Three cases of diagnostic delay of type A acute aortic dissection.

Diagnostic delay Diagnostic error Type A aortic dissection

Journal

The Egyptian heart journal : (EHJ) : official bulletin of the Egyptian Society of Cardiology
ISSN: 2090-911X
Titre abrégé: Egypt Heart J
Pays: Germany
ID NLM: 9106952

Informations de publication

Date de publication:
29 Jan 2024
Historique:
received: 31 07 2023
accepted: 19 01 2024
medline: 29 1 2024
pubmed: 29 1 2024
entrez: 29 1 2024
Statut: epublish

Résumé

Diagnostic delay (DD) can be lethal when patients with type A acute aortic dissection (TAAAD). We report 3 cases of DD associated with TAAAD. Case 1 is a female in her sixties presenting with severe back pain. A CT scan was taken, and TAAAD with a thrombosed false lumen was suspected by the radiology technician. He did not successfully transfer his concern to the physicians and the patient was sent home. The next day, she was transferred to another hospital with a recurrence of the symptom, and the diagnosis of TAAAD was made with a CT scan there. Case 2 was an 87-year-old female who was transferred to our hospital because of a loss of consciousness and bruises on the forehead. CT scan was taken and the displaced intimal flap in her aortic arch was overlooked by the part-time physician almost at the end of his shift. The diagnosis of TAAAD was made by the radiologist. Case 3 was the 44-year-old male who did not have health insurance and experienced severe back pain a few days before the visit to our clinic. On that day, he went to the nearby hospital's emergency room, and only pain medication was prescribed. A few days later, a CT scan was taken at our hospital to investigate the cause of pyuria and the diagnosis of TAAAD was made. DD may be common and multifactorial in our practice. Physicians need to take every step to improve diagnostic accuracy.

Sections du résumé

BACKGROUND BACKGROUND
Diagnostic delay (DD) can be lethal when patients with type A acute aortic dissection (TAAAD). We report 3 cases of DD associated with TAAAD.
CASE PRESENTATION METHODS
Case 1 is a female in her sixties presenting with severe back pain. A CT scan was taken, and TAAAD with a thrombosed false lumen was suspected by the radiology technician. He did not successfully transfer his concern to the physicians and the patient was sent home. The next day, she was transferred to another hospital with a recurrence of the symptom, and the diagnosis of TAAAD was made with a CT scan there. Case 2 was an 87-year-old female who was transferred to our hospital because of a loss of consciousness and bruises on the forehead. CT scan was taken and the displaced intimal flap in her aortic arch was overlooked by the part-time physician almost at the end of his shift. The diagnosis of TAAAD was made by the radiologist. Case 3 was the 44-year-old male who did not have health insurance and experienced severe back pain a few days before the visit to our clinic. On that day, he went to the nearby hospital's emergency room, and only pain medication was prescribed. A few days later, a CT scan was taken at our hospital to investigate the cause of pyuria and the diagnosis of TAAAD was made.
CONCLUSION CONCLUSIONS
DD may be common and multifactorial in our practice. Physicians need to take every step to improve diagnostic accuracy.

Identifiants

pubmed: 38285096
doi: 10.1186/s43044-024-00444-y
pii: 10.1186/s43044-024-00444-y
doi:

Types de publication

Journal Article

Langues

eng

Pagination

10

Informations de copyright

© 2024. The Author(s).

Références

Flower L, Arrowsmith JE, Bewley J, Cook S, Cooper G, Flower J et al (2023) Management of acute aortic dissection in critical care. J Intensive Care Soc 24:409–418
doi: 10.1177/17511437231162219 pubmed: 37841293 pmcid: 10572474
Jassar AS, Sundt TM 3rd (2019) How should we manage type A aortic dissection? Gen Thorac Cardiovasc Surg 67:137–145
doi: 10.1007/s11748-018-0957-3 pubmed: 29926291
Dixon M (2011) Misdiagnosing aortic dissection: a fatal mistake. J Vasc Nurs 29:139–146
doi: 10.1016/j.jvn.2011.08.003 pubmed: 22062792
Nienaber CA, Eagle KA (2003) Aortic dissection: new frontiers in diagnosis and management: Part II: therapeutic management and follow-up. Circulation 108:772–778
doi: 10.1161/01.CIR.0000087400.48663.19 pubmed: 12912795
Miller AC, Cavanaugh JE, Arakkal AT, Koeneman SH, Polgreen PM (2023) A comprehensive framework to estimate the frequency, duration, and risk factors for diagnostic delays using bootstrapping-based simulation methods. BMC Med Inform Decis Mak 23:68
doi: 10.1186/s12911-023-02148-w pubmed: 37060037 pmcid: 10103428
Lovatt S, Wong CW, Schwarz K, Borovac JA, Lo T, Gunning M et al (2022) Misdiagnosis of aortic dissection: a systematic review of the literature. Am J Emerg Med 53:16–22
doi: 10.1016/j.ajem.2021.11.047 pubmed: 34968970
Pourafkari L, Tajlil A, Ghaffari S, Parvizi R, Chavoshi M, Kolahdouzan K et al (2017) The frequency of initial misdiagnosis of acute aortic dissection in the emergency department and its impact on outcome. Intern Emerg Med 12:1185–1195
doi: 10.1007/s11739-016-1530-7 pubmed: 27592236
Harris KM, Strauss CE, Eagle KA, Hirsch AT, Isselbacher EM, Tsai TT et al (2011) Correlates of delayed recognition and treatment of acute type A aortic dissection: the International registry of acute aortic dissection (IRAD). Circulation 124:1911–1918
doi: 10.1161/CIRCULATIONAHA.110.006320 pubmed: 21969019
Cigarroa JE, Isselbacher EM, DeSanctis RW, Eagle KA (1993) Diagnostic imaging in the evaluation of suspected aortic dissection. Old standards and new directions. N Engl J Med 328:35–43
doi: 10.1056/NEJM199301073280107 pubmed: 8416269
Shiga T, Wajima ZI, Apfel CC, Inoue T, Ohe Y (2006) Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Arch Intern Med 166(13):1350–1356
doi: 10.1001/archinte.166.13.1350 pubmed: 16831999
Fisher ER, Fau SE, Godwin 2nd JD, Otto CMF (1994) Acute aortic dissection: typical and atypical imaging features. Radiographics 14(6):1263–1271
doi: 10.1148/radiographics.14.6.7855340 pubmed: 7855340
Graber M, Gordon R, Franklin N (2002) Reducing diagnostic errors in medicine: what’s the goal? Acad Med 77:981–992
doi: 10.1097/00001888-200210000-00009 pubmed: 12377672
Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L et al (2015) Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 16:233–270
doi: 10.1093/ehjci/jev014 pubmed: 25712077
Nazerian P, Mueller C, Soeiro AM, Leidel BA, Salvadeo SAT, Giachino F et al (2018) Diagnostic accuracy of the aortic dissection detection risk score plus D-dimer for acute aortic syndromes: the ADvISED prospective multicenter study. Circulation 137:250–258
doi: 10.1161/CIRCULATIONAHA.117.029457 pubmed: 29030346
Evangelista A, Maldonado G, Gruosso D, Gutierrez L, Granato C, Villalva N et al (2019) The current role of echocardiography in acute aortic syndrome. Echo Res Pract 6:R53–R63
doi: 10.1530/ERP-18-0058 pubmed: 30921764 pmcid: 6454227
Kaeley N, Gangdev A, Galagali SS, Kabi A, Shukla K (2022) Atypical presentation of aortic dissection in a young female and the utility of point-of-care ultrasound in identifying aortic dissection in the emergency department. Cureus 14:e27236
pubmed: 36035033 pmcid: 9399661

Auteurs

Takeshi Shimamoto (T)

Department of Cardiovascular Surgery, Hamamatsu Rosai Hospital, 25 Shogen-cho, Hamamatsu, Shizuoka, 430-8525, Japan. takeshishimamoto@hamamatsuh.johas.go.jp.

Sanae Tomotsuka (S)

Department of Cardiovascular Surgery, Hamamatsu Rosai Hospital, 25 Shogen-cho, Hamamatsu, Shizuoka, 430-8525, Japan.

Makoto Takehara (M)

Department of Cardiovascular Surgery, Hamamatsu Rosai Hospital, 25 Shogen-cho, Hamamatsu, Shizuoka, 430-8525, Japan.

Shinichi Tsumaru (S)

Department of Cardiovascular Surgery, Hamamatsu Rosai Hospital, 25 Shogen-cho, Hamamatsu, Shizuoka, 430-8525, Japan.

Classifications MeSH