A 49-year-old man with a history of hypertension presented to the emergency department because of chest pain and syncope. Acute coronary syndrome was suspected; both ECG and laboratory test were negative. Echocardiography demonstrated a dilated ascending aorta (56 mm), and a mildly regurgitant bicuspidal aortic valve; neither left ventricular wall motion abnormalities nor pericardial effusion were detected. Aortic dissection was suspected and the patient underwent transoesophageal echocardiography. The study could not identify any intimal flap in the whole thoracic aorta, but attentive inspection of the posterior ascending aorta revealed subtle signs of discrete aortic dissection, namely a limited intimal splitting tear (IT), a discrete adjacent intramural haematoma (IH), and a minimal fluid periaortic effusion (PE). The patient underwent emergent surgery; the echocardiographic findings were confirmed after the ascending aorta was opened; valve-sparing surgery (valve reimplantion into a tube graft, according to David technique) was performed. The patient was discharged 1 week later in good general condition; transthoracic echocardiography identified mild residual aortic regurgitation.

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Figure 1 Transoesophageal echocardiographic image of the proximal ascending aorta demonstrating subtle typical signs of discrete aortic dissection.

The classification of aortic dissection proposed by the European Society of Cardiology is based on anatomic presentation and comprises five classes: 1) classic aortic dissection with true and false lumen separated by an intimal flap; 2) intramural haematoma; 3) subtle or discrete aortic dissection; 4) penetrating atherosclerotic ulcers; and 5) iatrogenic or traumatic dissection. Aortic dissection cannot be ruled out by simply excluding the presence of an intimal flap separating the aorta into two lumina (indicative of class 1 dissection), but attentive inspection of the whole aorta should be performed in order to detect signs typical or suggestive of class 2–4 aortic dissection. In patients with class 3 dissection, attentive inspection of the proximal ascending aorta by transoesophageal echocardiography can provide unique diagnostic information (subtle intimal discontinuity, circumscribed intramural haematoma, discrete periaortic effusion) given the proximity of the aorta to the oesophagus and the millimetric spatial resolution of the technique, leading to prompt emergency surgery, short hospital stay, and good outcome.