Case summary : We report a 27-year-old female with history of conservatively managed VSD known since childhood. She presented with acute decompensated cardiac failure requiring intubation and inotropic support. Bedside echocardiography performed in the emergency department suggested a ruptured SoVA at the right coronary cusp with underlying supracristal VSD. Despite the patient being critically ill with multi-organ failure, surgery was performed as it was the patient's best chance for survival. Intraoperative findings tallied with the early echocardiographic results. She recovered gradually and was eventually discharged despite a stormy post-operative period.
Discussion : This case report highlights the importance of prompt recognition of SoVA rupture by using bedside echocardiography. Surgical intervention needs to be early despite ongoing sepsis in view of acute mechanical failure. This case was unique as it illustrates a successful management of an acutely ill patient with multi-organ failure through early diagnosis, intensive perioperative stabilization, and surgical intervention.
METHODS/RESULTS: 32 cases of which 12 females and 20 male and 18 out of 32 cases were aged below 40. All of the cases were examined macroscopically and microscopically. 30 out of 32 cases (93%) died due to rupture associated with the AD. Two unusual complications were proximal extension of AD into left coronary artery (CA) with intramural haematoma blocking the vessel and AD involving the ostium of the right CA resulting in avulsion of the right CA from the aorta. Mode of death in both these cases were myocardial ischemia. Sections of the aorta in all cases confirmed extensive cystic medial degeneration with disorganisation, fragmentation and disappearance of the elastin fibres with increased collagen and smooth muscle nuclear degeneration.
CONCLUSION: Pathologists should be thorough when examining the aorta, the aortic valve and root in AD. When a rupture site cannot be found it is important to look for unusual complications involving the CAs. Histology plays an important role to corroborate the cause of death.
PATIENTS AND METHODS: Male patients aged 50 years and above (including indigenous people) with angiographically diagnosed significant CAD in the recent one year were screened for AAA. Standard definition of abdominal aortic aneurysm and CAD was used. All new patients were followed up for six months for AAA events (ruptured AAA and AAA-related mortality).
RESULTS: A total of 277 male patients were recruited into this study. The total prevalence of undiagnosed AAA in this study population was 1.1% (95% CI 0.2-3.1). In patients with high-risk CAD, the prevalence of undiagnosed AAA was 1.7% (95% CI 0.3-4.8). The detected aneurysms ranged in size from 35.0mm to 63.8mm. Obesity was a common factor in these patients. There were no AAA-related mortality or morbidity during the follow-up. Although the total prevalence of undiagnosed AAA is low in the studied population, the prevalence of sub-aneurysmal aortic dilatation in patients with significant CAD was high at 6.6% (95% CI 3.9-10.2), in which majority were within the younger age group than 65 years old.
CONCLUSION: This was the first study on the prevalence of undiagnosed AAA in a significant CAD population involving indigenous people in the island of Borneo. Targeted screening of patients with high-risk CAD even though they are younger than 65 years old effectively discover potentially harmful asymptomatic AAA and sub-aneurysmal aortic dilatations.