A Tale of Tears and Healing

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A 78-year-old woman with a background of hypertension and osteoarthritis presented with a history of syncope secondary to severe aortic stenosis. She underwent a computed tomography (CT) scan that showed a heavily calcific trileaflet aortic valve (Panel A).  Her aortic annulus was measured at 445 mm² with relatively modest aortic wall calcification. Following Heart Team discussion, she underwent a transfemoral transcatheter aortic valve implantation. A 26 mm Sapien S3 Ultra valve (Edwards Lifesciences) was deployed under rapid pacing. The patient reported chest pain extending to her back associated with a drop of blood pressure to 78/50 mm Hg. A check aortogram revealed an acute aortic dissection starting from the top frame of the transcatheter heart valve (Panel B). An echocardiogram revealed 0.8 cm of pericardial effusion with no evidence of right ventricular diastolic compromise (Panel C). In preparation for emergency open aortic repair, the patient became hemodynamically stable with no further chest pain. A repeat aortogram revealed that the dissection flap is no longer visible and likely to have sealed itself (Panel D). The patient was subsequently transferred for an urgent CT scan, which confirmed an ascending aortic dissection of 8.5 cm with no communication between the true and false lumen (Panel E). A conservative approach was elected, with the on-call cardiothoracic surgical team on standby if any change occurred in symptoms or hemodynamic, echocardiographic, or CT appearance. She was commenced on intravenous labetalol and was transitioned to oral antihypertensive, aiming for systolic blood pressure of less than 110 mm Hg. A repeat CT a few days later confirmed the dissection flap had not progressed (Panel F) and the patient was discharged home.

Affiliations and Disclosures

From the ¹Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK, ²Translational and Clinical Research Institute, Newcastle University, Newcastle, UK

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein. Each author acknowledges that they have the authority to transfer copyright to HMP.

Address for Correspondence: Mohammad Alkhalil, Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, United Kingdom. Email: mak-83@hotmail.com