Case 20 - Torn Apart...

Author: Dr Nick Mani Reviewer: Dr Nish Cherian

A middle-aged man presents with a 1-week history of chest pain radiating to the back which came on suddenly during exertion and described as a ‘popping’ sensation.

You elect to perform a bedside focused transthoracic echo with a dedicated suprasternal notch view as an extension of your standard clinical assessment:

Clip Collection (Press right/Left to change the clips)

Focused TTE PLAX, PSAX and SSN (other windows are limited)

TTE- Transthoracic Echocardiography, PLAX- Parasternal Long Axis, PSAX- Parasternal Short Axis, SSN- Suprasternal Notch

• What are the 4 key abnormalities identified on the images?

  1- Thoracic Aortic Aneurysm

  1- Pericardial Effusion (most likely haemopericardium in this case)

  3- Bicuspid Valve

  4- Intimal Flap (seen only in the the suprasternal notch view supported by doppler)

• What is the accuracy of echo for diagnosis the condition?

  Presence of direct TTE signs (mainly intimal flap) had a sensitivity and specificity of 45.2% [95% confidence interval (CI) 37-53.6%] and 97.4% (95% CI 95.9-98.4%), while presence of any TTE sign, e.g. pericardial effusion or aortic valve regurgitation or aneurysm, had a sensitivity and specificity of 89% (95% CI 82.8-93.6%) and 74.5% (95% CI 71-77.7%).

  Nazerian P, Mueller C, Vanni S, Soeiro AM, Leidel BA, Cerini G, Lupia E, Palazzo A, Grifoni S, Morello F. Integration of transthoracic focused cardiac ultrasound in the diagnostic algorithm for suspected acute aortic syndromes. Eur Heart J. 2019 Jun 21;40(24):1952-1960. doi: 10.1093/eurheartj/ehz207. PMID: 31226214.

• What are the windows to visualise thoracic descending aorta?

  Standard PSAX

  and/or 2 chamber apical view

  and/or proximal abdominal aorta view in longitudinal

• What is the most likely provisional diagnosis?

  Thoracic Aortic Syndrome/Dissection, (Type A) with background of undiagnosed thoracic aortic aneurysm and bicuspid valve, complicated by haemopericardium

• What is the gold standard for diagnosis?

  CTA (unless haemodynamic instability unable to be optimised in which case TEE might need to be deployed)

Clip Collection 2 (Press right/Left to change the clips)

CT Aortogram views confirms the diagnosis with early complication of haemopericardium

Case Resolution

The patient was urgently transferred to the regional cardiothoracic centre for surgical repair.

Take Home points

• TTE could be useful as extension of clinical assessment particularly in haemodynamic instability, and/or resource limited settings

• TTE should NOT be used to exclude and/or delay CT/transfer/surgery

• CT Aortogram is the gold diagnostic standard