Diagnosis Of Acute Chest Pain Research Articles

Quadruple-Rule-Out Computed Tomography Angiography (QRO-CT): A Novel Dual-Energy Computed Tomography Technique for the Diagnostic Work-Up of Acute Chest Pain.

Computerized tomography (CT) has been increasingly utilized in the differential diagnosis of acute chest pain. Combining the triple rule out CT angiography (TRO-CT) approach with dual-energy CT (DECT) can enhance the diagnostic capability by identifying myocardial perfusion deficiencies. This combination can yield a quadruple-rule-out computed tomography angiography (QRO-CT) technique. The aim of this study is to determine the efficacy of the QRO-CT. Intraluminal diseases and abnormalities in the main coronary arteries and branches were investigated. The myocardial dark spots on the color-coded iodine map were identified as perfusion deficiencies. Pulmonary arteries and aorta were also evaluated. The study population consisted of 211 patients. The sensitivity, specificity, and positive and negative predictive values of QRO-CT for pulmonary embolism were 93.5%, 100%, 100%, and 95.3%, respectively. For obstructive coronary artery disease, the values were 96.1%, 93.4%, 89.2%, and 97.7%, respectively. For myocarditis, the values were 69.2%, 100%, 100%, and 93.6%, respectively. the QRO-CT method may successfully evaluate myocardial perfusion deficits, hence expanding the differential diagnosis capabilities of the standard TRO-CT method for myocarditis. It can provide useful information on myocardial perfusion, which may influence the choice to perform invasive catheterization in cases of coronary artery obstruction.

Epipericardial fat necrosis in chest CT and MRI: a case report of an unusual cause of chest pain associated with the initial diagnosis of undifferentiated connective tissue disease

BackgroundEpipericardial fat necrosis (EFN) is a benign and self-limited condition of unknown cause with a good prognosis, usually affecting otherwise healthy patients. Clinically, it presents with severe acute left pleuritic chest pain, often leading the patient to the Emergency Room (ER).Case presentationA 23-year-old male, smoker (5 pack-years), was evaluated in the ER due to left pleuritic chest pain, worsening with deep breathing and Valsalva maneuver. It was not associated with trauma and did not present other symptoms.The physical examination was unremarkable. The arterial blood gases while breathing room air and the laboratory tests, including D-dimers and high-sensitivity cardiac Troponin T, were normal. The chest radiograph, electrocardiogram, and transthoracic echocardiogram showed no abnormalities.A computed tomography (CT) pulmonary angiogram showed no signs of pulmonary embolism but depicted at the left cardiophrenic angle a focal 3 cm ovoid-shaped fat lesion with stranding and thin soft tissue margins, consistent with necrosis of the epicardial fat, which was confirmed by magnetic resonance (MRI) of the chest.The patient was medicated with ibuprofen and pantoprazole, with clinical improvement in four weeks. At a two-month follow-up, he was asymptomatic and presented radiologic resolution of the inflammatory changes of the epicardial fat of the left cardiophrenic angle on chest CT. Laboratory tests revealed positive antinuclear antibodies, positive anti-RNP antibody, and positive lupus anticoagulant. The patient complained of biphasic Raynaud’s phenomenon initiated five years ago, and a diagnosis of undifferentiated connective tissue disease (UCTD) was made.ConclusionsThis case report highlights the diagnosis of EFN as a rare and frequently unknown clinical condition, which should be considered in the differential diagnosis of acute chest pain. It can mimic emergent conditions such as pulmonary embolism, acute coronary syndrome, or acute pericarditis. The diagnosis is confirmed by CT of the thorax or MRI. The treatment is supportive and usually includes non-steroidal anti-inflammatory drugs. The association of EFN with UCTD has not been previously described in the medical literature.

Evaluation and Diagnosis of Acute Chest Pain

Acute chest pain is a frequent cause of visits to emergency departments. As the major etiologies of such pain include life-threatening acute myocardial infarction, aortic dissection, and pulmonary embolism, prompt diagnosis and management are essential. After exclusion of coronary artery disease, other cardiac causes must be considered. In this review, we discuss the diagnosis of acute chest pain with a focus on clinical symptoms and the initial examination.

St-elevation myocardial infarction in a healthy 16-year-old adolescent: a clinical case

Background. Diagnosis of acute myocardial infarction (AMI) in pubertal patients is a diagnostic challenge, as individuals of such a young age usually do not have traditional risk factors for coronary heart disease (CHD) and, as a result, are at increased risk of misdiagnosis.Objective. To describe a clinical case of AMI in a 16-yearold patient against the background of complete well-being.Design and methods. A 16-year-old patient, against the background of complete well-being, developed pressing pains in the chest, which stopped on their own after a few hours. During hospitalization, in addition to an increase in the level of troponin, the results of other laboratory and instrumental studies did not confirm the version of AMI, as a result of which other cardiac and non-cardiac causes of the development of chest pain formed the basis of the diagnostic search. This was the reason for the delayed diagnosis and endovascular treatment of thrombotic occlusion of the right coronary artery, and, as a result, the formation of an area of persistent hypokinesia of the lower parts of the left ventricle. Further search for possible causes of AMI, including the analysis of genetically associated conditions, did not yield results.Results. This publication describes a case of acute inferior myocardial infarction with ST segment elevation and thrombotic occlusion of the right coronary artery in a 16-year-old adolescent and the impact of an irrational diagnostic process on long-term prognosis.Conclusion. The presented clinical case demonstrates the importance of including the diagnosis of AMI in the process of differential diagnosis of acute chest pain, even in adolescent patients.

High-Sensitivity Cardiac Troponin and the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guidelines for the Evaluation and Diagnosis of Acute Chest Pain.

The 2021 American Heart Association/American College of Cardiology/American Society of Echocardiography/American College of Chest Physicians/Society for Academic Emergency Medicine/Society of Cardiovascular Computed Tomography/Society for Cardiovascular Magnetic Resonance guidelines for the evaluation and diagnosis of acute chest pain make important recommendations that include the recognition of high-sensitivity cardiac troponin (hs-cTn) as the preferred biomarker, endorsement of 99th percentile upper reference limits to define myocardial injury, and the use of clinical decision pathways, as well as acknowledgment of the uniqueness of women and other patient subsets. Details on how to integrate hs-cTn into clinical practice are less extensively addressed. Clinicians should be aware of some of the analytical aspects related to hs-cTn assays regarding the limit of detection and the limit of quantitation and how they are used clinically, especially for the single sample strategy to rule out acute myocardial infarction. Likewise, it is important for clinicians to understand issues related to the derivation of the 99th percentile upper reference limit; the value of sex-specific 99th percentile upper reference limits; how to use changing concentrations (deltas) to facilitate diagnosis and risk stratification of patients with suspected acute coronary syndrome, including the differentiation of acute from chronic myocardial injury; and how to best integrate the use of hs-cTn with clinical decision pathways. With the use of hs-cTn, conditions such as type 2 myocardial infarction become more common, whereas others such as unstable angina become less frequent but still occur. Sections relating to these issues are included.

Diagnostic Value of Multislice Spiral CT Cardiothoracic Combined with Angiography in Acute Chest Pain.

Acute chest pain is a common clinical emergency condition with a variety of causes, including acute coronary syndrome, pulmonary embolism, aortic coarctation, and pneumothorax. It is essential for emergency physicians to quickly and accurately understand the cause of acute chest pain. 64-slice spiral CT combined cardiothoracic angiography is an accurate and rapid way to diagnose and differentiate the cause of acute chest pain. 64-slice combined cardiothoracic angiography can accurately and rapidly display the thoracic aorta, both pulmonary arteries, the main trunk of the coronary artery and its major branches, and also provide a comprehensive view of both lungs and mediastinum, which is an effective test for the diagnosis and differential diagnosis of acute chest pain. Based on this, this study further investigated the value of 64-slice spiral CT triplex examination in the diagnosis of acute chest pain. The results showed that 64-slice spiral CT has the advantages of fast scanning speed, high resolution, and advanced postprocessing technology, and combined cardiothoracic angiography can quickly and accurately help emergency physicians analyze the cause of acute chest pain, which plays a very important role in formulating the correct treatment plan in a timely manner. At the same time, with the continuous development of CT technology, the temporal and spatial resolution has improved the quality of CT images, giving us more options to reduce the effective radiation dose and reduce the total amount of contrast, making the 64-row spiral CT cardiothoracic imaging more perfect.

Establishing the role of serum cardiac markers in diagnosis of acute chest pain(A Study of 200 cases)

Introduction:Acute myocardial infarction (AMI) continues to be a major health problem in industrialized and developing countries like India despite progressive research in diagnostic and management over last three decades.AMI has typically been diagnosed on the basis of triad of clinical syndromes of chest pain, electrocardiogram (ECG) changes and elevated serum enzyme activity.Due to high cardiac specificity of ckmb,cTnI, these biomarkers have become the recommended biomarkers for the diagnosis of myocardial injury. Aims:To study changes in serum cardiac markers and determine the sensitivity and specificity of Highly sensitive Troponin I, CK-MB and LDH. Material and Methods:It was undertaken from November-2015 to December-2016 during which 200 patients were studied. All the patients having complaint of acute chest pain admitted in the emergency wards are included. Serum level of cardiac Troponin I was determined by using vidashigh sensitive troponin i (human cardiac specific) enzyme immunoassay kit, CK-MB was determined by the vitros 250 fully automated biochemistry analyser,serum level of LDH was determined by ldh-(p-l) reagent kit (kinatic procedure). Result:In present study, out of 200 patients who admitted for complaining of acute chest pain, 110 patients actually diagnosed to have acute myocardial infarction. Sensitivity and specificity of hsTroponin I for diagnosis of acute myocardial infarction was 100%. CK-MB was 89.1% and 88.8% andLDH was 65.4% and 60% respectively. Conclusion:Among the cardiac markers studied hsTroponin I is the most specific and sensitive for diagnosis of acute myocardial infarction. As CK-MB levels become normal within 2-3 days, it is helpful in diagnosis of reinfarction.

A potential diagnostic pitfall in acute chest pain: Massive pulmonary embolism mimicking acute STEMI

BackgroundPulmonary embolism (PE) represents a clinical challenge for clinicians because of nonspecific presentations, including dyspnea, chest pain, and tachycardia. The immediate 12-lead electrocardiogram (ECG) is commonly used to facilitate differential diagnosis of acute chest pain. Although relative rare, massive pulmonary embolism could induce ST segment elevation and mimic acute myocardial infarction. Case presentationWe present a challenging scenario that ECG showed ST segment elevation, nevertheless, urgent coronary angiogram revealed non-obstructive coronary artery disease. Unfortunately, the patient suffered from cardiac arrest and required extracorporeal membrane oxygenation devices. Finally, massive pulmonary embolism was diagnosed. ConclusionThis case illustrates acute PE could mimic ST segment elevation myocardial infarction. ST elevations on ECG should be interpreted after considering clinical presentations before making a decision.

Analysis of Patients with Spontaneous Pneumomediastinum.

Spontaneous pneumomediastinum is characterized by the presence of air in the mediastinum without any reason. The objective of this study is to report our experience in the diagnosis and treatment of this clinical condition. 21 patients with spontaneous pneumomediastinum who were referred to our clinic between January 2010 and May 2015 were evaluated retrospectively. The presence of radiological pneumomediastinum and the absence a traumatic cause were taken as the basic criterion. The mean age of the patients was 24.78 ± 4.37 years. Thirteen patients were male, eight patients were female. The main complaints of the patients were chest pain, dyspnea, neck pain, sore throat and cough. Thirteen patients were smokers. Seven patients had a prior history of asthma, five patient had chronic bronchitis and one patient had cronic obstructive lung diseases. No precipitating factor was identified in 9 patients. While initial complaints was associated with physical effort in 7 patients, three patients cough and two patients had a history of severe crying. Pneumomediastinum was diagnosed by chest radiography in 8 patients, and with chest CT in 13 patients. All the patients were performed bronchoscopy and radiograph of esophagus. Electrocardiogram was taken for all patients. Arrhythmia was detected in 4 of the patients. Treatment included analgesia, rest and oxygen therapy. Mortalitiy and morbidity were not seen. The mean length of hospital stay was 4.4 ± 2.17 days. Spontaneous pneumomediastinum is a benign process. Despite its low incidence, it should be considered in the differential diagnosis of acute chest pain.

Utilidad de copeptina en el diagnóstico de síndrome coronario agudo en el departamento de urgencias de un hospital de tercer nivel

ObjectivesThis study was conducted in order to evaluate the usefulness of copeptin (a stable fragment of the precursor of arginine vasopressin) in the differential diagnosis of acute chest pain of probable coronary origin. Material and methodsThe study includes 82 patients who were initially evaluated according to the protocol of a patient with suspected acute coronary syndrome (ACS) in our Emergency Department, including the determination of troponin and copeptin with specimens taken on admission (time 0) and at 6h. ResultsStatistically significant differences were observed in copeptin concentrations at time 0 among patients diagnosed with non–ST-segment elevation (NTEACS): 42.1±38.7pmol/L and non-NSTEACS patients: 15.6±21.2pmol/L (P<. 01). However, the differences did not reach statistical significance at 6h (P=.093).The analysis of the area under the ROC curve for Copeptin in NSTEACS patients at time 0 was 0.713, with a confidence interval of 95% from 0.592 to 0.834 and a significance level of P=.001. ConclusionsThe concentration of copeptin represents an additional value in the differentiation between NSTEACS patients and non-NSTEACS patients, as well as between ACS patients and patients with stable angina. The cut-off point of 10pmol/L provides the best values for sensitivity, negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR–) in the diagnosis of NSTEACS patients.

Spontan Pnömomediastinumda Tedavi Yaklaşımlarının Karşılaştırılması

Objective: Spontaneous pneumomediastinum (SPM) is defined as the presence of air in the mediastinum that develops in the absence of traumatic, iatrogenic, or preceding pulmonary pathologies. In this study, the etiology of SPM patients who developed clinical course were evaluated, and compared the effectiveness of treatment modalities in these cases. Material and Methods: A retrospective case series was conducted to identify adult patients with SPM who were diagnosed and treated between January 2011 and December 2014. Results: Eleven patients were identified included 10 men and 1 women with a mean age of 21.09 years. The most common presenting complaint was chest pain in 8 patients, dyspnea in 5, swellings of their necks in 3.Cases While cervical mediastinotomies were perfomed in 5 cases, conservative approaches were preferred in 6 of the cases. Although hospital stays of the patients with cervical mediastinotomies and those who received conservative treatment were not significantly different), the patients with cervical mediastinotomies showed a more rapid clinical improvement. Conclusion: SPM is a benign process primarily affecting young men. SPM should be considered in the differential diagnosis of acute chest pain. A cervical mediastinotomy helps to improve the patient?s clinical status via a rapid air decompression.

Pulmonary embolism

Acute pulmonary embolism is an important differential diagnosis of acute chest pain. The clinical signs are often non-specific. However, diagnosis and therapy must be done quickly in order to reduce morbidity and mortality. The new (2014) European guidelines for acute pulmonary embolism (PE) focus on risk-adapted diagnostic algorithms and prognosis adapted therapy concepts. According to the hemodynamic presentation the division in a high-risk group (unstable patient with persistent hypotension or shock) or in non-high-risk groups (hemodynamically stable) was proposed. In the high-risk group the immediate diagnosis is usually done by multidetector spiral computed tomography (MDCT) and primarily the medical therapy of right ventricular dysfunction and thrombolysis is recommended.In the non-high-risk group, this is subdivided into an intermediate-risk group and low-risk group, the diagnosis algorithm based on the PE-pretest probability--determined by validated scores. Moreover, the diagnosis is usually secured by MDCT--the new gold standard in the PE-diagnosis, scores, or it can be primarily ruled out due to the high negative predictive value of D-dimer determination. To improve the prognostic risk stratification in non-high-risk group patients the additional detection of right ventricular dysfunction (MDCT, echocardiography), cardiac biomarkers (troponin, NT proBNP) and validated scores (e.g. Pulmonary Embolism Severity Index) is recommended. Therefore, the intermediate-risk group can be further subdivided. For treatment of non-high-risk group patients, the initial anticoagulation (except those with severe renal insufficiency) using low molecular weight heparin/fondaparinux and conversion to vitamin-K antagonists or alternatively with direct oral anticoagulants (DOAK) is recommended. Hemodynamically stable patients with right ventricular dysfunction and myocardial ischemia (Intermediate-high-risk group patients) but with clinically progressive hemodynamic decompensation may benefit from systemic thrombolysis as well. Due to the high risk of bleeding in the PEITHO study, however, a critical individual risk-benefit evaluation should be done. A dose reduced systemic or local ultrasound-assisted thrombolysis could gain importance in the future. For very selected patients in the low-risk group early outpatient treatment could be considered.The diagnosis and treatment of pulmonary embolism remains complex. Improved algorithms support the diagnosis procedures and therapy decisions. Direct oral anticoagulants are a new first-line therapy alternative for hemodynamically stable non-high-risk patients.

Multislice CT coronary angiography is an additional tool for provisional diagnosis of acute chest pain with neither ECG nor echocardiography significant findings in emergency room

Background Multislice coronary computed tomography (CT) angiography is used to diagnose coronary artery disease (CAD) with good spatial and temporal resolution. Objective The aim of this study was to assess the uses of thin-slice multidetector row CT in the diagnosis of different vascular coronary causes of chest pain. Patients and methods A total of 20 patients were examined with full history taking, resting 12-lead ECG, cardiac biomarkers, and echocardiography. Thereafter, on the basis of their clinical manifestations or suspected progression of past condition they were enrolled for 160-multislice CT angiography using Ultravist 370 as a contrast medium. Results CT coronary angiography revealed the following: two cases were normal, two showed nonsignificant CAD, three showed significant CAD, 10 showed mild-to-moderate CAD, two showed anomalous coronary arteries, and one showed myocardial bridge. Conclusion CT angiography nowadays is considered the primary tool of diagnosis for different thoracic vascular disorders, being a safe, rapid method of diagnosis. Multislice coronary CT is a relatively new technique that gives physicians the advantage of screening emergency patients presenting with acute chest pain in a rapid and safe way for detection of their vascular diseases.

Impact of d-Dimers on the Differential Diagnosis of Acute Chest Pain: Current Aspects Besides the Widely Known.

d-dimers are cleavage products of fibrin that occur during plasmin-mediated fibrinolysis of blood clots. In the emergency department, d-dimer measurement represents a valuable and cost-effective tool in the differential diagnosis of acute chest pain including the main life-threatening entities: acute coronary syndrome, pulmonary embolism, and acute aortic syndrome. Whereas the diagnostic and prognostic values of d-dimer testing in acute coronary syndrome is of less priority, increases of d-dimers are frequently found in venous thromboembolism and acute aortic syndromes, especially acute aortic dissection. As to the high negative predictive value of d-dimer in those disorders, patients with low to intermediate pretest probability may profit in terms of less necessity of further non-invasive or even invasive imaging, simultaneously reducing potential complications and healthcare-related costs. However, because of the low specificity of the different d-dimer tests in contrast to its frequent usage, adequate interpretation is required. Age-related adjustment of d-dimer levels may be used to increase its diagnostic power.

Diagnosis and management of ischemic cardiomyopathy: Role of cardiovascular magnetic resonance imaging

Coronary artery disease (CAD) represents an important cause of mortality. Cardiovascular magnetic resonance (CMR) imaging evolved as an imaging modality that allows the assessment of myocardial function, perfusion, contractile reserve and extent of fibrosis in a single comprehensive exam. This review highlights the role of CMR in the differential diagnosis of acute chest pain by detecting the location of obstructive CAD or necrosis and identifying other conditions like stress cardiomyopathy or myocarditis that can present with acute chest pain. Besides, it underlines the prognostic implication of perfusion abnormalities in the setting of acute chest pain. Furthermore, the review addresses the role of CMR to detect significant CAD in patients with stable CAD. It elucidates the accuracy and clinical utility of CMR with respect to other imaging modalities like single-photon emission computed tomography and positron emission tomography. Besides, the prognostic value of CMR stress testing is discussed. Additionally, it summarizes the available CMR techniques to assess myocardial viability and describes algorithm to identify those patient who might profit from revascularization those who should be treated medically. Finally, future promising imaging techniques that will provide further insights into the fundamental disease processes in ischemic cardiomyopathy are discussed.

Cost-Effectiveness of a Novel Blood-Pool Contrast Agent in the Setting of Chest Pain Evaluation in an Emergency Department

We evaluated three diagnostic strategies with the objective of comparing the current standard of care for individuals presenting acute chest pain and no history of coronary artery disease (CAD) with a novel diagnostic strategy using an emerging technology (blood-pool contrast agent [BPCA]) to identify the potential benefits and cost reductions. A decision analytic model of diagnostic strategies and outcomes using a BPCA and a conventional agent for CT angiography (CTA) in patients with acute chest pain was built. The model was used to evaluate three diagnostic strategies: CTA using a BPCA followed by invasive coronary angiography (ICA), CTA using a conventional agent followed by ICA, and ICA alone. The use of the two CTA-based triage tests before ICA in a population with a CAD prevalence of less than 47% was predicted to be more cost-effective than ICA alone. Using the base-case values and a cost premium for BPCA over the conventional CT agent (cost of BPCA ≈ 5× that of a conventional agent) showed that CTA with a BPCA before ICA resulted in the most cost-effective strategy; the other strategies were ruled out by simple dominance. The model strongly depends on the rates of complications from the diagnostic tests included in the model. In a population with an elevated risk of contrast-induced nephropathy (CIN), a significant premium cost per BPCA dose still resulted in the alternative whereby CTA using BPCA was more cost-effective than CTA using a conventional agent. A similar effect was observed for potential complications resulting from the BPCA injection. Conversely, in the presence of a similar complication rate from BPCA, the diagnostic strategy of CTA using a conventional agent would be the optimal alternative. BPCAs could have a significant impact in the diagnosis of acute chest pain, in particular for populations with high incidences of CIN. In addition, a BPCA strategy could garner further savings if currently excluded phenomena including renal disease and incidental findings were included in the decision model.

Low Radiation Dose with Triple-Rule-Out CT Angiography in Diagnosis of Acute Chest Pain

Acute chest pain (ACP) is one of the most common reasons in adults regarding visits to the emergency department (ED). The triple-rule-out CTA (TRO CTA) is feasible to evaluate ACP in the ED and potentially lead to earlier triage. However, just a few patients with ACP were evaluated with the protocol of TRO CTA, one of the major reasons which preclude the TRO CTA to be a routine diagnostic tool is the associated radiation dose. Herein we review the variety of techniques which can reduce the radiation dose during TRO CTA. With reasonable application of those techniques, the radiation dose can be reduced obviously, and the patients suffered from ACP will benefit from TRO CTA with techniques of reducing radiation dose. Keywords: Acute chest pain, CT Angiography, Triple-rule-out, Radiation dose, ECG-gating, Pitch.

319: An exemple of extreme cardiology: chest pain on the high seas and helicoptered medical evacuations. The French Navy experience

French Navy provides medical evacuations by helicopter (HME) on the Atlantic coast, up to 320 kilometers offshore, and under all weather conditions. The epidemiology of acute chest pain (ACP) on the high seas is little known. In this study, we aimed to assess the prevalence and constraints found in the management of these emergencies. This was a retrospective, descriptive, monocentric study performed from January 1, 2000, to April 30, 2009. The inclusion criteria was the occurrence of ACP while the patient was on the high seas, which required a HME From January 1, 2000, to April 30, 2009, 286 HME were performed - of which 132 were due to traumatologic and 154 due to medical emergencies. ACP with 36 missions was the leading cause of HME. All evacuated patients were men (professional sailors or ferry passengers). The average age was 48 years (range, 26–79). The most common prehospital diagnosis was acute coronary syndrome (ACS) in 23 patients (64%) including 11 patients with ACS with ST-segment elevation. 32 patients were airlifted by helicopter. All patients benefited from monitoring, ECG, peripheral venous catheter, and medical management as soon as the technical conditions allowed it. Our study shows a predominance of ACS with ST-segment elevation in the diagnosis of ACP. Even if the working conditions are extreme, the management of ACP on the high seas may be optimal. The limits of HME are not therapeutic, but diagnostic. Indeed, 42% of the initial diagnoses were rectified. A management flowchart has been proposed within the framework of the evaluation of professional practices, with a diagnostic reasoning based around the ECG and the patient's monitoring (fig1). The study has highlighted the high prevalence of ACP occurring in an offshore environment. The diagnosis is difficult in a dangerous context, which makes these medicalized evacuations singular. Figure – Abstract 319 – Flowchart of the management of ACP in the high sea

Complete graft dehiscence 8 months after repair of acute type A aortic dissection

Acute type A aortic dissection is a dreaded differential diagnosis of acute chest pain. Long-term outcome mainly depends on pre-existing comorbidities and post-operative complications. We present a patient with aortic graft dehiscence and subsequent severe aortic regurgitation due to fungal graft infection 8 months after repair of acute type A aortic dissection. Redo aortic surgery had to be delayed for 28 days due to intracerebral haemorrhage caused by septic embolism and clipping of a mycotic left middle cerebral artery aneurysm. Surgery revealed a circumferentially detached graft at the site of the proximal anastomosis thereby forming a massive pseudoaneurysm. The patient underwent successful aortic root replacement using a Freestyle porcine root bioprosthesis (25 mm), followed by re-anastomosis of the coronary arteries and partial replacement of the ascending aorta with a 28 mm Dacron graft. The patient was discharged on day 67 in stable cardiac condition with persistent neurological deficits. This case highlights the challenging management of patients with aortic graft infection and neurological dysfunction after redissection of the ascending aorta who require redo cardiac surgery.

The role of multi slice computed tomography in the evaluation of acute non-cardiac chest pain

Introduction: Differential diagnosis of acute chest pain encompasses a broad spectrum of illnesses which are most likely followed by benign outcomes (pneumonia, pneumothorax, pleurisy, pericardial effusion, hiatus hernia), but also illnesses of lethal outcomes (pulmonary embolism, myocardial infarction, aortic dissection,thoracic aortic aneurysms, thoracic aortic aneurysm rupture, etc). Illnesses associated with benign and lethal outcomes may present very similar if not the same symptoms, resulting in a diffi cult establishment of accurate diagnosis.Methods: During the period of one year, 123 patients presented with non-cardiac acute chest pain were referred for the multi slice computed tomography (MSCT) examination. Scanning of thorax was conductedin two series: unenhanced and contrast-enhanced, using a window for pulmonary parenchyma and mediastinum.Results: From a total number of patients 21.1% had normal results while the other 79.9% had pathological results. Out of the total number of patients with pathological result MSCT established potentially lethal outcome for 35.0%, out of which 83.7% was contributed to vascular territory of pulmonary artery, while 16.3% was contributed to aorta.Conclusion: MSCT scanning, owe to its ability of simultaneous analysis of vascular and non-vascular thoracic structures, represents a very effi cient and reliable method for establishing accurate diagnosis and appropriatetriage of patients with acute chest pain. Accurate and effi cient diagnosis enables benefi cial outcome for the patient in this group of illness. MSCT enables the differentiation of etiological factors, which present as acute onset of non-cardiac chest pain.