PMC6231389_01
A parasternal long axis view on transthoracic echocardiography demonstrating an enlarging aortic root at 5.2 cm.
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We present a 66-year-old Caucasian male with a history of hypertension and chronic type A aortic dissection who was found to have an enlarging aortic root measuring 5.2 cm in diameter on an echocardiography done as part of surveillance of aortic dissection repair done 9 years ago using a tube graft with resuspension of the aortic valve (Figure 1).
Transesophageal echocardiography post cardiac arrest revealed severe right ventricular dilatation.
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Urgent transesophageal echocardiography (TEE) was done that showed a new, severe dilatation of the right ventricle along with reduced ejection fraction but a normal left ventricle (Figure 2).
Catheterization showing a spiral dissection extending from the ostium of the right coronary artery (RCA) down to its distal segment, sparing the bifurcation.
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A concern for iatrogenic injury to the coronary vessels prompted an emergent coronary angiography which revealed dissection of the right coronary artery (RCA) extending from the ostium down to its distal segment, sparing the bifurcation (Figure 3; see Video 1 in Supplementary Materials).
Intravascular ultrasound (IVUS) demonstrating the true and false lumens of coronary artery dissection.
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IVUS catheter was performed to ensure location of the wire in the true lumen distally, evaluate the nature and extent of coronary dissection, and select appropriate size of coronary artery stents. IVUS confirmed a spiral coronary dissection spanning between the distal RCA and ostium and sparing the right posterolateral and right posterior descending arteries (Figure 4).
Angiogram showing stent deployment in the right coronary artery at the site of dissection as marked by white arrows in panels (a) and (b).
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A 3.5 x 32 mm drug eluting stent (SYNERGY, Boston Scientific) was placed in the distal segment followed by four 4.0 mm drug eluting stents (SYNERGY, Boston Scientific) in overlapping fashion under IVUS guidance that restored TIMI-3 blood flow in the posterior descending and posterolateral branches of the right coronary artery (Figures 5(a), 5(b), and 6; see Videos 3-8 in Supplementary Materials).
Transthoracic echocardiography one week later showing improvement in right ventricular size and function.
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A transthoracic echocardiography one week later showed improved right ventricular size and function (Figure 7).