ÖZET Transtorasik ekokardiyografide posteriyor yerleşimli kitle olarak belirlenen asendan aort disseksiyonu

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Introduction
A patient with aortic dissection generally has
symptomatic presentation including abrupt onset
chest or back pain (1). Unfortunately, the diagnosis
of an aortic dissection in an asymptomatic patient,
by definition, is usually based on incidentally detected findings. Some dissecting aneurysms may reach
to a very large size (2). We herein present an asymptomatic patient with type A aortic dissection detected on routine echocardiographic examination as a
posteriorly located mass and confirmed by further
diagnostic studies.
Case Report
A 63-year-old female patient admitted to our outpatient clinic for a routine control. Her past medical
history revealed the presence of previous coronary
angiogram which showed slow flow in left anterior
descending artery four years ago. Since that time,
she has used a beta blocker and acetylsalicylic acid
(100 mg once a day) without any complaint. Her vital signs were normal and a diastolic murmur at the
left sternal border was detected during physical examination. During transthoracic echocardiography
(Philips Envisor C, Philips Medical Systems, Andover,
MA, USA) a moderate degree aortic regurgitation
and a mild degree mitral regurgitation with normally functioning left ventricle were demonstrated.
Furthermore, a mass located at the posterior aspect
of the heart reaching 8 cm diameter was detected at
apical four chamber view. Right parasternal view was
tried for better understanding of the problem, which
indeed revealed a dissection flap beginning at the
proximal ascending aorta, a large false lumen and a
small true lumen (Figure 1). However, entry and exit
points of dissection were not confirmed in transthoracic echocardiography views, and hence, transesophageal echocardiographic (TEE) study (Philips I33 machine) was performed. TEE revealed the presence of
* Department of Cardiology, Gulhane Military Medical Faculty
**Department of Radiology, Gulhane Military Medical Faculty
Reprint request: Dr. Mehmet Yokuşoğlu, Department of Cardiology,
Gulhane Military Medical Faculty, Etlik-06018, Ankara
E-mail: myokusoglu@yahoo.com
Date submitted: August 18, 2009 • Date accepted: June 29, 2010220 • September 2010 • Gulhane Med J Baysan et al.
Figure 2. Transesophageal echocardiographic view with true (TL)
and false (FL) lumens
Figure 3. Computed tomography: 3D reconstruction
Figure 1. Transthoracic right parasternal view showing a small true
lumen* and a large false lumen**
aortic dissection starting from a point 4 cm distal to
sinotubular junction with very prominent swirling
spontaneous echo contrast (Figure 2). Descending
aorta had normal diameter and appearance. We ordered a computed tomography (CT) study because we
were not able to conceptualize the dissection and aortic lumen relation. Multi-detector CT was very helpful, which showed very large false lumen with inferoposteriorly oriented outpouching. Interestingly,
this dissection oriented in a spiral-like direction and
wrapped around true lumen to the point of left subclavian artery (Figure 3). Based on these findings we
transferred the patient to another center for surgical
intervention.
Discussion
A cardiac mass located at close vicinity to posterior aspect of heart can be caused by various etiologies including descending aortic aneurysm (3) and
Valsalva sinus aneurysm (4). However, a dilated ascending aorta as a cause in such a situation is not an
expected finding because of anterior location of this
structure. Interestingly, the patient did not have a
previous history of predisposing factors such as hypertension, atherosclerosis, aortic aneurysm or cardiac surgery. We questioned the patient about her
relatives again after the diagnosis and revealed that
her brother was operated for aortic aneurysm and
dissection 13 years ago. We thought that a familial
predisposition may be possible in our case because
up to 19% of patients who present with a thoracic
aneurysm or dissection have a first-degree relative
with a similar history (1). We also were not able to
exclude iatrogenic aortic dissection related to previous coronary angiography. However, if it is the
case, the presence of a 4-year time period without
symptoms is an unexpected course according to our
opinion. Although endovascular repair is possible
especially in type B dissections, surgical therapy is
generally advocated in chronic type A dissections
with aneurysmal dilatation as in our patient because of poor outcome (5), but it requires high surgical
experience which was the underlying factor for our
decision to transfer the patient. In conclusion, an
aortic dissection with aneurysmal dilatation can be
detected in routine transthoracic echocardiography
as a mass which should always be kept in mind for
the differential diagnosis.