Ascending Aortic Rupture Incidentally Revealed at the Cath Lab: Surprising, Rare, and Life-Threatening

Ascending aortic rupture is generally secondary to preexisting pseudoaneurysm or aneurysm associated with connective tissue disorders. Spontaneous ascending aortic rupture without prior aortic disorders is rare and unpredictable, with only a few cases reported to date and high mortality rates.^1,2

An 80-year-old woman who was an active smoker with neglected long-term hypertension, but no known previous aortic or connective tissue disorders, presented to the emergency department complaining of sudden chest pain associated with cardiogenic shock. The admission electrocardiogram showed ST-segment elevation in the inferior and lateral leads (Figure 1). Immediately upon catheterization laboratory arrival, her clinical status degenerated to cardiac arrest (pulseless electrical activity).

After 2 cycles of standard cardiopulmonary resuscitation (CPR), without any apparent rib or sternal fractures, return of spontaneous circulation was achieved and then followed by emergency coronary angiography. No epicardial coronary significant lesions were found, but an unexpected ascending aortic wall rupture was surprisingly noticed, with a clear movable flap and contained dye extravasation (Figure 2; Videos 1-3). Just after the fast angiograms, there was recurrence of pulseless electrical activity. Despite advanced cardiovascular life support, sustained return of spontaneous circulation was not achieved after more than 30 minutes of CPR, thus precluding any complementary imaging modality evaluation and ultimately the mandatory aortic rupture surgical correction.

Ascending aortic rupture can be diagnosed by transesophageal or transthoracic echocardiography, computed tomography, magnetic resonance, or invasive angiography. Asymptomatic spontaneous rupture of the ascending aorta resulting in pseudoaneurysm is a very rare condition. Aortic pseudoaneurysm is usually a consequence of aortic wall dissection, iatrogenic injury, blunt chest trauma, connective tissue disorders, or infection.² Penetrating atherosclerotic ulcer³ and atherosclerotic calcification, especially in longstanding hypertension, like in the present case, are also described as alternative causes.⁴

Aortic rupture may also be a rare but catastrophic complication of CPR.⁵ In the present case, no evident rib or sternal fractures related to the chest compressions were found. Because of their lethal nature, most CPR-associated aortic injuries have been discovered on necropsy, which was unfortunately not performed in the present case due to COVID-19 pandemic constraints. This points to the need to consider and rapidly evaluate for aortic injury in the face of refractory hemodynamic instability immediately after CPR to expedite potentially lifesaving surgical intervention.⁵ Rapid diagnosis and prompt multidisciplinary approach are essential for the management of this challenging, life-threatening, and rare occurrence with huge morbidity and mortality rates.

Affiliations and Disclosures:

From the ¹Interventional Cardiology Unit, Hospital MedRadius, Maceió, Alagoas, Brazil; ²Discipline of Cardiology, Interventional Cardiology Unit, Hospital Universitário I, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Adriano Caixeta, MD, PhD, Department of Interventional Cardiology, Hospital São Paulo, Escola Paulista de Medicina, UNIFESP. Napoleão de Barros, nº 715 - Vila Clementino, São Paulo-SP, 04024-002, Brazil. Email: acaixeta@me.com

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