Investigations
Laboratory analysis revealed elevated troponin T of 3.3 ng/mL and EKG revealed new right bundle branch block. CT angiography of the thorax revealed prominent aortic sinus (image 1), pneumomediastinum, an aortic root disruption with Stanford type A dissection with hemopericardium (image 2) and rupture of the epicardium of the right ventricle and adventitia of the pulmonary artery. The epicardial hematoma was contained but the patient had significant intrapericardial bleeding and clot. TTE revealed dissection flap in the ascending aorta extending into the right sinus of Valsalva (image 6 and media 1) and severe aortic regurgitation with holodiastolic flow reversal in the abdominal aorta (image 3, image 4 and image 5, media 2). Intraoperative TEE revealed dilated aortic root to 4 cm, dissection flap in the ascending aorta extending into the right sinus of Valsalva and severe aortic regurgitation (image 7, media 3).