LAUSR

September 15, 2018 • Volume 11 • Number 6 cases-anesthesia-analgesia.org 169 DOI: 10.1213/XAA.0000000000000706 A 19-year-old pregnant woman at 34 weeks of gestation suffering from gravid hypertension was admitted to the maternity unit of our regional university hospital for persistent acute chest and epigastric pain lasting for 1 day. She was diagnosed with preeclampsia, since the preliminary examination revealed significant hypertension and proteinuria, and she underwent cesarean delivery under spinal anesthesia. She was then admitted to the intensive care unit. Because of increasing chest pain and dyspnea, transthoracic echocardiography and lung ultrasonography were performed using a 1–5 MHz probe (xMATRIX array transducer X5-1; Philips, Amsterdam, the Netherlands) and the EPIQ 7C ultrasound system (Philips, Eindhoven, the Netherlands) in search of signs of acute pericarditis, pleural effusion, acute heart failure, or pulmonary embolism. The parasternal long-axis view revealed a small, noncompressive pericardial effusion. The aortic root was not dilated. The parasternal short-axis view did not show any regional wall motion abnormalities. In an apical 4-chamber view, size and systolic function were normal for the 2 ventricles. A complete 8-zone lung ultrasound examination using the same cardiac probe was performed, with the settings unchanged and the patient in a semirecumbent position. The examination was negative for pneumothorax. However, the transverse view of the left basal chest area (with the probe located on the posterior axillary line at the fifth intercostal space) did show a small left pleural effusion, presenting as an anechoic area between the visceral and parietal pleura. It also showed an oscillating hyperechoic linear structure located in the descending aorta at a depth of 12 cm (Figure 1A; Supplemental Digital Content 1, Video 1, http://links.lww.com/AA/C82). The same findings were observed after a 90° clockwise rotation and posterior sliding of the probe revealing the long-axis view of the aorta (Figure 1B; Supplemental Digital Content 2, Video 2, http://links.lww.com/AA/C83). As this pathologic feature was considered to be highly suggestive of an intimal flap, a computed tomography scan with enhanced contrast injection was performed and rapidly confirmed the diagnosis of type B aortic dissection (Figure 2) with the absence of perfusion of the left renal artery. Blood pressure and heart rate were strictly controlled, and the patient underwent endovascular aortic repair guided by transesophageal ultrasound the next day. The procedure was successful, and the patient recovered fully.