We describe a case of a 49-year-old man who presented
with an uncomplicted aortic root aneurysm, aortic insufficiency, and
ST-elevation myocardial infarction (STEMI) without obstructive coronary artery
disease on angiography. The computed tomo- graphy angiogram (CTA) of the
thorax, performed without cardiac gating,
was misinterpreted as normal. In retrospect, an overlooked extravasation
of contrast material lateral to the aortic root was detected on non-gating
magnetic resonance angiography (MRA). Exploration of the aortic root revealed
an unsuspected horizontal intimal tear of the left sinus of Valsalva with
limited extramural hematoma. The presence of an otherwise silent intimal tear
on preoperative imaging studies makes the overall management more problematic. For example, initiating early broad
empirical anticoagulants or fibrinolytics therapy to treat the accompanied myocardial
infarction may extend the tear into a full life-threatening aortic dissection,
tamponade or rupture. We highlight many of the
difficulties associated with the diagnosis and treatment of limited
sinus tear when aortic root aneurysm is presenting with cryptogenic STEMI.
Accurate morphologic characterization of intimal tear would be best defined
with either an electrocardiogram-gating CTA or MRA imagings. These non-invasive
tests are needed to make appropriate management
decisions. Depending on other pathologic components of aortic root, cusps and the commissural geometry, sinus
tear is a critical component for the overall treatment plan and it shifts the
surgical intervenetion from valve-sparing
operation, commissural resuspension and leaflet repair to composite aortic root replacement (modified version of the Bentall procedure).
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