Circulation. 2007;115:e38-e40
doi: 10.1161/CIRCULATIONAHA.106.653550
(Circulation. 2007;115:e38-e40.)
© 2007 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Serial Images Demonstrating Proximal Extension of an Aortic Intramural Hematoma
Sonal Jani, MD;
Michael Liou, MD;
Kerry Anne Sibert, MD;
Paul Stelzer, MD;
Marvin Berger, MD;
Susan R. Hecht, MD
From Beth Israel Medical Center, University Hospital (S.J., M.L., K.A., P.S., S.R.H.) of the Albert Einstein College of Medicine (M.B.), New York, NY.
Correspondence to Sonal Jani, MD, Division of Cardiology, Beth Israel Medical Center, 16th St and 1st Ave, 5 Baird Hall, New York, NY 10010. E-mail sjani{at}chpnet.org
A 73-year-old woman with history of hypertension presented to our institution with short-term onset of severe back pain. On physical examination, her pulse was 110 bpm and blood pressure was 134/77 mm Hg, equal in both arms. Examination of the heart revealed a 1/6 diastolic murmur heard at the base. ECG showed sinus tachycardia with no evidence of ischemia. A computed tomography scan was performed to rule out aortic dissection. A type B intramural hematoma (IMH) was found, originating just distal to the left subclavian artery and extending to the superior mesenteric artery (Figure 1A). Four hours after the computed tomography scan, the patient developed additional symptoms of chest and stomach pain. A transesophageal echocardiogram was done to rule out further extension. No evidence of involvement proximal to the descending aorta (Figure 1B) was seen. In addition, mild aortic regurgitation was noted. A cardiac surgeon was consulted, and the decision was made to treat the patient medically.
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Figure 1. A, Initial computed tomography scan showing involvement of the intramural hematoma in the descending, but not ascending, aorta, with a subtle thin hyperdense crescent within the wall of the aorta slightly displacing intimal calcifications. B, Transesophageal echocardiogram showing the junction of the distal aortic arch and proximal descending aorta. The origin of the intramural hematoma is seen.
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The patient was stable until the fourth hospital day, when she developed recurrent severe back pain and throat pain. Repeat computed tomography scans performed with and without contrast showed proximal extension of the IMH into the ascending aorta (Figure 2). The patient underwent emergent cardiac surgery. An intraoperative epicardial echocardiogram of the ascending aorta confirmed the proximal location of the IMH (Figure 3). On gross inspection, the ascending aorta had bluish discoloration consistent with a hematoma. The ascending aorta was resected (Figure 4) and replaced by an intervascular graft. The aortic valve was structurally intact and was therefore not replaced. After surgery, the patient did well and was discharged on the third postoperative day.
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Figure 2. Repeat computed tomography performed without (A) and with contrast (B) after the patient developed recurrent symptoms of throat pain. The crescentic hyperdense intramural hematoma within the descending thoracic aorta has enlarged with increased displacement of intimal calcifications and now involves the ascending aorta.
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Figure 3. Intraoperative epicardial echocardiogram of the ascending aorta, confirming the proximal extension of the intramural hematoma.
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IMH is a variant form of aortic dissection characterized by a rupture of the vasa vasorum. IMH accounts for 13% to 27% of all aortic dissections, but it differs from typical aortic dissection in that there is no intimal tear or communication between the hematoma and the aortic lumen. Presentation, management, and classification are similar to those of typical dissection. Although type B IMH is usually treated medically, it may occasionally progress to type A dissection and require surgical intervention, as was the case with this patient.
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Acknowledgments
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Disclosures
None.
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Circulation 2007 115: 287.
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