a bizarre aortic dissection

IMAGES IN CARDIOTHORACIC SURGERY A Bizarre Aortic Dissection Marc Sirol, MD, PhD, Georgios Sideris, MD, Nicolas Deye, MD, Patricj Henry, MD, PhD, Frederic Baud, MD, and Philippe Soyer, MD, PhD Département d’imagerie Cardiovasculaire et Unité clinique de Radiologie Viscérale et Vasculaire, Hôpital Lariboisière, Paris, France, INSERM UFR U942, Insuffisance Cardiaque et Biomarqueurs, de Cardiologie, and de Réanimation Médicale et Toxicologique, Assistance Publique- Hôpitaux de Paris, Hôpital Lariboisière, Paris, France A 39-year-old man with an unremarkable history expe- rienced sudden cardiac arrest related to sustained ventricular fibrillation. Despite rapid and appropriate car- diopulmonary resuscitation, return to spontaneous circula- tion was not achievable. The patient was immediately transferred to our intensive care unit. Resuscitation maneu- vers allowed maintenance of correct cardiac output during transportation. An arteriovenous femorofemoral extracor- poreal membrane oxygenation (ECMO) device was im- planted at the bedside [1]. The patient recovered normal cardiac activity after several attempts of cardiac defibrilla- tion. Electrocardiography revealed sinus rhythm with no signs of myocardial infarction or ischemia as confirmed by coronary angiographic findings. No hypertrophy or dilated cardiomyopathy was noted on cardiac ultrasonography, but left ventricular dysfunction with low ejection fraction due to moderate and global hypokinesia was seen. In addition, a 6-mm circumferential peripheral effusion was noted. Therefore 64-slice computed tomography of the aorta was performed using cardiac triggering acquisition and admin- istration of iodinated contrast material through a jugular venous catheter. Axial images (Fig 1, A–C) showed partial enhancement of the ascending aorta. Sagittal and coronal views showed an adjacent intimal flap, suggesting De- Bakey’s type II aortic dissection (arrow on Fig 1, A–F). This patient had normal transesophageal cardiac ultrasono- graphic findings, and subsequent computed tomographic examination ruled out aortic dissection. After injection, contrast material is redistributed from the right atrium through the ECMO device into the aorta through the iliac artery. The ECMO device generates retrograde aortic blood flow. Spontaneous cardiac activity contributes to arterial outflow originating from the left ventricle. Enhanced ECMO blood mixes with unen- hanced blood from the left ventricle in the initial portion of the ascending aorta, thus creating marked turbulence and generating such a mimic condition. This case illustrates that in the setting of ECMO use, abnormal enhancement of the aorta does not uniformly indicate aortic dissection. When suspected, this diagnosis must be confirmed by other imaging tests. Reference 1. Mégarbane B, Leprince P, Deye N, Résière D, Guerrier G, Rettab S, Théodore J, Karyo S, Gandjbakhch I, Baud FJ. Emer- gency feasibility in medical intensive care unit of extracorpo- real life support for refractory cardiac arrest. Intensive Care Med 2007;33:758 – 64. Address correspondence to Dr Sirol, Université Paris VII, Denis Diderot Assistance Publique, Hôpitaux de Paris, Service de Radiologie Vasculaire, Hôpital Lariboisière, 2 rue Ambroise, 75010 Paris, France; e-mail: [email protected]. Fig 1. © 2012 by The Society of Thoracic Surgeons Ann Thorac Surg 2012;93:2070 • 0003-4975/$36.00 Published by Elsevier Inc doi:10.1016/j.athoracsur.2011.11.016 FEATURE ARTICLES

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FEAT

ICLES

IMAGES IN CARDIOTHORACIC SURGERY

A Bizarre Aortic DissectionMarc Sirol, MD, PhD, Georgios Sideris, MD, Nicolas Deye, MD, Patricj Henry, MD, PhD,Frederic Baud, MD, and Philippe Soyer, MD, PhDDépartement d’imagerie Cardiovasculaire et Unité clinique de Radiologie Viscérale et Vasculaire, Hôpital Lariboisière, Paris,

France, INSERM UFR U942, Insuffisance Cardiaque et Biomarqueurs, de Cardiologie, and de Réanimation Médicale etToxicologique, Assistance Publique- Hôpitaux de Paris, Hôpital Lariboisière, Paris, France

A39-year-old man with an unremarkable history expe-rienced sudden cardiac arrest related to sustained

ventricular fibrillation. Despite rapid and appropriate car-diopulmonary resuscitation, return to spontaneous circula-tion was not achievable. The patient was immediatelytransferred to our intensive care unit. Resuscitation maneu-vers allowed maintenance of correct cardiac output duringtransportation. An arteriovenous femorofemoral extracor-poreal membrane oxygenation (ECMO) device was im-planted at the bedside [1]. The patient recovered normalcardiac activity after several attempts of cardiac defibrilla-tion. Electrocardiography revealed sinus rhythm with nosigns of myocardial infarction or ischemia as confirmed bycoronary angiographic findings. No hypertrophy or dilatedcardiomyopathy was noted on cardiac ultrasonography, butleft ventricular dysfunction with low ejection fraction due tomoderate and global hypokinesia was seen. In addition, a6-mm circumferential peripheral effusion was noted.Therefore 64-slice computed tomography of the aorta wasperformed using cardiac triggering acquisition and admin-istration of iodinated contrast material through a jugularvenous catheter. Axial images (Fig 1, A–C) showed partial

Address correspondence to Dr Sirol, Université Paris VII, Denis DiderotAssistance Publique, Hôpitaux de Paris, Service de Radiologie Vasculaire,

Fig 1.

Hôpital Lariboisière, 2 rue Ambroise, 75010 Paris, France; e-mail:[email protected].

enhancement of the ascending aorta. Sagittal and coronalviews showed an adjacent intimal flap, suggesting De-Bakey’s type II aortic dissection (arrow on Fig 1, A–F). Thispatient had normal transesophageal cardiac ultrasono-graphic findings, and subsequent computed tomographicexamination ruled out aortic dissection.

After injection, contrast material is redistributed fromthe right atrium through the ECMO device into the aortathrough the iliac artery. The ECMO device generatesretrograde aortic blood flow. Spontaneous cardiac activ-ity contributes to arterial outflow originating from the leftventricle. Enhanced ECMO blood mixes with unen-hanced blood from the left ventricle in the initial portionof the ascending aorta, thus creating marked turbulenceand generating such a mimic condition.

This case illustrates that in the setting of ECMO use,abnormal enhancement of the aorta does not uniformlyindicate aortic dissection. When suspected, this diagnosismust be confirmed by other imaging tests.

Reference

1. Mégarbane B, Leprince P, Deye N, Résière D, Guerrier G,Rettab S, Théodore J, Karyo S, Gandjbakhch I, Baud FJ. Emer-gency feasibility in medical intensive care unit of extracorpo-

real life support for refractory cardiac arrest. Intensive CareMed 2007;33:758–64.

Ann Thorac Surg 2012;93:2070 • 0003-4975/$36.00doi:10.1016/j.athoracsur.2011.11.016

mailto:[email protected]

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