Right Heart Failure as an Atypical Presentation of Chronic Type a Aortic Dissection - Multimodality Imaging for Accurate Diagnosis and Treatment. A Case Report and Mini-review of Literature

Abstract

Background: An intrapericardial organized haematoma secondary to chronic type A aortic dissection is an extremely rare cause of right heart failure. Imaging studies are essential in recognising and diagnosis of this distinctive medical condition and guiding the anticipated treatment.

Case presentation: A 70-year-old male patient was admitted for progressive symptoms of right heart failure. His cardiovascular history exposed an aortic valve replacement 22 years before with a Medtronic Hall 23 tilting valve with no regular follow-up. Classical signs of congestion were recognized at physical examination. Transthoracic two-dimensional echocardiography and thoraco-abdominal computed tomography angiography, as essential parts of multimodality imaging algorithm, established the underlying cause of right heart failure. Under total cardiopulmonary bypass and cardiac arrest, surgical removal of the haematoma and proximal repair of the ascending aorta with a patient-matched vascular graft were successfully performed. The patient was discharged in good condition with appropriate pharmacological treatment, guideline-directed; no imagistic signs of acute post-surgery complications were ascertained.

Conclusion: This paper highlights the importance of recognizing and providing a timely clinical and imagistic diagnosis of this very rare, potentially avoidable cause of right heart failure in patients with previous cardiac surgery.

Keywords: cardiac surgery; chronic type A aortic dissection; multimodality imaging; pericardial hematoma; right heart failure.

Fig. 1

Transthoracic echocardiography examination: (a) the clear presence of the ascending aortic aneurysm (6.87 cm); (b–d) massive pericardial tumoral mass compressing the right atrium. Abbreviations: LA—left atrium; LV—left ventricle; MV—mitral valve; RA—right atrium; RV—right ventricle; SVC—superior vena cava; TV—tricuspid valve; AoV — aortic valve; AscAo — ascending aorta.

Fig. 2

Emblematic thoraco-abdominal CT scans. In the coronal and sagittal scans ((a) and (b), respectively), the presence of an ascending aortic aneurysm, hematoma, and compression on RA, SVC, and IVC can be observed. (c) Compression of RA; (d) compression of SVC and RPA (axial CCTA scans). Abbreviations: AscAo—ascending aorta; IVC—inferior vena cava; LV—left ventricle; PA—main pulmonary artery; RA—right atrium; RPA—right pulmonary artery; SVC—superior vena cava.

Fig. 3

Intraoperative images. (a) Post-sternotomy, the ascending aortic aneurysm was revealed; (b) the chronic pericardial hematoma; (c) the ascending aorta replaced with a 30 mm-diameter vascular graft; (d) the final result.