Cardiothoracic Surgery: Student/Resident Case Report Poster - Cardiac and Thoracic Surgery |

An Unusual Case of Complete Aortic Dissection in a Low-Risk Female FREE TO VIEW

Adnan Raza, MD; Mouzam Faroqui, MD; Salman Haq, MD
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New York Methodist Hospital, Brooklyn, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):60A. doi:10.1016/j.chest.2016.08.067
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SESSION TITLE: Student/Resident Case Report Poster - Cardiac and Thoracic Surgery

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: An interesting presentation of complete aortic dissection in a patient with minimal risk factors.

CASE PRESENTATION: 46-year-old female with past medical history of morbid obesity, hypertension presented with achy, midsternal chest pain for six hours. It was constant, 7/10, non-radiating, worse with deep inspiration, and with one episode of vomiting. She received no relief from Aspirin, Nitro, nor Morphine. Review of symptoms was unremarkable except for left sided abdominal pain. She was a non-smoker and non-compliant with her hypertensive medications. Her vital signs on admission were BP 120/86 in the left and right arm, HR 78, and respiration rate 26. She had sternal and left abdominal tenderness. Labs including cardiac biomarkers were within normal limits except for an elevated creatinine of 1.25 with no baseline and d-dimer greater than 1000. Chest x-ray showed widened mediastinum. EKG showed normal sinus rhythm with nonspecific t wave changes. A CT Angiogram showed an ascending dissection that continued into the bilateral common iliac arteries infarcting the inferior pole of the left kidney. She was taken to the operating room for an emergent aortic repair and was discharged after one week.

DISCUSSION: This is an atypical presentation of a middle-aged female with no smoking history and one year history of untreated hypertension. She presented normotensive with achy midsternal chest pain that was tender and aggravated by inspiration. These symptoms could have been misdiagnosed as costochrondritis or a rib fracture. The only findings suggestive of a dissection were an elevated creatinine, elevated d-dimer, and mediastinal widening. Therefore, it is important to use both clinical judgment and imagining when suspecting aortic dissection.

CONCLUSIONS: Even when history and physical exam point to a benign etiology, be aware of creatinine elevations, nonspecific t waves changes, and widened mediastinum which may suggest an aortic dissection requiring further workup.

Reference #1: Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, Evangelista A, Fattori R, Suzuki T, Oh JK, Moore AG, Malouf JF, Pape LA, Gaca C, Sechtem U, Lenferink S, Deutsch HJ, Diedrichs H, Marcos y Robles J, Llovet A, Gilon D, Das SK, Armstrong WF, Deeb GM, Eagle KA. International Registry of Acute Aortic Dissection (IRAD): new insights from an old disease. JAMA. 2000;283:897-903.

Reference #2: Braverman AC, Thompson R, Sanchez L. Diseases of the aorta. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald’s Heart Disease. 9th ed. Philadelphia, Pa: Elsevier

Reference #3: Asha, SE; Miers, JW (21 March 2015). “A Systematic Review and Meta-analysis of D-dimer as a Rule-out Test for Suspected Acute Aortic Dissection.” Annals of Emergency Medicine 66:368-78

DISCLOSURE: The following authors have nothing to disclose: Adnan Raza, Mouzam Faroqui, Salman Haq

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