328 Echocardiographic Features Aiding in Diagnosis of type A Dissection; Forgotten Acoustic Window and Indirect Features

Abstract

Aortic dissection remains an important differential diagnosis in the patients with chest pain. Typically, echocardiographers focus on visualisation of an intimal flap from a parasternal window when a type A dissection is the suspected diagnosis and in some cases this window does not provide diagnostic features. In these cases, additional acoustics windows which demonstrate secondary features are crucial. For example, a 54-year-old man presented with sudden onset of chest pain, dizziness, dyspnoea and diaphoresis after a transient anopia on the background of hypertension, sickle cell trait and neurosurgical repair for spinal fluid leak. 1mm ST-elevation in anteroseptal leads without reciprocal changes and a minor troponin rise was identified. CT-PA excluded pulmonary embolism however indicated pericardial effusion. The first two echo studies demonstrated a pericardial effusion subcostally with the third revealing echocardiographic characteristics of hemopericardium with evidence of haemodynamic compromise, congruent with the clinical scenario of hypotension requiring fluid resuscitation. The finding of hemopericardium raised suspicion for aortic dissection or cardiac chamber perforation. CT aorta showed a penetrating ulcer within the proximal ascending aorta with mural thickening, extending from root to level of isthmus, representing a type A dissection. Successful conduit with coronary re-implantation, ascending aorta replacement and mechanical AVR were urgently pursued with desirable outcomes. In acute chest pain patients with high-risk features, the presence of pericardial haematoma should raise suspicion for acute aortic syndromes and prompt further investigation. This case highlights the importance of utilising all acoustic windows and the importance of identifying secondary features to aid in identification and intervention thus improving patient outcomes.