key: cord-1036380-afdmx9m3
authors: Volvovitch, David; Ram, Eilon; Cohen, Hillit; Kogan, Alexander; Sternik, Leonid; Raanani, Ehud
title: Acute pulmonary embolism following acute type A aortic dissection in a patient with COVID‐19
date: 2021-02-02
journal: J Card Surg
DOI: 10.1111/jocs.15389
sha: 92d0ebb9a1f7dcc84af470f21679dcb5f65bd7b0
doc_id: 1036380
cord_uid: afdmx9m3

Acute aortic dissection and acute pulmonary embolism (PE) are life‐threatening emergencies that can mimic each other at presentation. Immediate and accurate diagnosis of these scenarios is crucial to initiate the appropriate interventions. In this case report we present a 73‐year‐old patient, who was admitted to our Medical Center with acute type A aortic dissection. She was tested for coronavirus disease 2019 (COVID‐19) infection and was found to be positive. During her admission in the COVID‐19 designated intensive care unit, she diagnosed with acute PE in the main right and left pulmonary arteries. She underwent surgery that included bilateral pulmonary embolectomy and aortic dissection repair. The patient was discharged from our hospital on the ninth postoperative day without any complications. Frequency of simultaneous presentation of acute aortic dissection and acute PE is increased with a history of coagulation abnormalities as seen in patients with COVID‐19.

and was found to be positive. During her admission in the COVID-19 designated intensive care unit, she diagnosed with acute PE in the main right and left pulmonary arteries. She underwent surgery that included bilateral pulmonary embolectomy and aortic dissection repair. The patient was discharged from our hospital on the ninth postoperative day without any complications. Frequency of simultaneous presentation of acute aortic dissection and acute PE is increased with a history of coagulation abnormalities as seen in patients with COVID-19.

COVID-19, pulmonary embolism, type A aortic dissection

Acute chest pain is a common presenting complaint in the emergency department on a daily basis, as many diseases of the heart, aorta, lungs, stomach, mediastinum, and so forth may cause chest discomfort. 1 Type A aortic dissection is a surgical emergency that occurs when an intimal tear in the aorta creates a false lumen in the ascending aorta. Emergent surgical repair is required and includes replacement of the dissected aorta. 2 Hypercoagulable states increase the risk for the development of blood clots. Severe coagulation abnormalities are presented in nearly 20% of patients with coronavirus disease 2019 (COVID-19). 3, 4 The coagulation changes suggest the presence of a hypercoagulable state that increases the risk of thromboembolic complications. 3 We present here a rare case that was diagnosed and successfully treated with ascending aorta replacement for type A aorta dissection repair and pulmonary embolectomy, in a patient who tested positive for COVID-19. The patient was discharged from our hospital on the ninth postoperative day with the same anticoagulation therapy and without any complications. The patient was followed-up in our outpatient clinic eight weeks after she was discharged home. In her last follow-up, the patient recovered totally from her hospital course, was classified with NYHA functional Class I and reported that she is in a good mental state. She was free from any symptoms, including angina or dyspnea. Follow-up CTA twelve weeks postoperative demonstrated good result of the aortic repair and PE repair (Figures 3 and 4 ). In epidemiological studies, the incidence of acute aortic dissection is approximately 3.5-6.0 per 100,000 patient-years 6 and the annual incidence rates for PE range from 39 to 115 per 100,000 patients. 7 The combined presentation of these two is very rare.

Immediate and accurate diagnosis is imperative as an emergency surgical procedure and is frequently necessary. Available data suggest that open heart surgical repair is the optimal treatment for type A aortic dissection. 6 In our case, the patient presented with sharp chest pain without other symptoms. The positive test for COVID-19 and the time that passed between the first CTA and the date of surgery, led us to repeat the CT scan that demonstrated new blood clots in the pulmonary arteries.

Acute aortic dissection and acute pulmonary embolism can mimic each other clinically. Rapid and accurate diagnosis is crucial to establish correct treatment.

While acute aortic dissection and acute pulmonary embolism are very rare, they could present simultaneously, especially where there is a history of coagulation abnormalities as seen in patients with COVID-19.

There are no sources of funding for this manuscript. 

Successful repair of concomitant acute type A aortic dissection and saddle pulmonary embolism

Acute type A aortic dissection

Coagulation abnormalities and thrombosis in patients with COVID-19

Prevention and treatment of venous thromboembolism associated with coronavirus disease 2019 infection: a consensus statement before guidelines

The role of imaging in aortic dissection and related syndromes

Acute aortic dissection and intramural hematoma: a systematic review

Global burden of thrombosis: epidemiologic aspects

The authors declare that there are no conflict of interests.

The study was approved by the Institutional Review Board with a waiver of informed consent.

http://orcid.org/0000-0002-8966-4641Eilon Ram http://orcid.org/0000-0003-3292-821X