Helping the surgeon. Epicardial 3D echocardiography in aortic dissection

A74-year-old woman was admitted to the emergency room with acute severe chest pain, dyspnoea and a history of giant cell arteritis and polymyalgia rheumatica. Her heart rate was 95 beats/min, arterial blood pressure was 100/60 mm Hg, and a diastolic murmur was present along the right upper sternal border. She was neurologically intact, with clear lungs, palpable normal pulses in the right radial and in both femoral arteries, and a filiform left radial pulse. Transthoracic echocardiography revealed aortic dissection type A with moderate aortic regurgitation. Aortography confirmed the diagnosis and the extension of the dissection. The patient was taken into the operating room where, after sternotomy, real-time threedimensional (RT3DE) epicardial echocardiography was carried out (iE33, Philips) with the new probe X5-1, demonstrating the tear (panel A). The exact location and dimension of the tear were easily pointed out, 5 mm from the sinotubular junction, with the false lumen reaching the aortic root above the coronary ostia (panel B). The patient underwent aortic dissection repair with a ‘‘button Bentall’’ procedure with a biologic prosthesis. RT3DE offered to the surgeon an impressive, dynamic, precise assessment of the tear and a realistic representation of the anatomical dissection, which was useful for surgical planning.