Real-time Imaging of Aortic Root Rupture and Cardiac Tamponade in Acute Aortic Dissection

A 62-year-old man was hospitalized in our emergency room because of chest pain. He had a history of severe aortic regurgitation due to Marfan syndrome. The patient underwent aortic valve replacement with a bileaflet prosthetic aortic valve.

On admission, a transthoracic echocardiography (TTE) showed Type A acute aortic dissection without pericardial effusion [Figure 1a]. Suddenly bubbles appeared inside the anterior pericardial sac due to bleeding of an acute rupture of the aortic root [Figure 1b]. There was mild pericardia effusion but this progressed rapidly to massive pericardial effusion [Figure 1c] and finally cardiac tamponade and death [ [Figure 1d and Video 1].

Figure 1.

Transthoracic echocardiography. Parasternal long-axis view shows Type A aortic dissection, acute aortic root rupture, and cardiac tamponade. (a) Aorta aneurysm involving the aortic root with a linear echo suggestive of a intimal flap (white arrows). No pericardial effusion is seen. (b) Acute aortic root rupture with a new developed pericardial effusion around the right ventricle with several bubbles inside (black arrows). (c) Large pericardial effusion around the right and left ventricle (asterisk). (d) Cardiac tamponade: marked right ventricular collapse is present in diastole (white arrow). Ao: Aorta, LV: Left ventricle, LA: Left atrium, RA: Right atrium, RV: Right ventricle

According to the TTE timer, the whole sequence from mild pericardial effusion to cardiac tamponade and cardiac arrest occurred in < 29 s. Any resuscitation effort made (including urgent pericardiocentesis) to save the patient's life was ineffective.

To our knowledge, this is the first case reported in the literature of cardiac tamponade in acute aortic dissection with real-time imaging. The images were suboptimal but it is a rare glimpse into how patients die with type A aortic dissection. The presence of cardiac tamponade should prompt urgent aortic repair, as the mortality is very high (1% per hour during the first 48 hours, if untreated).

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Conflicts of interest

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