A man with sudden onset chest pain.

PATIENT PRESENTATION

A 55‐year‐old male with a history of long QT syndrome status post implantable cardioverter‐defibrillator, polycystic kidney disease, and hypertension presented to the emergency department for sudden onset chest pain with radiation to the back and left arm. Initial vital signs demonstrated a blood pressure of 203/93 with a heart rate of 58. Troponin was 0.04 ng/mL, D‐dimer was >20 μg/mL, and creatinine was 4.89 mg/dL. Chest x‐ray demonstrated a widened mediastinum. Point‐of‐care ultrasound (POCUS), including parasternal, apical, subxiphoid, and abdominal aortic views, were unremarkable. Suprasternal view revealed a hyperechoic linear structure moving rhythmically with cardiac contraction independent of the vascular wall (Figure 1; Video 1).

FIGURE 1

Transthoracic echocardiography showing a hyperechoic linear structure in the lumen of the descending aorta (arrowhead), suprasternal view

DIAGNOSIS

Stanford type A aortic dissection

Cardiovascular Surgery and Cardiology were consulted. Emergent transesophageal echocardiography (Figure 2) and computed tomography (CT) angiography (Figure 3) confirmed the diagnosis of a Stanford type A dissection. The patient underwent emergent repair without complication.

FIGURE 2

Transesophageal echocardiography with color Doppler identifying true lumen (star) of an aortic dissection (arrowhead), descending aorta short axis view

FIGURE 3

Computed tomography angiography of the thorax demonstrating an aortic dissection (star), sagittal view

Aortic dissection is a vascular emergency that is potentially life threatening, and timely management is critical. CT angiography is considered the reference standard for noninvasive diagnosis. POCUS is efficient, highly specific, and can escalate management. Multiple transthoracic echocardiography views are recommended when assessing the thoracic aorta. , The suprasternal view is often not considered in this assessment but is of paramount importance, and it was key to diagnosis in the present case. Management of a Stanford type A dissection includes the control of blood pressure and heart rate and consultation for emergency surgery.

VIDEO 1. Transthoracic echocardiography showing a hyperechoic linear structure in the lumen of the descending aorta, suprasternal view.

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