A 78-year-old woman presented with dyspnea for 3 weeks PTA.

Questions: 
1. Please describe CXR findings (60 คะแนน)
2. What is the provisional diagnosis? (40 คะแนน)

โดย กองอายุรกรรม รพ.ภูมิพลอดุลยเดช กรมแพทย์ทหารอากาศ

ANSWERs

1.CXR findings

• There is widening of the mediastinum with soft tissue density lesion overlying right side cardiac bordering ddx ascending thoracic aortic aorta , anterior mediastinal mass
• Cannot evaluate cardio thoracic ratio
• The trachea is deviated slightly to the right, likely secondary to mediastinal mass effect.

 Transthoracic Echocardiogram (TTE) Findings:

• Concentric left ventricular hypertrophy (LVH) is present.
• Left ventricular systolic function is within normal limits.
• There is severe dilatation of the ascending aorta, with findings suspicious for aortic dissection.

 CT Angiography (CTA) Findings:

• A limited intimal tear is identified in the ascending aorta, without a visible dissection flap.
• There is a dilated ascending aortic aneurysm, with an eccentric mural thrombus present.
• Dilate infrarenal abdominal aorta with eccentric thrombus

2.Provisional diagnosis  Ascending aortic aneurysm with limited intimal tear, suspicious for early or contained Type A aortic dissection, associated with eccentric mural thrombus.
 
Immediate Management:

1. Emergency Cardiothoracic Surgery Consultation

• Urgent surgical repair is typically indicated for Type A dissections or aneurysms with intimal tears.
• Delay increases the risk of rupture and mortality.

2. Blood Pressure and Heart Rate Control

• Target BP: Systolic <120 mmHg (if tolerated).
• Target HR: <60 bpm.
• Medications:
  • IV Beta-blockers (e.g., Esmolol, Labetalol) to reduce shear stress.
  • Add vasodilators (e.g., Nitroprusside) if further BP reduction is needed after beta-blockade.
  • Avoid vasodilators without beta-blockade due to risk of reflex tachycardia.

3. Strict Hemodynamic Monitoring

• ICU admission for continuous monitoring of BP, ECG, and urine output.
• Repeat imaging (e.g., TEE or CTA) may be needed if clinical status changes.

4. Pain Control
 
Definitive Treatment:

• Open surgical repair of the ascending aorta

#cardio #CXR #dissection

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