Conclusions
Generally abrupt pain chest or back pain is the most common onset of
TAAAD according to IRAD and so at presentation about 80% of patient
experience pain.[5] An atypical presentation of aortic dissection
makes the diagnosis difficult and thus is contributing to elevated
mortality associated with this syndrome.[11,12] In this case
epiaortic vessels were also involved likely without clinical
manifestations. By definition, malperfusion describes signs and symptoms
of end organ dysfunction due to low blood flow [13]. The
inflammatory cascade related to end-organ dysfunction increase
significantly surgical risk. [14,15] In this case we observed a
total rupture of intima, media and adventitia about one centimeter from
the ostium of right coronary artery. Non signs and symptoms of ischemia
were documented. The characteristics of the hematoma suggest a recent
formation compatible with the diagnosis of sub-acute dissection. If it
is assumed that the onset was at the time of chest discomfort about 2
weeks earlier, several days have passed before the first medical contact
and admission to our ICU.
Probably, consolidation of the hematoma and a progressive increase in
the false lumen stretched the right coronary so as to allow complete
detachment. At the same time, however, the flow was contained by the
presence of the hematoma. The patient may have had a certain degree of
ischemia or angina at dissection, not recognized at the time of
admission.
Another hypothesis is the perioperative detachment compatible also with
the presence of right-side postoperative dysfunction as well as use of
retrograde cardioplegia. [16]
To our opinion, this is the first case of totally asymptomatic subacute
type A aortic dissection with right artery avulsion at presentation
described in literature. We also advise surgeons, in cases of aortic
root involvement, to be always ready to an unplanned myocardial
revascularization.
Conflicted of interest: none
Authors contribution: all authors gave substantial contribution
to study. Critical revision of data and revision of article (Aldo D.
Milano), data collection and revision of article ( Andriy Dralov).