Delayed asymptomatic progressive aortic dissecting aneurysm in patient with STEMI.

An 80-year-old woman visited emergency room because of resting chest pain for one hour. She had history of hypertension for 10 years. The blood pressure was 80/50 mmHg and the pulse rate was 51 beats/min. The electrocardiogram demonstrated Junctional bradycardia and ST elevation in lead II, III and aVF. Chest X-ray indicated cardiomegaly (Figure 1A). Coronary angiography revealed near total occlusion of proximal right coronary artery (RCA). She underwent percutaneous coronary intervention (PCI) for the RCA lesion successfully. Echocardiography showed hypokinesia of RCA territory (Figure 2A). Seven days later, she was discharged without any complication. One year later, we identified enlarged right paracardiac bulging lesion on chest radiography (Figure 1B). We performed chest computed tomography that revealed aortic dissecting aneurysm involving ascending aorta (Figure 3A). Echocardiography also showed intimal flap and aneurysmal change at ascending aorta (Figure 2B). We recommended operation, but the patient did not consent. Three years later, follow-up chest CT showed no significant interval change of the dissecting aneurysm (Figure 3B). The patient has been following up at outpatient department.

Figure 1.

Chest X-ray images.

(A): Chest X-ray showed mild cardiomegaly at pre-PCI; (B): enlarged right cardiac border at one year after PCI. PCI; percutaneous coronary intervention.

Figure 2.

Echocardiography images.

(A): Echocardiography revealed no definite aneurysm; (B): dissecting aneurysm with flap at one year PCI. AV: aortic valve; LA: left atrium; LV: left ventricle; PCI; percutaneous coronary intervention.

Figure 3.

Chest tomography images.

(A): Chest CT demonstrated aortic dissecting aneurysm at one year after PCI; (B): three years after PCI. There was no change of aneurysm size. PCI: percutaneous coronary intervention.

Aortic dissection often presents with sudden onset chest pain, however, some patients with asymptomatic or varied clinical manifestations. Confirmation of the diagnosis requires various imaging modalities include computed tomography, echocardiography, magnetic resonance imaging which identify the extent of aortic involvement, entry and reentry sites, aortic regurgitation, coronary artery involvement and pericardial effusion as well.[1]