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A 38-Year-Old Woman With Worsening Dyspnea After Giving Birth

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 38-year-old woman without a significant medical history presented with worsening dyspnea and lower extremity edema at 1 week post partum. When at full term, a planned vaginal delivery was complicated by breached position of the fetus, fetal distress, and new onset of fever. The delivery was converted to a cesarean birth, which was uncomplicated. Perioperatively, she had an episode of chest pain that resolved spontaneously. Troponin levels were normal. A vascular ultrasound study ruled out deep vein thrombosis in the lower extremities. A non–electrocardiogram (ECG)-gated computed tomography angiogram showed no pulmonary embolism but was otherwise not diagnostic owing to motion artifacts (Figure 1A). She had progressive dyspnea, mild pulmonary congestion noted on chest radiography, and an elevated brain-type natriuretic peptide level greater than 800 pg/mL (conversion to ng/L is 1:1). Physical examination findings showed a new heart murmur. A transthoracic echocardiogram (TTE) was performed, which showed a normal-sized left ventricle and preserved left ventricular ejection fraction, severe aortic regurgitation (AR), and a mildly dilated aortic root (Figure 1B and Video). The patient was transferred to our institution for further treatment. The patient was afebrile at that point, and her white blood cell count was within normal limits.

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Type A aortic dissection

D. Perform transesophageal echocardiography

In this patient, results of non–ECG-gated computed tomography angiography were not conclusive for aortic pathology. The short-axis view of TTE at the aortic valve level revealed echogenic tissue in the aortic sinus, which was not considered an aortic valve leaflet given its malalignment with the commissure (Figure 1B). This finding warranted further investigation and prompted us to perform transesophageal echocardiography, which confirmed the echogenic tissue as the intimal flap of a type A aortic dissection (TAAD), with limited extension beyond the aortic root (Figure 2).

Dyspnea and edema are common phenomena in late pregnancy; however, the sudden onset of chest pain with an associated heart murmur in the peripartum period should raise concerns for a cardiac event. Among the differential diagnoses, the index of suspicion for TAAD is high. When dissection is limited to a short segment of the aorta and creates subtle morphological changes, selection of proper diagnostic modalities and adequate interpretation become critical to facilitate an early diagnosis.

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Article Information

Corresponding Author: Masashi Kawabori, MD, Division of Cardiac Surgery, Tufts Medical Center, 800 Washington St, Boston, MA 02111 (kawabori.masashi@gmail.com).

Published Online: April 15, 2020. doi:10.1001/jamacardio.2019.5731

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

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