Διαχωρισμός αορτής. Ματθαίος Διδάγγελος Ειδικευόμενος Καρδιολογίας Α Πανεπιστημιακή Καρδιολογική Κλινική Π.Γ.Ν.Θ. ΑΧΕΠΑ

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1 Διαχωρισμός αορτής Ματθαίος Διδάγγελος Ειδικευόμενος Καρδιολογίας Α Πανεπιστημιακή Καρδιολογική Κλινική Π.Γ.Ν.Θ. ΑΧΕΠΑ

2 Disclosures None

3 Clinical Case

αιφνίδιας έναρξης ΑΥ (διέκοψε αγωγή) Κάπνισμα Παχυσαρκία (ΒΜΙ=33,02 kg/m

4 Άνδρας, 48 ετών Διακομιδή από περιφερειακό Νοσοκομείο Έντονο οπισθοστερνικό άλγος από 3ώρου περίπου με αντανάκλαση στη ράχη, συνεχές, αιφνίδιας έναρξης ΑΥ (διέκοψε αγωγή) Κάπνισμα Παχυσαρκία (ΒΜΙ=33,02 kg/m 2 ) Πολυκυστική νόσος νεφρών ΑΠ: 150/90 mmhg 55 bpm SpO 2 = 96% hstnt=62 pg/ml (ΦΤ<14)

5 Άνδρας, 48 ετών

6 Άνδρας, 48 ετών Ασπιρίνη Ticagrelor (φόρτιση) Tirofiban Fondaparinux d-dimers=1002 ng/ml (ΦΤ<500) Στεφανιαία αγγεία: ΚΦ Type A Aortic Dissection Προς ΚΧ αντιμετώπιση - απεβίωσε

8 Definition

9 Epidemiology Incidence: 6/100,000/year ED with chest ± back pain: 3/1,000 Autopsy: 1-3% Men > women Blacks > whites > asians Peak incidence in ages years Ayala et al 2012

10 Risk factors 1. Arterial Hypertension (poorly controlled): 65-75% 2. Pre-existing aortic diseases 3. Aortic valve disease (bicuspid AoV) 4. Family history of aortic diseases (Marfan s Syndrome or Ehler-Danlos Syndrome) 5. History of cardiac surgery 6. Cigarette smoking 7. Direct blunt chest trauma 8. Use of intravenous drugs (cocaine, amphetamines) 9. Pregnancy

11 72.5% 27.5% Kobza et al 2002

12 Clinical classification duration of symptoms Acute AD < 14 days Sub-acute AD: days Chronic AD > 90 days ESC Guidelines Aortic Diseases 2014

13 Mortality Acute Type A 1%/hour initially 50% by 3 rd day 80% by 2 nd week Acute Type B 10% at 30 days

14 Sharp, ripping, tearing, knife-like

15 Most specific characteri stic

16 Doubling of mortality

17 Misleading to ACS diagnosis and treatment

19 D-dimers D-dimers is immediately very high (compared with other disorders in which the D-dimer level increases gr adually) D-dimers yielded the highest diagnostic value during the first hour If the D-dimers are negative, IMH and PAU may still be present

21 Clinical Case

22 Άνδρας, 65 ετών ΑΥ υπό αγωγή

24 Which to chose?

25 Which to chose? Computed tomography, MRI, and TOE: equally reliable for confirming or excluding the diagnosis of AscAD CT and MRI: superior to TOE for the assessment of AAD extension and branch involvement, as well as for the diagn osis of IMH, PAU, and traumatic aortic lesions TOE-Doppler: superior for imaging flow across tears and identifying their locations

26 Sensitivity 77-80% 99% 95% 98% Specificity 93-96% 89% 96% 98%

27 Chest x-ray Wide mediastinum

intercostal spaces, obesity, pulmonary emphysema, and mechanical ventilation

28 Echo TTE-TOE Intimal flap (TTE-TOE) Extent of dissection (TTE-limited TOE) TTE restricted in patients with abnormal chest wall configuration, narrow intercostal spaces, obesity, pulmonary emphysema, and mechanical ventilation (TOE indicated) Distal segment of the ascending aorta: blind spot in TOE Entry Reentry site (TOE)

has slower flow and a larger diameter and may contain thrombi Cobweb sign Triple rule-out CT: ECG-gated 64

29 CT The most commonly used imaging technique Specific, precise measurements of the extent of dissection (including length and diameter of the aorta, and the TL and FL) involvement of vital vasculature, FL usually has slower flow and a larger diameter and may contain thrombi Cobweb sign Triple rule-out CT: ECG-gated 64 detector for AoDis, PulmEmbol, CAD Artefacts: Aorta pulsation Dense contrast enhancement Mediastinal clips Indwelling catheters

MRI Is considered the leading technique Demonstrates the extent of the disease and depicts the distal ascending aorta and the aortic arch in more detail Entry Reentry site Presence

31 MRI Is considered the leading technique Demonstrates the extent of the disease and depicts the distal ascending aorta and the aortic arch in more detail Entry Reentry site Presence of pericardial effusion, aortic regurgitation, carotid artery dissection, proximal coronary arteries Several methodological and practical limitations (cost, time, unstable patients)

32 Aortography No longer used for the diagnosis of AD, except during coronary angiography or endovascular intervention.

36 Clinical Case

37 Άνδρας, 59 ετών ΑΥ (αρρύθμιστη υπό αγωγή)

38 Άνδρας, 59 ετών

40 The term complicated means persistent or recurrent pain, uncontrolled hypertension despite full medication, early aortic expansion, malperfusion, and signs of rupture (haemothorax, increasing periaortic and mediastinal haematoma).

41 Chronic AD (>90 days) Survivors of an acute AD Previously operated for Type A AD, with persisting dissection of the descending aorta Uncomplicated: stable disease course Complicated: progressive aneurysmal degeneration, chronic visceral or limb mal perfusion, and persisting or recurrent pain or even rupture Imaging Diagnosis: CT, TOE, or MRI Chronicity of AD: thickened, immobile intimal flap, presence of thrombus in the FL, aneurysms of the thoracic aorta secondary, signs of (contained) rupture such as mediastinal haematoma or pleural effusion

42 What to remember AD - rare but fatal clinical entity Insidious diagnosis keep in mind risk factors (arterial hypertension) clinical presentation (abrupt onset of sharp pain) d-dimers echo CT Type A surgery Type B conservative

44 George II of Great Britain Frank Nicholls (the King's personal physician) Type A AD

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