DIAGNOSIS AND THERAPEUTIC CONSEQUENCES OF INTRAMURAL AORTIC HEMATOMA

The classical triad of sudden devastating chest pain, electrocardiogra phic absence of acute myocardial infarction, and identification of an upstream flap in the ascending aorta by transesophageal echocardiograp hy (TEE) indicates aortic type A dissection requiring emergent surgery . Among 34 patients presenting with clinical signs and symptoms of an aortic dissection, three did not show the mandatory flap in the upstre am aorta. The only echocardiographic finding was aortic wall thickenin g indicating an intramural hematoma. Two of these patients showed earl y aortic ectasia and one showed a pericardial effusion. Despite the mi ssing flap echocardiographically, surgery was performed in all three p atients. The surgical approach was the same as that for patients with a type A dissection. Two patients are doing well after the procedure, and one patient died after reoperation. The postoperative histologic w ork-up confirmed that there was no intimal tear or dissection of the i ntimal layer. We conclude that the echocardiographic finding of an int ramural hematoma combined with typical clinical signs of chest pain, w ith myocardial infarction ruled out, requires emergent surgical interv ention.