ABC | Volume 112, Nº2, February 2019

Anatomopathological Correlation Arq Bras Cardiol. 2019; 112(2):204-210 Favaratto & Aiello Heart failure after surgical correction of aortic dissection Figure 5 – Aortic valve seen from its arterial aspect. There is thickening of the free edge of the semilunar leaflets (arrows) and lack of central coaptation. Amultiloculated cavitary lesion (asterisks) is seen around the aorta, from which a pasty material emerged. areas of wine-colored parenchyma condensation, triangular in shape when sectioned. There were signs of generalized visceral congestion, as well as ascites (700 mL) and bilateral pleural effusion (200mL in each hemithorax). Histological examination showed accumulation of mucoid material in the tunica media throughout the aorta, as well as focal rupture of elastic fibers in the cavitary lesion described in the abdominal aorta (Figure 7). The anatomopathological study of the peri-aortic cavitary lesion showed mixed inflammation, with necrotic cellular and polymorphonuclear neutrophil debris, among sutures and other synthetic materials (Figure 8). Bacterial and fungal tests were negative at this site. The aortic valve showed fibrous thickening of the margins. There was chronic passive visceral congestion, with hepatic centrolobular necrosis; the wine-colored lesions in the lungs corresponded to recent infarctions. (Dr. Vera Demarchi Aiello) Anatomopathological diagnoses – Post-surgical correction of acute dissection of the ascending aorta – Peri-aortic cavitary lesion, with mixed inflammatory reaction, without the identification of infectious agents – Intramural dissection located in the abdominal aorta – Aortic valve regurgitation – Recent pulmonary infarctions Cause of death : Congestive heart failure with terminal shock (Dr. Vera Demarchi Aiello) Comments Aortic dissection is a serious disease, which is usually associated with systemic arterial hypertension and has as morphological finding the delamination of the vessel wall, with an intimal orifice called the "intimal tear" usually located in the ascending aorta, and the creation of a false lumen. This can extend to the tunica adventitia and undergo rupture, with massive bleeding into a cavity (pericardial, pleural or abdominal cavity). When the dissection does not rupture, there is usually an orifice called a re-entry, located more distally in the aortic lumen, usually in the descending aorta. Histologically, the presence of glycosaminoglycan accumulation in the tunica media, sometimes in the shape of the so-called "mucoid lakes", 10 in addition to the rarefaction and fragmentation of elastic fibers and decrease of collagen in the external third of the aortic wall can be observed, leading to the weakness of this part of the wall. In addition to the rupture, multiple organ ischemia due to the flow steal in the false lumen and aortic valve regurgitation are complications, due to collapse of its insertion when the dissection orifice is nearby. In our case, the dissection was limited to the ascending aorta, which was replaced by a synthetic tube. Although there was a reference to aortic valvuloplasty in the surgery, the patient developed congestive heart failure, probably as a result of the remaining valvular regurgitation, which was not detected on the echocardiogram, possibly due to hemodynamic changes (patient in shock). This situation was responsible for the poor postoperative evolution. The finding of a cavitary lesion in the aortic root, associated with the sutures, containing a purulent-like fluid, could mean local infection, but histological analysis did not detect the presence of microorganisms. (Dr. Vera Demarchi Aiello) 208