Aortic dissection is relatively uncommon, but often presents with acute severe chest or back pain and acute hemodynamic compromise and is associated with high mortality. We present a case of aortic dissection with an atypical presentation in a heart failure patient and the challenges encountered to make the diagnosis. The patient was a 54-year-old African American female who presented with progressively worsening exertional dyspnea and orthopnea for three days and sensation of indigestion and bloating. The patient denied any recent history of chest pain and she was initially admitted for heart failure exacerbation. Her admission chest x-ray showed severe cardiomegaly with a prominence of pulmonary vascular but there was a borderline widening of mediastinum measuring 8.2 cm. Physical exam showed unequal dorsalis pedis pulses (fainter on the right side) and systolic blood pressure difference of more than 20 mmHg between bilateral upper extremities. Computed tomography angiography (CTA) of chest, abdomen, and pelvis confirmed the diagnosis of dissection of thoracic and abdominal aorta extending from the left subclavian artery to the femoral artery. The patient was managed with labetalol drip and later transferred to a tertiary center for an elevated level of care where the endovascular intervention was performed. The patient then followed up with a vascular clinic for serial CTA and heart failure clinic for optimization of core measures. In conclusion, this case highlights the importance of clinical suspicion of aortic dissection and discusses the various clinical presentations of aortic dissection and its management. Being a highly fatal condition, prompt diagnosis is extremely important and is often life-saving. Therefore, it is important for physicians to be aware of atypical presentations of aortic dissection to initiate timely interventions to avoid catastrophic complications.
Abstract Background:Although the 12‐lead electrocardiogram (ECG) has been found useful in identifying the left anterior descending (LAD) coronary artery as the infarct‐related artery in acute myocardial infarction (MI), it has traditionally been felt to be incapable of localizing the culprit lesion within the LAD itself. Such a capability would be important, because anterior MI due to proximal LAD lesions carry a much worse prognosis than those due to more distal or branch vessel lesions. Hypothesis:This study investigated whether certain ECG variables—especially an ST‐segment injury pattern in leads aVL and/or V 1 —would correlate with culprit lesion site, and an ECG algorithm was developed to predict culprit lesion site. Methods:The initial ECGs of 55 patients who had undergone cardiac catheterization after an anterior or lateral MI were reviewed to identify the leads with an ST‐segment injury pattern; the corresponding catheterization films were then reviewed to identify the location of the culprit lesion; and these separate findings were then compared. Results:The sensitivity and specificity of an ST‐injury pattern in a VL in predicting a culprit lesion before the first diagonal branch were 91 and 90%, respectively; the same values in predicting a lesion prior to the first septal branch were 85 and 78%. ST‐segment elevation in V 1 , on the other hand, was a much less sensitive and specific predictor of a preseptal lesion. Overall, our algorithm correctly identified the culprit lesion location in 82% of our patients. Conclusion:Based on our findings, we conclude that an ST‐segment injury pattern in a VL during an anterior myocardial infarction predominantly reflects a proximal LAD lesion and therefore constitutes a high‐risk finding.
We present the case of an asymptomatic 21‐year‐old woman referred because of an abnormal routine electrocardiogram. Transthoracic and transesophageal echocardiography revealed a complete absence of the atrial septum, a common atrium septated posteriorly from the pulmonary venous chamber, a partial atrioventricular canal, a cleft mitral valve and a persistent left superior vena cava draining into an enlarged coronary sinus. These findings were confirmed during surgical correction. Our patient presented with an unusual and fascinating combination of congenital malformations that remained well tolerated and undiscovered into adulthood.
tients.Ribotyping [6] showed that the blood isolates were identical to those recovered from the initial skin samples but different from those recovered from all of the other patients.This finding suggests that infection of implanted material by skin isolates of S. schleiferi may be a more important problem than is presently appreciated.
