Acute aortic dissection with intimal intussusception: transesophageal echocardiographic appearances.

A 71-yr-old man presented to our emergency department, with 12 hr of chest pain and dyspnea. A computed tomography scan demonstrated the presence of a 7.4 cm ascending aortic aneurysm, type A aortic dissection, in the distal ascending aorta extending into brachiocephalic and right common carotid arteries. A transthoracic echocardiogram showed type A dissection, with intimal flap prolapsing through the aortic valve into the left ventricular outflow tract, and severe aortic regurgitation.1 The intraoperative transesophageal echocardiography (TEE) midesophageal short axis view revealed a circumferential intimal dissection flap in the proximal ascending aorta (Figure 1). The five-chamber and midesophageal long axis views showed a large intimal flap, prolapsing into the left ventricular outflow tract, up to the tips of anterior mitral valve leaflet during diastole (Figure 2; video images available as Additional Material at: www.cja-jca. org). The TEE images highlighted the intussusception of the cylindrical flap. Severe aortic insufficiency was noted.2 Surgical findings showed that the dissection started in the mid-ascending aorta, with the dissected media and intima intussuscepting and telescoping back into the left ventricular outflow tract. The aortic valve was tricuspid and heavily calcified, with a fenestration in the noncoronary leaflet. Replacement of ascending aorta, hemi-arch, and aortic valve was performed. The patient recovered from anesthesia and surgery uneventfully, and she was discharged home on postoperative day 12.