Level Of Ligamentum Arteriosum Research Articles

Congenital kinking of aorta – A rare aortic arch anomaly

Congenital kinking of aorta or pseudocoarctation is a rare anomaly of the aortic arch with elongation and kinking of aorta at the level of ligamentum arteriosum. This anomaly is not a true coarctation as there is no significant hemodynamic obstruction or pressure gradient across the lesion. We report two cases with this anomaly diagnosed during the evaluation for incidental finding of murmur. Both patients had flow gradient across the kinked segment of aorta by echocardiography but did not require any intervention. Long term complication is aneurysmal dilatation and rupture beyond the kinked segment. Computed tomography of the aorta is a simple noninvasive diagnostic modality for the definitive diagnosis. Surgical repair should be performed for all symptomatic individuals. Regular periodic follow up is mandatory for all asymptomatic patients. Keywords: Aortic arch syndromes, Aortic coarctation, Congenital heart defects, Echocardiography, Thoracic aorta

AN INCIDENTAL FINDING OF MASSIVE MEDIASTINAL DENSITY FROM A CHEST RADIOGRAPH

SESSION TITLE: Cardiothoracic Surgery SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Bicuspid aortic valve (BAV) is one of the most common congenital heart diseases, occurring in about one percent of the population. Patients with BAV have higher frequency of aortic root and ascending aortic dilatation on echocardiogram compared to patients with normal tricuspid aortic valve. The aortic dilatation caused by BAV generally involves aortic root and ascending thoracic aorta, but it may also involve transverse aorta (1). The following case demonstrates an isolated aortic arch aneurysm, which has not been reported in the literature to our knowledge yet. CASE PRESENTATION: A 23-year-old African American male with past medical history of ventricular septal defect repair had a routine chest radiograph, which showed mediastinal widening (Figure 1). Transesophageal echocardiography showed a bicuspid aortic valve, moderate to severe aortic regurgitation, severely dilated right atrium and right ventricle, dilated aortic root, and moderately dilated proximal ascending aorta measuring 4.4cm. Computed tomography angiography (CAT) showed massive dilatation of the transverse aortic arch extending from the origin of the brachiocephalic artery to just distal to the left subclavian artery, followed by a sharp transition to a normal descending aorta without any collateral circulation (Figure 2, Figure 3). DISCUSSION: Aortic root and ascending aorta dilatation are known complications of bicuspid aortic valve, but an isolated aneurysm of the aortic arch has not been previously reported. This is favored to represent a congenital anomaly given his BAV, history of VSD, and relatively early albeit incidental presentation of his massive aneurysm (2). Coarctation of the aorta is a narrowing of the aorta near the ductus arteriosus, which is associated with bicuspid aortic valve. Our patient’s CTA showed no enlarged intercostal arteries or other collateral circulation. A variation of pseudocoarctation of the aorta, which is a rare congenital deformation and elongation of the aortic arch at the level of ligamentum arteriosum without obstruction or pressure gradient is also on the differential (3). Cervical aortic arch can present similarly, but the patient’s chest radiograph showed aortic arch located unequivocally below the clavicle, making this diagnosis less likely. The treatment for aortic aneurysm depends on the location and the extent of the aortic dilatation. The patient required complex aortic surgery with possible elephant trunk repair and was referred to a tertiary care center for further surgical evaluation. CONCLUSIONS: Aneurysmal dilatation of the aortic root and ascending aorta is common among BAV patients. An isolated aortic arch aneurysm with relatively minimal dilatation of the aortic root and ascending aorta has not been reported in the literature. This may represent part of a spectrum of congenital disorder, and pathological studies would help to further evaluate this unknown entity. Reference #1: Fazel, Shafie S., et al. "The aortopathy of bicuspid aortic valve disease has distinctive patterns and usually involves the transverse aortic arch." The Journal of thoracic and cardiovascular surgery 135.4 (2008): 901-907. Reference #2: Caglayan, Ahmet Okay, and Munis Dundar. "Inherited diseases and syndromes leading to aortic aneurysms and dissections." European Journal of Cardio-Thoracic Surgery 35.6 (2009): 931-940. Reference #3: D’Cruz, Ivan A., et al. "Noninvasive diagnosis of right cervical aortic arch." Chest 83.5 (1983): 820-822. DISCLOSURES: No relevant relationships by william bates, source=Web Response No relevant relationships by jayanth keshavamurthy, source=Web Response No relevant relationships by Haesung Lee, source=Web Response No relevant relationships by Ilkyu Oh, source=Web Response No relevant relationships by Allan Wang, source=Web Response

Unusual Aortic Dissection Mimicking Penetrating Atherosclerotic Ulcer after Blunt Chest Trauma

A 73-year-old man was referred for multiple blunt trauma after an automobile accident with drowsy mentality. At the time of impact, he sat unstrained in the back seat behind the driver. To evaluate the organ damages, brain and chest computed tomography (CT) scans were performed. The chest CT with sagittal reconstruction showed 2 separate contrast-filled false lumens composed of ruptured intimal flaps in aortic arch and descending thoracic aorta. The lesions communicated directly with the aortic lumen. The proximal lesion in aortic arch, occurred just above the left subclavian artery, had 8 mm-depth ulceration into the aortic media and the distal lesion in descending aorta had 5mm-depth ulceration into the aortic media, mimicking penetrating atherosclerotic ulcer. Also, multiple atherosclerotic plaques were found in the whole thoracic aortic wall (Fig. 1). Transesophageal echocardiography (TEE) of the aorta showed similar findings with chest CT. The continuity of endothelium was completely disrupted and 2 separate false lumens were made due to endothelial detachment. The ruptured endothelium of proximal lesion was highly movable. During systole, it disturbed the aortic flow (Fig. 2A). The distal lesion didn't disturb the aortic flow (Fig. 2B). Fig. 1 The chest CT with sagittal reconstruction. The proximal dissection (*). The distal dissection (arrow). Fig. 2 Transesophageal echocardiography, color Doppler. Proximal dissection (A), distal dissection (B). Dissection of the aorta after blunt chest trauma usually occurs at the level of ligamentum arteriosum just distal to the left subclavian artery. However, in our case, the lesions occurred at unusual sites. We suggest that the decelerating force propagated through the aortic wall may cause underlying atherosclerotic plaques breakage forming endothelial detachment and rupture at unusual sites.