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Quando uma dissecção aórtica complica... : a propósito de um caso clínico
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A dissecção aguda da aorta é a causa mais frequente de emergência da patologia aórtica, apresentando elevada taxa de morbilidade e mortalidade. É importante estabelecer rapidamente o quadro clínico e o diagnóstico para o tratamento mais adequado. É apresentado o caso clínico de um homem de 62 anos, com antecedentes de dislipidemia, hipertensão arterial, tiroidectomia total por bócio coloide e DPOC por hábitos tabágicos, internado no serviço de CCT com o diagnóstico de dissecção aórtica do tipo A. Fez implantação de prótese tubular Vascutek nº28 e manteve inicialmente válvula aórtica nativa com ressuspensão das comissuras valvulares apoiadas em pledgets. Esteve internado 26 dias com necessidade de suporte inotrópico prolongado e cursou com diversas complicações: 1) sépsis; 2) insuficiência renal aguda com necessidade HDFVVC; 3) bradiarritmia sintomática, em contexto de doença do nódulo sinusal com necessidade de implantação de pacemaker DDD-R e 4) mediastinite. Ao 13º dia após alta hospitalar, entrou em insuficiência cardíaca por insuficiência aórtica aguda com necessidade de novo internamento e implantação de prótese aórtica biológica assim como de revascularização miocárdica (cirúrgica e angioplastia). Teve como complicações neste internamento hemorragia digestiva alta, agravamento da insuficiência renal e nova mediastinite. Atualmente, aos 24 meses de follow-up, encontra-se em classe II da NHYA com prótese normofuncionante; CDI e dissecção aórtica crónica tipo B.
Acute aortic dissection is the most frequent cause of aortic emergency, with high morbidity and mortality. It is important to quickly establish the diagnosis and adequately characterize the clinical data for the most suitable treatment.1 It is described the clinical case of a 62-years-old man, with a history of dyslipidemia, hypertension, colloid goiter with total thyroidectomy and COPD due to smoking habits, admitted to the CCT service with the diagnosis of type A aortic dissection. A tubular prosthesis Vascutek no. 28 was implanted and he remained initially with native aortic valve with ressuspension of the valve commissures supported on pledgets. He was hospitalized for 26 days and prolonged inotropic support and surgical procedure for mediastinitis was needed. In the post surgery several complications occurred: 1) sepsis; 2) acute kidney injury with the need of HDFVVC; 3) symptomatic bradyarrhythmia in the context of sinus disease needing the implantation of pacemaker DDD-R and 4)mediastinitis. Thirteen days after hospital discharge, worsening heart failure due to aortic insufficiency was observed and the patient was again to hospital. A biological prosthetic aortic implantation as well as coronary artery bypass and angioplasty were performed. The post surgery was complicated with upper gastrointestinal bleeding, worsening of acute kidney injury and new mediastinitis. Currently, in follow-up of 24 months, he is in NYHA class II with normally functioning prosthesis, ICD and chronic type B aortic dissection.
Acute aortic dissection is the most frequent cause of aortic emergency, with high morbidity and mortality. It is important to quickly establish the diagnosis and adequately characterize the clinical data for the most suitable treatment.1 It is described the clinical case of a 62-years-old man, with a history of dyslipidemia, hypertension, colloid goiter with total thyroidectomy and COPD due to smoking habits, admitted to the CCT service with the diagnosis of type A aortic dissection. A tubular prosthesis Vascutek no. 28 was implanted and he remained initially with native aortic valve with ressuspension of the valve commissures supported on pledgets. He was hospitalized for 26 days and prolonged inotropic support and surgical procedure for mediastinitis was needed. In the post surgery several complications occurred: 1) sepsis; 2) acute kidney injury with the need of HDFVVC; 3) symptomatic bradyarrhythmia in the context of sinus disease needing the implantation of pacemaker DDD-R and 4)mediastinitis. Thirteen days after hospital discharge, worsening heart failure due to aortic insufficiency was observed and the patient was again to hospital. A biological prosthetic aortic implantation as well as coronary artery bypass and angioplasty were performed. The post surgery was complicated with upper gastrointestinal bleeding, worsening of acute kidney injury and new mediastinitis. Currently, in follow-up of 24 months, he is in NYHA class II with normally functioning prosthesis, ICD and chronic type B aortic dissection.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2015
Palavras-chave
Aorta Doenças da aorta Cardiologia