Secondary imaging tests such as transesophageal echocardiography should be performed when clinical suspicion for acute type A aortic dissection is high despite a negative non-cardiac gated CT angiogram.
High suspicion for type A dissection may warrant TEE after negative non-gated CTA; leaves open need for prospective validation.
INTRODUCTION: Though computed tomographic angiography has very high sensitivity and specificity to diagnose acute aortic dissection, false-negative studies can occur and secondary tests may be required to make the diagnosis. CASE PRESENTATION: We report the case of a 57-year-old Caucasian man with a typical presentation for acute type A aortic dissection in whom the initial non-cardiac gated computed tomographic angiogram was negative, leading to a delay in surgical management. Transesophageal echocardiography and post hoc 3D reconstruction of the original computed tomographic scan revealed a dissection flap confined to the aortic root, immediately superior to the sinuses of Valsalva and masquerading as part of the aortic valve apparatus. CONCLUSION: This case demonstrates that false-negative computed tomographic angiograms taken to rule out type A aortic dissection can occur and that secondary imaging tests, such as echocardiography, should be performed in cases in which the pre-test probability of aortic dissection is high. Cardiac gating of computed tomographic angiograms to exclude aortic dissection may enhance diagnostic accuracy.
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Nagra et al. (2013) studied this question.
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