Ann Thorac Surg 2007;84:278-280
© 2007 The Society of Thoracic Surgeons
Case Reports
Acute Stanford Type B Dissection and Cardiac Tamponade: Rupture From Around Ductus Arteriosus
Kazuhito Imanaka, MD*,
Takahiro Matsuoka, MD,
Keiko Abe, MD,
Motonobu Nishimura, MD,
Shunei Kyo, MD
Department of Cardiovascular Surgery, Saitama Medical School, Saitama, Japan
Accepted for publication December 18, 2006.
* Address correspondence to Dr Imanaka, Department of Cardiovascular Surgery, Saitama Medical School, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan (Email: imanakaz{at}saitama-med.ac.jp).
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Abstract
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Pericardial tamponade is rarely associated with acute Stanford type B aortic dissection. We encountered this unusual combination in a 59-year-old patient. He underwent an emergency drainage procedure through a midline sternotomy. Operative findings strongly suggested that the dissected aorta ruptured into the pericardial cavity from around the ductus arteriosus. Clinicians should be aware that Stanford type B aortic dissection can cause pericardial tamponade.
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Introduction
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Pericardial tamponade is rarely associated with acute Stanford type B aortic dissection. An emergency surgical procedure strongly suggested the mechanism of this unusual combination.
A 59-year-old man experienced an acute, severe pain in the back and chest. Several hours later, he visited a nearby hospital complaining of persistent back pain and evolving dyspnea. Computed tomography (CT) of the chest revealed a considerable amount of pericardial effusion, a thrombosed Stanford type B aortic dissection, and a doubly layered main pulmonary artery mimicking pulmonary artery dissection (Fig 1). The radiographic density of the pericardial effusion strongly suggested intrapericardial hemorrhage. The dissection affected the entire descending aorta and the upper part of the abdominal aorta, but hematoma around the aorta or pleural effusion was absent. His blood pressure was 80/60 mm Hg. Transesophageal echocardiography (TEE) gave no additional finding, but pulmonary hypertension was denied.
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Fig 1. (A) Computed tomography shows a thrombosed Stanford type B aortic dissection (arrows) and doubly layered main pulmonary artery mimicking pulmonary artery dissection (arrowheads). (B) A considerable amount of pericardial effusion (arrowheads) was present.
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The patient underwent an emergency surgical exploration for diagnosis, drainage, and, if necessary, repair. The pericardial cavity was found to contain 450 grams of fresh coagula and blood. The ascending aorta, the proximal aortic arch, and the anterior mediastinum were intact. The epicardial surface was normal.
A clot was found beneath the adventitia of the main pulmonary artery. This clot was removed, and the pulmonary artery was closely examined. The clot lay from the anterior aspect of the upper main pulmonary artery to the ductus arteriosus (Fig 2). There was neither pulmonary artery dissection nor further bleeding. The adventitia was sutured after tight application of oxidized cellulose sheets, and the operation was finished.
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Fig 2. (A) An inraoperative photograph shows a clot beneath the adventitia of the anterior aspect of the main pulmonary artery (arrows). This clot was extended from the ductus arteriosus. The ascending aorta, the proximal aortic arch, and the epicardial surface were intact. (B) A schematic drawing shows the mechanism of this unusual combination. The arrow shows the direction of the rupture into the pericardial cavity from around the ductus arteriosus.
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The patient’s postoperative clinical course was unremarkable. A repeat TEE 2 weeks later disclosed a tiny ulceration of 6 mm in diameter at the anterior aspect of the distal aortic arch within a few centimeters from the ductus arteriosus. The patient has been doing well 1 year since, and the pseudolumen of the aorta has disappeared.
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Comment
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Various diseases can cause acute cardiac tamponade. Some can be diagnosed by using CT or TEE, but others cannot. For this patient, several critical causes were considered because the onset was abrupt and the pericardial effusion was sanguineous. Confusingly, findings such as periaortic hematoma or pleural effusion were absent in this patient, and it was indefinite whether this type B dissection was acute. Although Stanford type A aortic dissection, the most common cause of this condition, appeared to be unlikely, CT or TEE can not completely rule out small lesions in the ascending aorta such as a penetrating aortic ulcer. Spontaneous bleeding from the coronary arteries was another possible cause [1]. Moreover, CT images mimicked pulmonary artery dissection, which was also potentially fatal [2, 3].
Pericardiocentesis or drainage through a small incision appears undesirable in patients with hemorrhagic cardiac tamponade, especially of unclear cause, because life-threatening hemorrhage may ensue during and after these procedures [4]. We believe that surgical inspection is mandatory for such patients.
It is very rare that an acute Stanford type B aortic dissection causes intrapericardial hemorrhage and tamponade [5]. Judging from the findings during the procedure, bleeding into the pericardial cavity occurred from around the ductus arteriosus, and hemorrhage extended beneath the adventitia of the pulmonary artery to form the clot in its front. Actually, the intimal tear was nearby, but the pseudolumen had already thrombosed by the time of surgery and the true bleeding site in the aorta was not identified. Aortic surgery was not performed in this case, because there was no further bleeding and it was unclear which part of the aorta needed repair. However, inspection and drainage may not be sufficient in some patients of this kind of dissection.
Clinicians should be aware that Stanford type B aortic dissection can cause pericardial tamponade. This case disclosed a likely mechanism of such an unusual combination.
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References
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- Kaljusto ML, Koldsland S, Vengen OA, Woldbaek PR, Tonnessen T. Cardiac tamponade caused by acute spontaneous coronary artery rupture J Card Surg 2006;21:301-303.[Medline]
- Andrews R, Colloby P, Hubner PJ. Pulmonary artery dissection in a patient with idiopathic dilatation of the pulmonary artery: a rare cause of sudden cardiac death Br Heart J 1993;69:268-269.[Abstract/Free Full Text]
- Le Bret E, Lupoglazoff JM, Bachet J, et al. Pulmonary artery dissection and rupture associated with aortopulmonary window Ann Thorac Surg 2004;78:e67-e68.[Abstract/Free Full Text]
- Book W, Mollod M, Felner JM. Proximal aortic dissection complicated by cardiac tamponade Echocardiography 1997;14:271-276.[Medline]
- Takagi H, Manabe H, Sekino S, Kato T, Matsuno Y, Umemoto T. Paradoxical hemopericardium in type B acute aortic dissection J Thorac Cardiovasc Surg 2005;129:939-940.[Free Full Text]
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Abstract
Introduction
