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ran V, Westveer DC, Gordon S. Aneurysm of the atria1 septum as diagnosed by echocardiography: analysis of 11 patients. Am J Cardiol 1984;53:1401-2.

3. Longhini C, Brunaxzi MC, Musacci G, Caneva M, Bandello A, Bolomini L, Barbiero M, Toselli T, Barbaresi F. Atria1 septal aneurysm: echopolycardiographic study. Am J Cardiol 1985;56:653-6.

4. Gallet B, Malergue MC, Adams C, Saudemont JP, Collot AMC, Druon MC, Hiltgen M. Atria1 septal aneurysm-a po- tential cause of systemic embolism. Br Heart J 1985;53:292-7.

5. Higgins CB, Byrd BF, McNamara MT, Lanzo P, Lipten MJ, Botvinick E, Schiller NB, Cooks LE, Kaufman L. Magnetic resonance imaging of the heart: a review of the experience in 172 subjects. Radiology 1985;155:671-9.

6. Panidis IP, Kotler MN, Mintz GS, Ross J. Clinical and echocardiographic features of right atrial masses. AM HEART J 1984;107:745-58.

7. Alfonso F, Rey M, Balaguer J, Artiz V, Rabago G. Hydatid cyst of the right atrium diagnosed by echocardiography. Am J Cardiol 1987;60:931-2.

Dissecting aortic aneurysm eight years after aortic commissurotomy for congenital aortic stenosis: Detailed identification by transesophageal echocardiography

Thomas Porter, MD, Michael Lenhart, MD, James Arrowood, MD, William Moskowitz, MD, Walter Paulsen, MD, Gary Lofland, MD, and J. V. Nixon, MD. Richmond, Va.

A 2%year-old white man presented with a 7-day history of intermittent retrosternal chest pain. Eight years previously he had undergone an aortic valve commissurotomy for congenital aortic stenosis. Physical examination revealed a healthy white man with a blood pressure in the right arm of 130/78 mm Hg and a pressure in the left arm of 120/80 mm Hg. Precordial examination revealed normal heart sounds, a 216 systolic ejection murmur at the right sternal border, and a 214 early diastolic murmur at the cardiac apex. Pulses were equal and there were no focal neuro- logic abnormalities. His laboratory examination was nor- mal. A chest x-ray film showed cardiomegaly with a dilated ascending aorta. An electrocardiogram recorded normal sinus rhythm and voltage criteria for left ven- tricular hypertrophy. A transthoracic color flow Doppler echocardiogram revealed a massively dilated aortic root, severe aortic regurgitation, and a small pericardial effu- sion.

From the Division of Cardiology, Cardiac Surgery, and Pediatric Cardiol- ogy at the Medical College of Virginia.

Reprint requests: J. V. Nixon, MD, Division of Cardiology, Medical College of Virginia, MCV Station-Box 128, Richmond, VA 23298.

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The patient was admitted to the hospital and underwent combined transthoracic and transesophageal studies, using a 5.0 MHz probe No. 77020 AC, Hewlett-Packard Co., Medical Products Group, Andover, Mass.). This revealed an easily identifiable intimal flap with an entry size approximately 2 to 3 cm above the aortic valve cusps. The dilated aortic root was 8 cm in diameter (Fig. 1). Color Doppler studies demonstrated bidirectional flow in both the true and false lumens. Color Doppler analysis of the descending aorta (Fig. 1) in this region showed more than one exit site. The patient underwent aortic valve replace- ment with a Medtronic Hall aortic valved conduit (the Bentall procedure) (Medtronic Inc., Minneapolis, Minn.). The patient made a good recovery and on the first postop- erative day underwent another transesophageal examina- tion. This revealed a stable aortic valve prosthesis and conduit surrounded by thrombus in the previous native aortic lumen (Fig. 2). In both the transverse and the descending aorta, a persistent false lumen with systolic flow was recorded.

The probable etiology of the aortic dissection in this pa- tient relates to his history of a congenitally biscuspid aor- tic valve despite his having a commissurotomy, due to the accompanying abnormal blood flow velocities. Aortic dis- section in young men may also be secondary to trauma, or associated with Marfan’s syndrome or Ehlers-Danlos syn- drome. Although aortic dissection has been described fol- lowing aortic cross clamping or aortic cannulation, it is usually seen in the early postoperative period. Proximal aortic dissections have been described late after aortic valve replacement,i with the most likely reason being ab- normal turbulent motion in the ascending aorta. However, aortic dissection late after aortic valvotomy has not been described.

Transesophageal echocardiography is a sensitive and specific diagnostic technique for the diagnosis of aortic dissection.2 In addition, it has been useful in the serial evaluation of dissection repair, which has been complicated by a small incidence of aneurysms at the site of anastomo- sis, and aneurysms occurring distal to the previous anastomosis.4 The transthoracic Doppler echocardiogram complemented the examination by documenting the se- verity of aortic regurgitation and identifying the upper as- cending aorta, which was not easily identified by transe- sophageal examination. In conclusion, transesophageal echocardiography was the definitive diagnostic procedure in this unique case of type I aortic dissection. Transesoph- ageal echocardiography has become the procedure of choice for the diagnosis of aortic dissection and the serial follow- up of its repair.

REFERENCES

1. Muna WF, Spray TL, Morrow AG. Aortic dissection after aortic valve replacement in patients with valvular aortic stenosis. J Thorac Cardiovasc Surg 1977;74:65.

2. Erbel R, Engberding R, Daniel W, Rowlandt J, Visser C, Ren- nollet H, and the European Cooperative Study Group for

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Fig. 1. Two-dimensional transthoracic echocardiographic images of the ascending and descending thoracic aorta contrasted with transesophageal images of the two regions. Note intimal flap in ascending aortic images and dual exit sites of the dissection on transesophageal descending thoracic aortic images.

Fig. 2. Transesophageal echocardiographic images taken 8 hours after an aortic valve conduit was placed. The large amount of thrombus surrounding the conduit is seen on the ascending thoracic aortic images. The descending thoracic images show the turbulent color jet from the false lumen in systole.

September 1990 7 18 Brief Communications American Heart Journal

Echocardiography. Echocardiography in diagnosis of aortic 4. Seward JB, Khandheria BK, Oh JK, Abel MD, Hughes RW, dissection. Lancet 1989;1:457. Edwards WD, Nichols BA, Freeman WK, Tajik J. Transe-

3. Mohr-Kahaly S, Erbel R, Rennollet H, Wittlich N, Drexler M, sophageal echocardiography: technique, anatomic correla- Oelert H, Meyer J. Ambulatory follow-up of aortic dissection tions, implementation, and clinical applications. Mayo Clin by transesophageal two-dimensional and color-coded Doppler Proc 1988;63:649. echocardiography. Circulation 1989;80:24.