ST Elevation in Lead aVR with Malperfusion Syndrome: Sign of Severe Aortic Dissection

Aortic dissection presenting with ST elevation in lead aVR of electrocardiogram is strongly associated with mortality. It is also associated with dissection involving the root of aorta and coronary vessels. We report a case of young male with hypertension, who presented with severe chest pain and unilateral lower limb pain. Physical examination of the left lower limb was consistent with acute limb ischemia. Electrocardiogram revealed acute anterolateral myocardial infarction together with ST elevation in aVR. Bedside transthoracic echocardiography showed a dilated aortic root measuring 4.51 cm with presence of intimal flap which raised the suspicion of dissection of root of aorta and left coronary artery. Computed tomography angiogram revealed aortic dissection from the root of aorta including the intimal flap near the origin of the left coronary artery, down to common iliac extending to the left iliac artery. Unfortunately, the patient opted for non-surgical intervention and succumbed 48 hours later. This case highlights that in case of aortic dissection, which presents with malperfusion syndrome, the presence of ST segment elevation at lead aVR should raise the suspicion for extensive aortic dissection involving the aortic root and left coronary artery which signifies unfavourable outcome

Acute liver failure and seizure: a case report of an unusual presentation of acute painless aortic dissection

Background Painless aortic dissection presenting with seizure and acute liver failure is uncommon. We described a case of early recognition leading to successful treatment of painless aortic dissection with atypical presentation. Case summary A young lady presented with generalized tonic-clonic seizures coupled with hepatitic pattern of deranged liver function test. Examination revealed blood pressure of 99/75 mmHg and hepatic flap. Electrocardiography showed sinus tachycardia. Urgent bedside echocardiography showed preserved cardiac function without significant valvular pathology, but noted a moderate pericardial effusion. Abdominal Ultrasound excluded liver cirrhosis or biliary obstructions. Viral hepatitis serologies and anti-liver panel were negative. She was progressively hypotensive with concurrent acute liver failure and oliguric acute kidney injury. Despite no chest pain, her rising serum troponin and widened mediastinum prompted an urgent computed-tomography aortogram, which showed a 4.3 cm dilatation of ascending thoracic aorta with acute haemopericardium and cardiac tamponade. She was diagnosed with malperfusion syndrome from Stanford type A aortic dissection. She underwent emergent ascending aorta and aortic arch repair and dialysis. She experienced complete recovery in her kidney, liver, and neurological function post-operatively. Discussion Painless aortic dissection masquerade as acute liver failure is uncommon. We describe a successful early recognition of malperfusion syndrome from painless aortic dissection, thus providing window for timely, life-saving intervention. Clinical challenges in this case include: (i) atypical presentation of aortic dissection, (ii) worsening acute liver failure which could lead to unnecessary liver transplantation, and (iii) risk of contrast-induced nephropathy in the setting of acute renal failure.

Abstract 13504: Timely Recognition and Successful Clinical Outcome of an Acute Debakey Type I Aortic Dissection

Background: Acute Aortic dissection is a critical etiology of chest pain with very high mortality. 1% to 2% of patients die per hour during the initial 24 to 48 hours. Case: A 62 year old lady with history of diabetes, hypertension, hyperlipidemia, hypothyroidism, smoking and no pertinent family history presented with atypical chest pain. She remained hemodynamically stable with no discrepancy of BP between arms. Labs: troponin 0.64, 0.63 ng/ml. EKG: sinus bradycardia. Chest x-ray: no mediastinal widening or signs of aortic aneurysm. Coronary angiogram showed 20-30 % stenosis in left anterior descending and right coronary arteries. An aortogram showed dilated aortic root over 6 cm with aortic regurgitation. Decision-making: An emergent echocardiogram confirmed acute aortic regurgitation and dissection. CT angiogram showed DeBakey type I aortic dissection extending from aortic annulus to infra renal aorta, supra aortic great vessels, celiac axis and left renal artery. She had no signs of malperfusion syndrome. She was started on iv Esmolol and emergently airlifted to tertiary care facility for surgical repair. Intra operative TEE showed findings consistent with acute aortic dissection. She had successful modified Bentall procedure with replacement of aortic valve, aortic root, ascending aorta and hemi arch. She had excellent recovery and continues to do well at follow up visits in our clinic. Conclusion: An early diagnosis of acute aortic dissection requires high index of suspicion due to variable symptoms and clinical manifestations. DeBakey type I aortic dissection may have better chance of survival in the absence of malperfusion syndrome if treated early as in this case.