PMC4313002_01
Admission EKG showing normal sinus rhythm (NSR) with T wave flattening and inversion in the inferior leads.
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fig1
Serum troponin I peaked at 0.24 microgram/liter (microg/L); electrocardiogram (ECG) showed nonspecific ST-T wave changes (Figure 1).
Diagnostic catheterization via simultaneous injection of the right and left coronary systems showing moderate collaterals from the distal LAD supplying the RCA and chronic total occlusion of the proximal RCA.
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fig2
Moderate collateral arteries from the septal LAD branches and distal circumflex supplied the distal right coronary artery (RCA) (see Figure 2).
(a) Acute aortic dissection at the time of dye injection with the guide catheter and wire in place. (b) Visualization of the extent of dissection after injection of the dye. (c) Dye injection into left main coronary, no propagation to left coronary artery. (d) Aortogram showing dye staining of the aortic root dissection.
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fig3
This led to the dissection of the proximal RCA with retrograde extension into the aortic root and ascending aorta seen in Figure 3.
Trend in vital signs during acute aortic dissection. The time of dissection indicated by the asterisk, which is followed by the drop in systolic BP to around 60 (arrow) and the subsequent response to fluid resuscitation.
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fig4
There were brief episodes of hypotension with systolic blood pressure (SBP) dropping to 60-65 mmHg (Figure 4). She was immediately given a 1-liter bolus of normal saline resulting in an increased arterial blood pressure (Figure 4).
Blood pressure variation following aortic dissection with the inspiratory and expiratory phases denoted by the solid line. The inspiratory phase corresponds to a systolic blood pressure drop of about 22 mmHg.
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fig5
During this time the patient was noted to have approximately 22 mmHg decrease in blood pressure during inspiration, consistent with pulsus paradoxus (Figure 5).
Echocardiographic evidence of pericardial effusion (measuring 0.31 cm) after aortic dissection on parasternal long axis view. Ao = aorta, RV = right ventricle, LV = left ventricle, and LA = left atrium.
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fig6
On emergent echocardiography a small pericardial effusion was identified anterior to the right ventricle on the parasternal view measuring 0.31 cm (Figure 6).
(a)-(b) CT angiogram at the level of the LCA and RCA, respectively (yellow arrows). (c)-(d) Arrows indicate the area of increased intensity suspicious for hemorrhage before (c) and after (d) contrast injection.
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fig7
Along the ascending aorta up to the arch there was an increased surrounding density measuring roughly 30-40 HU, which was consistent with hemorrhage (Figures 7(c) and 7(d)).