LAUSR

A 96-year-old female was admitted to our hospital complaining acute chest and back pain. On admission, her blood pressure was 106/67 mmHg and her heart rate 85 pace/min. A Levine grade II/VI diastolic murmur was auscultated at the upper right sternal border. An electrocardiogram revealed an all-ventricular pacing rhythm. A chest radiogram showed dilated upper mediastinum. An echocardiogram revealed normal wall motion of a left ventricle, suggesting that acute coronary syndrome was less likely. Moderate aortic regurgitation was shown. On the usual left side parasternal longaxis view, a mobile flap in the aortic root was suspected but was not definitive. Therefore, we performed more precise echocardiogram. Because of her enlarged upper mediastinum, we considered that the mediastinum, especially ascending aorta itself could be an optimal echo-window through the right upper sternal boarder. The patient laid in the supine position, and the echo-probe was approached via her right-sternal border (Supplementary Fig. 1). As shown in Fig. 1, an intraaortic mobile flap was clearly observed (see also Movie 1, 2, and 3). In addition, entry of the dissection was also clearly shown (Fig. 1e, Movie 3). A Stanford A type acute aortic dissection was definitively diagnosed. An enhanced computed tomography confirmed the diagnosis. Considering her high age and comorbidities, conservative therapy was recommended.