Hakkı KAYA, Hatice KAPLANOĞLU, Süleyman SÜRER, Osman BETON, Mehmet Birhan YILMAZ

Yalancı lümen aortografi ile tanısı konan çıkan aort diseksiyonu

Düzenli antihipertansif tedavi kullanmayan, 48 yaşındaki hipertansif erkek hasta, son iki saattir devam eden şiddetli retrosternal göğüs ağrısı nedeniyle acil servisimize başvurdu. Hastanın anemnezinde sırt ağrısı saptanmadı. Elektrokardiyografide sinüs ritmi, II, III ve aVF derivasyonlarında ST segment elevasyonu ve I, aVL ve V1-V3 derivasyonlarda ST segment depresyonu izlendi. Transtorasik ekokardiyografide inferior ve posterior-septum duvar hareketleri hipokinetik (ejeksiyon fraksiyonu %45), hafif mitral ve hafif aort yetmezliği ve diseksiyon bulgusuna rastlanmaksızın çıkan aort dilatasyonu (4.5 cm) saptandı. Akut inferior miyokard infraktüsü nedeniyle primer perkütan koroner girişim için anjiyografi laboratuvarına alınan hastanın sağ koroner arterine kateter ile girilemedi. Sağ koroner arteri görüntülemek amacıyla manuel aortografi yapıldı. Aortografi sırasında kateterinin yalancı lümen içerisinde olduğu saptanması üzerine, aort diseksiyonu tanısı kondu. Acilen yapılan toraks BT anjiyografide, çıkan aortadan başlayan ve iliyak artere uzanan De Bakey tip 1 aort diseksiyonu saptandı. Hasta çıkan aort ve aort kapak replasmanı ve koroner arter bypass greftleme ile başarılı bir şekilde tedavi edildi

Diagnosis of ascending aortic dissection by false lumen aortography

A 48-year-old male hypertensive patient with who was not on a regular antihypertensive treatment was admitted to our emergency department due to severe retrosternal chest pain for two hours. He did not suffer from back pain. Electrocardiogram showed sinus rhythm with ST segment elevation in leads II, III, and aVF, and ST segment depression in leads I, aVL and V1-V3. Transthoracic echocardiography revealed hypokinetic inferior and posterior-septum wall motions (ejection fraction 45%) with mild mitral and mild aortic regurgitation, and a dilated ascending aorta (4.5cm) without any sign of dissection. The patient was taken to angiography lab for primary percutaneous intervention for acute inferior myocardial infraction; however, the catheter was unable to be placed in the right coronary artery. A manual aortogram was performed to visualize the right coronary artery. Because of unintentional placement of the catheter in the false lumen during aortography dissection the aorta was diagnosed. Urgent thoracic computed tomographic angiography showed De Bakey type I aortic dissection, extending from the ascending aorta to the iliac artery. The patient was successfully treated with the ascending aorta and aortic valve replacement, and coronary artery bypass grafting

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1. Kohn MA, Kwan E, Gupta M, et al. Prevalence of acute myocardial infarction and other serious diagnoses in patients presenting to an urban emergency department with chest pain. J Emerg Med. 2005; 29:383-90.
2. Horszczaruk GJ, Roik MF, Kochman J, et al. Aortic dissection involving ostium of right coronary artery as the reason of myocardial infarction. Eur Heart J 2006;27:518.
3. Pego-Fernandes PM, Stolf NA, Hervoso CM, et al. Management of aortic dissection that involves the right coronary artery. Cardiovasc Surg 1999;7:545-8.
4. Asouhidou I, Asteri T. Acute aortic dissection: Be aware of misdiagnosis. BMC Res Notes 2009;2:25.
5. Coselli JS. Treatment of acute aortic dissection involving the right coronary artery and aortic valve. J Cardiovasc Surg 1990;31:305-9.
6. Horszczaruk GJ, Roik MF, Kochman J, et al. Aortic dissection involving ostium of right coronary artery as the reason of myocardial infarction. Eur Heart J 2006;27:518.
7. Shapira OM, Davidoff R. Images in cardiovascular medicine. Functional left main coronary artery obstruction due to aortic dissection. Circulation 1998;98:278-80.
8. Rogers AM, Hermann LK, Booher AM, et al. Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of acute aortic dissection at initial presentation: Results from the international registry of acute aortic dissection. Circulation 2010; 123:2213-8.
9. Borger MA, Preston M, Ivanov J, et al. Should the ascending aorta be replaced more frequently in patients with bicuspid aortic valve disease? J Thorac Cardiovasc Surg 2004; 128:677-83.
10. Hart WL, Berman EJ, LaCom RJ. Hazard of retrograde aortography in dissecting aortic aneurysms. Circulation 1963; 27:1140–2.
11. Miller JS, Lemaire SA, Coselli JS. Evaluating aortic dissection: when is coronary angiography indicated? Heart. 2000; 83:615-6.