Acute aortic dissection can occur at the time of intense physical exertion in strength-trained athletes like weightlifters, bodybuilders, throwers, and wrestlers

A Biddinger

BM Pluim

C de Virgilio

CR Ficar

D Corrado

Hossein Ahmadi

I Hatzaras

J Gammie

J Morganroth

Parin Yazdanifard

Shapour Shirani

English

PubMed

Springer - Publisher Connector

BioMed CentralCases Journal
ssOpen AcceCase Report
Aortic dissection type I in a weightlifter with hypertension: A case 
report
Hossein Ahmadi*, Shapour Shirani and Parin Yazdanifard
Address: Associate Professor of cardiovascular and thoracic surgery, Tehran Heart Center, North Kargar Street, Tehran, Iran
Email: Hossein Ahmadi* - dr.ahmadi2006@yahoo.com; Shapour Shirani - sh_shirani@yahoo.com; 
Parin Yazdanifard - parinyazdanifard@yahoo.com
* Corresponding author    
Abstract
Acute aortic dissection can occur at the time of intense physical exertion in strength-trained
athletes like weightlifters, bodybuilders, throwers, and wrestlers.
Rapid rise in blood pressure and history of hypertension are the most common causes of aortic
dissection in athletes. It is a very tragic event because of its high mortality rate of about 32% in
young patients. We report a case of aortic dissection in a young weightlifter with an extensive
intimal tear of the aorta, from the sinus of Valsalva to the abdominal aorta.
Introduction
Acute aortic dissection results from a tear in the intima
and media of the aortic wall, with the subsequent creation
of a false lumen in the outer half of the media and elon-
gation of this channel by pulsatile blood flow. Dissection
of the aorta is associated with a high degree of morbidity
and mortality despite continuing improvements in diag-
nostic and surgical techniques [1], and hypertension is
present as the most common cause in 70–90% of patients
with aortic dissection [2]. A number of normal daily and
athletic activities require isometric or static exercise.
Sports such as weightlifting and other high-resistance
activities are used by power athletes to gain strength and
skeletal muscle bulk. These exercises significantly increase
blood pressure, heart rate, myocardial contractility, and
cardiac output. Hypertension has long been recognized as
an important risk factor for the development of aortic
aneurysms and dissections [1,3]. Also, it has been specu-
lated that the very high blood pressure generated during
the lifting of weights, particularly with staining accompa-
nied by a Valsalva maneuver, may be the cause of an aortic
intimal tear [3]. Pre-participation cardiovascular evalua-
tion of young competitive athletes is warranted on the
basis of the available evidence [4]. Patients with predis-
posing conditions to aortic dissection, including hyper-
tension, should be sturdily encouraged to refrain from
weightlifting. We present a case of aortic dissection in a
young athlete with a history of hypertension.
Case presentation
A 37-year-old Iranian man with a history of hypertension
and long history of weightlifting was admitted to our hos-
pital complaining of knifelike retrosternal chest pain,
which was abrupt while lifting weight, accompanied by
severe sweating and palpitation. Distal pulses were weakly
palpable. Electrocardiography showed non-sinus arrhyth-
mia, Wolf-Parkinson-White (WPW) syndrome, and Q in
lead III and avf. Echocardiography findings were normal
left ventricular size with concentric left ventricular hyper-
trophy (LVH), left ventricular ejection fraction (LVEF) of
about 55%, dilated ascending aorta of about 56 mm, and
mild mitral regurgitation. In addition, the intimal flap in
Published: 18 August 2008
Cases Journal 2008, 1:99 doi:10.1186/1757-1626-1-99
Received: 14 June 2008
Accepted: 18 August 2008
This article is available from: http://www.casesjournal.com/content/1/1/99
© 2008 Ahmadi et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
Cases Journal 2008, 1:99 http://www.casesjournal.com/content/1/1/99the ascending aorta was seen collapsed. The diagnosis was
obtained by computed tomography (CT) angiography,
which showed a typical aspect of type A of Stanford clas-
sification of aortic dissection (ascending aorta, transverse
arch, and descending thoracic aorta were involved) [fig 1].
The intimal tear was located just above the Valsalva sinus
running to the abdominal aorta with hemopericardium
[fig 2, 3]. Subsequently, the patient developed cardiac
arrest and cardiopulmonary resuscitation (CPR) was per-
formed. He was taken emergently for the surgical replace-
ment of the aortic valve and repair of type I aortic
dissection. Femoral artery cannulation, median sternot-
omy, and right atrial cannulation for total cardiopulmo-
nary bypass (CPB) were carried out. At the opening of the
pericardium, there was a typical ascending aneurysm
which was extended to the origin of the innominate artery
[fig 4]. After aortotomy, the entry site of the aortic dissec-
tion was identified anteriorly. The dissection was
extended into the aortic arch and then into the aortic root.
On the other hand, the ascending aorta was fully dissected
with an extension of the proximal dissection toward the
abdominal aorta. Because of the destruction of the sinus
of Valsalva by the dissection, the Bental procedure was
performed. The segment of the aorta containing the inti-
mal tear was subsequently resected and replaced with a
Dacron graft. Teflon felt was used and attached to the aor-
tic wall with continuous sutures on the outer bound of it.
Also, glue was applied to fill the entire space between the dissected fragile layers. CPB and aortic cross-clamp times
were 300 and 240 minutes, respectively. After long-run
anesthesia and cardiopulmonary bypass, the patient was
weaned from CPB and admitted to intensive care unit
(ICU) with inotropic support. Twenty-four hours after
ICU admission, the patient developed a deep coma with
pupils reactive to light, fully dilated left pupil, and no
response to painful stimuli. Brain CT scan demonstrated
acute infarction in the left cerebral hemisphere, right fron-
tal lobe, brain swelling with midline shift, and subtento-
rial hernia. The blood pressure was dependent on
inotropic support, and the cardiac rhythm was junctional.
Cardiac arrest occurred after a few minutes. Unfortu-
nately, CPR was not successful and the patient expired on
the first day of operation.
Discussion
The cardiovascular system adapts to exercise. Top-level
training is often associated with morphological changes
in the heart including increases in the left ventricular
chamber size, wall thickness, and mass. The increase in
the left ventricular mass as a result of training is called"
athletes' heart" [5]. Morganroth and his colleagues [6] dis-
tinguished two different morphological forms of athletes'
heart: a strength-trained heart and an endurance-trained
heart. According to their theory, athletes involved in
endurance training, sports with a high dynamic compo-
nent like running, are presumed to demonstrate eccentric
Axial source image of CT angiography reveals the flap in the ascending aorta compatible w th ty e A of Stanford dissec-tion: Arrows are sh wing the flap in asc nding a rt  and trixes a e showing hemop ricardiumFigure 2
Axial source image of CT angiography reveals the 
flap in the ascending aorta compatible with type A of 
Stanford dissection: Arrows are showing the flap in 
ascending aorta and astrixes are showing hemoperi-
cardium.
Semicoronal reconstructed CT angiography reveals flap in the ascending aorta and arch (arrow)Figure 1
Semicoronal reconstructed CT angiography reveals 
flap in the ascending aorta and arch (arrow). The false 
and true lumens are patent. Hemopericardium is also seen 
(astrix).Page 2 of 4
(page number not for citation purposes)
Cases Journal 2008, 1:99 http://www.casesjournal.com/content/1/1/99left ventricular hypertrophy, characterized an unchanged
relationship between left ventricular wall thickness and
left ventricular radius (i.e. ratio of wall thickness to
radius), which means an increased left ventricular cham-
ber size with a proportional increase in wall thickness. On
the other hand, strength-trained athletes involved in
mainly static or isometric exercise like weightlifting, body-
building, and wrestling, are presumed to demonstrate
concentric left ventricular hypertrophy, which is charac-
terized by an increased ratio of wall thickness to radius,
which means an increased left ventricular wall thickness
with an unchanged left ventricular chamber size. In addi-
tion to the aforementioned changes, in weightlifters as
strength-trained athletes, cardiac output, heart rate, and
blood pressure tend to increase. A rapid increase in the
systemic arterial blood without a decrease in the periph-
eral vascular resistance, in combination with aortic medial
degeneration, may contribute to the development of the
aortic dissection [7]; this is an event that may occur in
non-trained weightlifters or those with predisposing fac-
tors for aortic dissection, like hypertension, congenital
cardiovascular disease (e.g. coarctation of aorta, congeni-
tal stenotic aortic valve, and unicuspid and bicuspid aortic
valve), supravalvular aortic stenosis, connective tissue dis-
orders (e.g. the Marfan syndrome and familial cystic
medial degeneration syndromes), and fibromuscular dys-
plasia. Also in athletes who have mild-to-moderate aortic
enlargement, an increased blood pressure due to heavy
weightlifting, raises aortic wall stress to a level that begets
aortic dissection [8]. Aortic dissection is a very tragic event
because of its high mortality rate of about 32%, and the
most common causes of death after aortic dissection
involving the ascending aorta include the rupture into the
pericardial cavity with resultant tamponade, occlusion of
the coronary arteries, and free rupture into the chest or
abdomen [2]. All athletes must be assessed for predispos-
ing factors for aortic dissection, and all patients should be
encouraged to undergo appropriate diagnostic studies like
echocardiography and blood pressure monitoring while
weightlifting to recognize possible predisposing factors
for aortic dissection. Athletes who do have a problem
should be encouraged to avoid or limit their exercise or
activity by their cardiologist. It is vital that this disastrous
event be prevented in young people.
Conclusion
We strongly advise that athletes with one of the predispos-
ing factors for aortic dissection eschew intense physical
exertion. Unfortunately, survival after such dissections is
extremely unanticipated because of the lengthy extension
of the intimal tear, massive hemorrhage, and organ dys-
function.
Abbreviations
WPW: Wolf-Parkinson-White; CT: Computed tomogra-
phy;  LVH: Left ventricular hypertrophy; LVEF: Left ven-
tricular ejection fraction; ICU: Intensive care unit; CPR:
Cardiopulmonary resuscitation; CPB: Cardiopulmonary
bypass.
Axial source image of CT angiography reveals the flap in the descending aort  compatible with type A of Stanford dissec-tion: Arrows are sh wing the flap in descending a rtaFigure 3
Axial source image of CT angiography reveals the 
flap in the descending aorta compatible with type A 
of Stanford dissection: Arrows are showing the flap in 
descending aorta.
Axial source image of CT angiography show aneurysmal dila-tion of ascending aorta along with type A aortic dissectionFigure 4
Axial source image of CT angiography show aneurys-
mal dilation of ascending aorta along with type A 
aortic dissection.Page 3 of 4
(page number not for citation purposes)
Cases Journal 2008, 1:99 http://www.casesjournal.com/content/1/1/99Publish with BioMed Central   and  every 
scientist can read your work free of charge
"BioMed Central will be the most significant development for 
disseminating the results of biomedical research in our lifetime."
Sir Paul Nurse, Cancer Research UK
Your research papers will be:
available free of charge to the entire biomedical community
peer reviewed and published immediately upon acceptance
cited in PubMed and archived on PubMed Central 
yours — you keep the copyright
Submit your manuscript here:
http://www.biomedcentral.com/info/publishing_adv.asp
BioMedcentral
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
AK carried out the surgery and was directly involved in the
conception, design and drafting of the manuscript. SS par-
ticipated in the diagnosis and treatment; also gave critical
comments on the results. PY collaborated in the design of
the study and was directly involved in drafting and revis-
ing the manuscript. All the authors read and approved the
final manuscript.
Consent section
Written informed consent was obtained from the patient's
family for publication of this case report and accompany-
ing images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
References
1. Biddinger A, Rocklin M, Coselli J, Milewicz DM: Familial thoracic
aortic dilations and dissections: A case control study.  J Vasc
Surg 1997, 25:506-11.
2. Gammie J, Katz WE, Swanson ER, Anrew P: Acute aortic dissec-
tion after blunt chest trauma.  Trauma 1996, 40(1):126-127.
3. Ficar CR, Koch S: Etiologic factors of acute aortic dissection in
children and young adults.  Clin Pediatr 2000, 39:71-80.
4. Corrado D, Pelliccia A, Bjornstad HH, Vanhees L, Biffi A, Borjesson
M, Panhuyzen-Goedkoop N, Deligiannis A, Solberg E, Dugmore D,
Mellwig KP, Assanelli D, Delise P, van-Buuren F, Anastasakis A, Hei-
dbuchel H, Hoffmann E, Fagard R, Priori SG, Basso C, Arbustini E,
Blomstrom-Lundqvist C, McKenna WJ, Thiene G, Study Group of
Sport Cardiology of the Working Group of Cardiac Rehabilitation and
Exercise Physiology and the Working Group of Myocardial and Peri-
cardial Diseases of the European Society of Cardiology: Cardiovas-
cular pre-participation screening of young competitive
athletes for prevention of sudden death: proposal for a com-
mon European protocol. Consensus Statement of the Study
Group of Sport Cardiology of the Working Group of Cardiac
Rehabilitation and Exercise Physiology and the Working
Group of Myocardial and Pericardial Diseases of the Euro-
pean Society of Cardiology.  Eur Heart J 2005, 26:516-24.
5. Pluim BM, Zwinderman AH, Laarse A van der, Wall EE van der: The
athlete's heart. A meta-analysis of cardiac structure and
function.  Circulation 2000, 101:336-44.
6. Morganroth J, Maron BJ, Henry WL, Epstein SE: Comparative left
ventricular dimensions in trained athletes.  Ann Intern Med
1975, 82:521-524.
7. de Virgilio C, Nelson RJ, Milliken J, Synder R, Chiang F, MacDonald
WD, Robertson JM: Ascending aortic dissection in weight lift-
ers with cystic medial degeneration.  Ann Thorac Surg 1990,
49:638-642.
8. Hatzaras I, Tranquilli M, Coady M, Barrett PM, Bible J, Elefteriades JA:
Weight lifting and aortic dissection: more evidence for a
connection.  Cardiology 2007, 107:103-106.Page 4 of 4
(page number not for citation purposes)


Aortic dissection type I in a weightlifter with hypertension: A case report

Crossref

Anrew P: Acute aortic dissection after blunt chest trauma. Trauma

Elefteriades JA: Weight lifting and aortic dissection: more evidence for a connection. Cardiology

Etiologic factors of acute aortic dissection in children and young adults. Clin Pediatr

JM: Ascending aortic dissection in weight lifters with cystic medial degeneration. Ann Thorac Surg

Laarse A van der, Wall EE van der: The athlete's heart. A meta-analysis of cardiac structure and function. Circulation

Milewicz DM: Familial thoracic aortic dilations and dissections: A case control study. J Vasc Surg

SE: Comparative left ventricular dimensions in trained athletes. Ann Intern Med

file:///data/core-remote/dit/data/Springer-OA/pdf/44b/aHR0cDovL2xpbmsuc3ByaW5nZXIuY29tLzEwLjExODYvMTc1Ny0xNjI2LTEtOTkucGRm.pdf

Aortic dissection type I in a weightlifter with hypertension: A case report

Abstract

Similar works

Full text

Available Versions

Springer - Publisher Connector

Crossref