Ectatic ascending aorta and chronic descending aorta dissection – a surprising diagnosis and a heart team approach

Introduction: Chronic aortic dissection of the descending thoracic or thoracoabdominal aorta is a possible life threatening condition due to the possibility of severe complications. In order to determine the risk of rupture and the appropriate surgical intervention time, it is important to proper evaluate the ascending and descending aorta.
Case presentation: We present a case of a 73 year-old man, hypertensive, who presented to our clinic with persistent atrial fibrillation and heart failure NYHA 2 class. In order to perform electrical cardioversion, we performed a transesophageal echocardiography, to exclude left auricle thrombosis and diagnosed ascendant aorta ectasis and chronic Stanford type B descending aortic dissection. For optimal evaluation of the aorta, we performed a thoracic CT, which confirmed the ec-tatic aorta (maximum diameter of 54 mm) and also the dissection of thoracic and abdominal aorta. We deci-ded conservative treatment, with oral anticoagulation, tight control of blood pressure and reevaluation in 3 months. At this moment, the patient returns to our clinic, asymptomatic, but with slightly rise of systolic blood pressure (150 mmHg). The multislice compu-ted tomography (CT) showed unchanged diameter of the ascending aorta (54/53 mm) with dissection fold distal from the origin of left subclavian artery down to the descending thoracic-abdominal aorta with left common iliac artery continuing the false lumen. Ma-ximum diameter of the thoracic descending aorta was 64/61 mm. Furthermore, the CT showed a small se-cond dissection fold on the thoracic descending aorta in its medium contour, 6 cm distal from left subclavi-an artery. The transthoracic echocardiography showed preserved left ventricle ejection fraction, with no sig-nificant valvular lesions. For proper risk assessment we performed a coronary angiography which revea-led atherosclerotic stenosis of 30-40% in the left main and 50-60% stenosis of the anterior descending artery. Under these circumstances we decided the treatment based on a heart team with cardiologist, cardiac surge-on and anesthesiologist. According to the guidelines, chronic Stanford B descending aorta dissection has no indication for surgical treatment and, also, taking into consideration the stationary diameter of the ascending aorta, less than 55 mm in an asymptomatic patient, we decided conservative treatment with intensive control of blood pressure (systolic blood pressure under 120 mmHg).
Conclusions and particularities: This challenging case highlights the pitfalls of diagnosis and risk stratification in patients with chronic descending aorta dissection associated with ascending aortic ectasis. It also rises the attention on the importance of a heart team decision in order to avoid possible fatal complications.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)
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