ARTICLE IN PRESS www.icvts.org doi:10.1510/icvts.2009.205849 Interactive CardioVascular and Thoracic Surgery 9 (2009) 141–143  2009 Published by European Association for Cardio-Thoracic Surgery New Ideas Case Report Protocol Institutional Report ESCVS Article Historical Pages Negative Results Follow-up Paper Best Evidence Topic Proposal for Bail- out Procedure Work in Progress Report State-of-the-art Brief Communication Nomenclature Case report - Aortic and aneurysmal Aortic dissection due to sildenafil abuse Selma Kenar Tiryakioglu , Osman Tiryakioglu *, Tamer Turan , Ethem Kumbay a b, c a Department of Cardiology, Bursa Acibadem Hospital, Bursa, Turkey a Department of Cardiovascular Surgery, Bursa Yuksek I Ÿ htisas Education and Research Hospital, Bursa, Turkey b Department of Cardiovascular Surgery, Bursa Acibadem Hospital, Bursa, Turkey c Received 20 February 2009; received in revised form 3 April 2009; accepted 6 April 2009 Abstract This report deals with a 28-year-old male patient, admitted with a type A aortic dissection, potentially related to the use of sildenafil. In the literature, we found only two other potentially sildenafil-related cases of aortic dissections, one type A and one type B. In our patient, a bicuspid aortic valve and an ascending aortic aneurysm were other underlying anomalies that could have led to the aortic dissection.  2009 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Sildenafil; Aortic dissection 1. Introduction Aortic dissection is one of the most dramatic diseases that cardiovascular surgeons have encountered since the first detailed description suggested by Morgagni in 1761 w1x. Acute aortic dissection is defined as blood present between the layers of the aortic wall (false lumen), outside the true lumen, as a result of the decomposition of the media. The separation in the media is in 95% of the cases caused by the blood flowing through a tear in the intima (intimal tear or flap), while in 5% of the cases the cause is bleeding within the media (intramural hematoma). Accord- ing to some series, the aortic dissection might be unde- tected up to 38% during the initial evaluation and a considerable number of patients are diagnosed during post- mortem evaluations w2x. Early diagnosis and surgical treatment are essential in acute type A and in complicated type B aortic dissections. That surgical results are more acceptable is mostly the consequence of recently applied retrograde or anterograde cerebral perfusion techniques, hemostatic and anti-fibri- nolytic agents such as aprotinin, biological binding agents, and albumin and collagen-coated grafts. The most frequent etiologic factors are reported to be chronic systemic hypertension, hereditary connective tissue diseases and congenital aortic valve diseases (bicuspid and unicuspid aorta). In this case, we present a type A dissection following use of sildenafil. *Corresponding author. Bursa Yuksek I Ÿ htisas Hastanesi, Prof. Tezok cad. No. 1, 16320 Yildirim, Bursa, Turkey. Tel.: q90 2243605055; fax: q90 2243605055. E-mail address: tiryaki64@hotmail.com (O. Tiryakioglu). 2. Case report A 28-year-old male patient with no known history of cardiac problems was taken to the emergency service for sudden chest pain and fainting ; 2 h after the use of 50 mg sildenafil – without any sexual intercourse involved. The patient had been using sildenafil in intervals for approxi- mately a year, without any doctor prescriptions and no adverse effects had occurred. The patient was not using any other medicines regularly. The patient was not known to have any other disease. Apart from a daily consumption of approximately three packages of cigarettes, he did not have a history of stimulant use. In the emergency service, the patient was conscious, complained of severe chest pain; the physical examination revealed tachycardia and severe diastolic murmur in the aortic focus. No characteristics were detected in the res- piratory sounds of both lungs. The abdominal examination did not reveal any characteristics and bilateral femoral pulses were present. The ECG of the patient showed findings of left ventricular hypertrophy. The transthoracic echocardiography revealed a dissection phlep reaching out to the valves in the ascend- ing aorta, and the patient had a moderate – severe aortic failure (due to a cusp involvement) and a bicuspid aorta. The valve opening was sufficient and no gradients were detected on the aortic valve. The other cardiac structures were normal as much as they were observed. The ascending aorta diameter was 6.13 cm. The patient underwent a computed tomography angiography (CTA) immediately. The tomography detected an intimal phlep in the ascending aorta, beginning from the level of aortic valve and ending in the level of left subclavian artery (De Bakey type II) (Figs. 1 and 2). In the segments analyzed by the CTA-scan of the patient, no other vascular aneurysms were detected.