Differential diagnosis, investigations and treatment
Initial ECG showed normal sinus rhythm, normal axis with ST elevation in aVR and V1 leads and ST depression in I, aVL, V4-6 leads (Figure 1). According to patient’s presentation with chest pain, unequal radial pulses, a difference in blood pressures of arms and her ECG, aortic dissection was the most likely diagnosis and aortic computed tomography (CT) angiography was requested for the patient.
In laboratory tests, D-dimer was 4820 ng/ml (reference up to 600), serum ferritin 417.4 ng/ml (reference 10-291), lactate dehydrogenase 666 U/lit (reference 230-480), troponin 0.2 ng/ml (normal population < 0.05), CPK 58 U/lit (24-170), CK-MB 20 U/lit (reference 1-24), C-reactive protein 16 mg/lit (reference up to 5.9), ESR 26 mm/h (reference up to 20 in below 50 years old patients). Other para-clinical tests were normal.
Following aortic CT angiography, aortic dissection type A according to Stanford classification and type 1 according to DeBakey classification was diagnosed for the patient.
The intimal flap started at aortic valve extending to ascending aorta, aortic arch, descending thoracic aorta, abdominal aorta to right common iliac artery and then terminating in right external iliac artery. Dissection flap extension to right carotid artery, right common carotid artery and left subclavian artery were noted (Figure 2). Right coronary artery was supplied by true lumen and left main artery was supplied by false lumen. The chest CT scan showed patchy ground glass opacity in anterior segment of superior and middle lobes of right lung consistent with COVID-19 infection.
Due to the diagnosis of aortic dissection, the patient was candidate for emergency surgery and due to inadequate facilities, she was prepared to be transferred to another hospital, but as soon as she entered the ambulance, she became bradycardic, leading to asystole. Cardiopulmonary resuscitation was performed and she was returned to the first hospital. The patient underwent intubation and atropine injection, after which the patient was successfully recovered after a few minutes and she regained consciousness. After an hour, she was transferred to another hospital for emergency surgery.