Painless Aortic Dissection: An Unusual Presentation of Cardiomyopathy

Abstract

Only 6% of aortic dissections (AoD) present with acute congestive heart failure (CHF). These patients may have an atypical presentation, including hypotension and absence of pain. CHF in the presence of AoD is due to aortic regurgitation and/or coronary hypoperfusion. CASE PRESENTATION: A 31-year-old woman with no medical history presenting with cough and nausea/vomiting was found to be hypoxic and hypotensive. Electrocardiogram (EKG) demonstrated diffuse ST segment depressions. Labs were notable for leukocytosis, hyponatremia, and acute kidney injury, as well as elevated cardiac troponin and probrain natriuretic peptide. Cardiology was consulted after point of care ultrasound showed reduced systolic function. Urgent transthoracic echocardiogram (TTE) showed a large dissection flap prolapsing across the aortic valve and causing severe aortic regurgitation. The patient was also noted to have biventricular failure with moderate mitral regurgitation. Computed tomography angiography (CTA) confirmed the presence of an extensive Type A AoD. The patient underwent urgent aortic valve, root, and arch replacement with improvement in left ventricular function. Later analysis revealed a FBN1 genetic mutation associated with Marfan Syndrome. DISCUSSION: This case illustrates an unusual presentation of AoD as CHF in a young patient without pain. Like the patient in this case, individuals presenting with AoD and CHF are more likely to present without chest pain and in shock, as well as to have a valvular abnormality and a Stanford type A dissection. CHF can lead to a delay in surgical intervention, although it did not in this case. CONCLUSIONS: AoD must be considered in the differential diagnosis of unexplained CHF, even in the absence of pain, in order to minimize surgical delay and mortality.