MD
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Rosalind Franklin University, Buffalo Grove, IL

Chest. 2015;148(4_MeetingAbstracts):422A. doi:10.1378/chest.2236052
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SESSION TITLE: Disorders of the Mediastinum Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Thoracic Aortic Aneurysm (TAA) is a life threatening condition that affects men two to four times more than women in the sixth and seventh decades of life. In the thoracic aorta, a diameter more than 3.5 cm is considered dilated while a diameter more than 4.5 cm is considered aneurysmal. The prevalence and incidence of TAA is difficult to measure since it is a characteristically silent disease. Reported incidence is 5.9 per 100,000, and is increasing possibly due to the aging population and an increase in detection from imaging. (1) The majority of TAA's are degenerative and occur in association with atherosclerosis risk factors. (2)

CASE PRESENTATION: We present the case of a 44 year old African American male who was referred to our facility after a routine employment health check revealed a cardiac murmur. He was otherwise asymptomatic except for occasional dyspnea on exertion. His exercise tolerance was excellent and included weightlifting for about 2 hours multiple times a week with no significant limitation and playing basketball. He smoked about 5 cigarettes a day on weekends and denied illicit drug use. Physical exam was as follows: Temp 97.3F, pulse 79bpm, BP 150/56, RR 20 and SP02 was 97%. Cardiac examination revealed a grade 4/6 pansystolic apical murmur and 3/4 sternal border diastolic decrescendo murmur. This along with wide pulse pressure was suspicious for severe aortic regurgitation (AR). 2D echocardiogram revealed enlarged left ventricle with marked dilation of aortic root (6.8 cm) and severe wide open AR . CTA confirmed the aneurysmal dilatation of aortic root measuring 7.6 cm in diameter and also reported a curvilinear focus which was suspicious for dissection and later confirmed with TEE. He underwent surgery where a hemashield heart tube graft replaced the ascending aorta and the hemiarch. The aortic valve was replaced with a St. Jude's mechanical prosthesis, the right and left coronaries were re-implanted and he also underwent mitral valve annuloplasty.

DISCUSSION: Despite having a massive TAA and dissection, the patient had excellent exercise tolerance and minimal symptoms. His risk factors for developing TAA included smoking and untreated hypertension. Pathologic evaluation of the tissue samples from the aortic leaflets documented hyalinization/fibrosis and myxoid degenerative changes and atherosclerosis. Testing for syphilis and genetic testing for Marfan's syndrome was also negative.

CONCLUSIONS: As seen in our patient, massive TAA can be a silent killer. However more importantly and highlighting the importance of this case, thoracic aortic dissection may also be asymptomatic. The patient was still able to engage in strenuous physical exercise which may have placed him in grave and fatal risk.

Reference #1: Isselbacher EM. Thoracic and abdominal aortic aneurysms. Circulation. 2005 Feb 15;111(6):816-28.

Reference #2: Reed D, Reed C, Stemmermann G, Hayashi T. Are aortic aneurysms caused by atherosclerosis? Circulation. 1992 Jan;85(1):205-11.

DISCLOSURE: The following authors have nothing to disclose: Yenal Harper, Khalid Al-Khafaji, Zaid Haddad, George Sousanieh, Marwan Odeesh, Sneha Parmar, Yazan Ghosheh, Raul Gazmuri, Amin Nadeem

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