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).