CC BY
4УДК: 616.135-007.64-036.11-07 DOI: 10.24412/2790-1289-2024-4-60-68
МРНТИ: 76.29.30
RETURNING TO THE QUESTION OF THE DIVERSITY OF CLINICAL MASCS IN AORTIC ANEURYSM
DISSECTION
N. Aidargaliyeva1*, A. Teleusheva2, K. Nurmanbetova3, G. Aitbay4, S. Sharipova2,
A. Seydkhan1, A. Zhaksylykov1
1NEI «Kazakh-Russian Medical University», Kazakhstan, Almaty 2Medical Center «TAN Clinic», Kazakhstan, Almaty 3City Communal Enterprise on the Rights of Economic Management
«City Clinical Hospital No.1», Kazakhstan, Almaty 4City Communal Enterprise on the Rights of Economic Management «City Clinical Hospital No.7», Kazakhstan, Almaty *Corresponding author
Abstract
Acute aortic dissection is often referred to as the «grand masquerade» due to the variety of clinical manifestations. Since clinical manifestations often include symptoms and signs associated with other diseases, such as acute coronary syndrome, cardiac arrhythmia, pulmonary embolism and stroke, the initial misdiagnosis of aortic dissection occurs in up to 34 % of cases.
We present a clinical case of a 54-year-old man with hypertension, whose clinical symptoms include chest pain and lower jaw pain combined with transient neurological symptoms and atrial fibrillation.
Transthoracic echocardiogram revealed dilatation of the ascending aorta and arch, membrane dissection in the ascending aorta. CT scan of the thoracic and abdominal aorta with contrast: Stanford type A and B aortic dissection.
The patient underwent the Bentall-de Bono procedure at the first stage with a positive effect.
Thus, timely differential diagnostics and instrumental studies improve clinical outcomes in aortic dissection.
Keywords: aortic aneurysm dissection, clinical manifestations.
Introduction
The incidence of aortic dissection is estimated to be 5 to 30 cases per million people per year, with men being more commonly affected [1].
This is in stark contrast to acute myocardial infarction, which accounts for approximately 4,400 cases per million people per year. Aortic dissection accounts for 3 out of every 1,000 emergency department visits related to acute chest, back, or abdominal pain. This condition mainly affects people between the ages of 40 and 70, with most cases occurring in patients between the ages of 50 and 65. Approximately 75 % of dissections occur in this age range, which highlights age as a key risk factor.
While men are 3 times more likely to suffer from aortic dissection than women, women often seek help in the later stages of the disease and have
worse outcomes [2].
Every hour of delay in the diagnosis of acute aortic dissection is associated with a 1 % increase in mortality. However, in half of the cases, the diagnosis is made more than 24 hours after symptom onset. The clinical manifestations of this condition can be varied: from pain in the chest, back, abdomen or extremities to fainting, focal neurological disorders, and in some cases, shock or cardiac arrest [3].
The Stanford classification is divided into two groups, A and B, depending on whether the ascending aorta is involved. The Stanford type A aortic dissection involves the ascending aorta and/or aortic arch and has a higher mortality rate and usually requires primary surgical treatment [4]. The dissected flap may extend antegrade or retrograde and lead to a number of life-threatening complications, including acute aor-
tic regurgitation, myocardial ischemia, cardiac tamponade, acute stroke or malperfusion syndromes. The initial symptoms of aortic dissection are very varied and have masks of many diseases, which often puts the doctor in a difficult position. High mortality, in turn, requires making operative optional decisions. We present a case of Stanford type A dissecting aortic aneurysm with clinical symptoms of pain in the chest and lower jaw in combination with transient neurological symptoms and atrial fibrillation.
Case report
A 54-year-old man has been admitted with complaints of burning chest pain, jaw pain, dizziness, headaches, blurred vision, numbness of the right upper and lower extremities. These symptoms arose within 3 days, on the last day he noted an increase in blood pressure to 226/120 mmHg. From
the anamnesis: arterial hypertension for 3 years with a maximum increase in pressure up to 230/110 mmHg. Regularly takes a fixed combination of per-indopril/indapamide/amlodipine (10 mg/2.5mg/5 mg). Physical examination revealed cyanosis of the lips, irregular heart rhythm with a heart rate of 200115 beats per minute, blood pressure 130/80 mmHg. The neurological status is presented by dizziness, tongue deviation to the right, decreased strength in the right lower limb, right-sided hemihypesthesia, as well as positive Barre and Romberg tests. These symptoms were relieved within 12 hours.
The initial electrocardiogram: Paroxysmal form of atrial fibrillation with a heart rate of 200120 beats per minute. ST segment depression in anterolateral leads (Image 1).
Image 1. Paroxysmal form of atrial fibrillation with a heart rate of 200-120 beats per minute.
ST segment depression in anterolateral leads. Compiled by the authors
Sinus rhythm was restored by medical cardioversion with intravenous amiodarone 300 mg. CT scan of the head without contrast enhancement did not reveal ischemic changes, intracranial hemorrhages, or space-occupying lesions. High-sensitivity Troponin T was measured twice (upon admission and 3 hours later), both results were below reference values. Genogram, liver function tests and creatinine level were normal, but there was an in-
crease in the level of C-reactive protein (121 mg/L) and D-dimer (1.91 mg/L).
Transthoracic echocardiogram: Dilatation of the ascending aorta to 4.3 cm (index 0.25 cm/m2), grade 1 aortic valve regurgitation. In the aorta, from the aortic valve cusps to the ascending aorta and arch, intimal detachment is determined. No left ventricular wall motion abnormalities were detected. Conclusion: Stanford type A aortic dissection (Image 2 and Image 3).
Image 2. Transthoracic echocardiogram, 2D image, parasternal long-axis view showing aortic dilation and membrane dissection beginning at the aortic valve cusps.
Compiled by the authors
Image 3. Transthoracic echocardiogram, 2D image, suprasternal view showing dilatation of the ascending aorta and arch, membrane dissection in the ascending aorta.
Compiled by the authors
CT angiography of the thoracic and abdom- from the aortic valve cusps to the descending aorta inal aorta with contrast: the dissected flap extends (Image 4).
Image 4. This contrast-enhanced early arterial phase CT image shows that the dissected flap extends from the aortic valve cusps to the descending aorta.
Compiled by the authors
The CT angiography 3D reconstruction reveals a dissecting aneurysm involving both the ascending and descending aorta throughout its
entire length, extending to the left common iliac artery (Image 5). Conclusion: Stanford type A and B aortic dissection.
Image 5. 3D reconstruction of CT angiography reveals a dissecting aneurysm, involving both the ascending and descending aorta throughout its entire length, extending to the left common iliac artery (type A and B according to the Stanford classification). Compiled by the authors
After examining the patient by a cardiac surgeon and confirming the diagnosis of total aortic dissection, transfer to a vascular surgical center for surgical intervention was recommended. At the first stage, the patient underwent a Bentall-de Bono procedure (replacement of the ascending aorta with a valve-containing conduit with reimplantation of the coronary artery ostia). The postoperative period was uneventful and the patient was safely discharged.
Discussion
Sudden pain was the most common presenting symptom in the International Registry of Acute Aortic Dissection study [5]. Anterior chest pain is more commonly associated with type A acute aortic dissection, whereas patients with type B dissection more often complain about back or abdominal
pain [6; 7]. The clinical manifestations of the two types of aortic dissection may frequently overlap. Pain may migrate from its point of origin to other sites, following the dissection path as it spreads through the aorta [8]. Clinical records of 102 consecutive patients with aortic dissection showed that thirty patients had initial neurological symptoms (29 %). Neurological symptoms were associated with ischemic stroke (16 %), spinal cord ischemia (1 %), ischemic neuropathy (11 %), and hypoxic encephalopathy (2 %). Other common symptoms were syncope (6 %) and seizures (3 %). In half of the patients, neurological symptoms were transient. Neurological symptoms are not necessarily associated with increased mortality [9]. Approximately 11.4 % of cases with aortic dissection were found to have cardiac arrhythmias in a retrospective study
[10]. Paroxysmal attacks of sympathetic hyperac-tivity and type A aortic dissection, manifested by atrial fibrillation, have been described. [11]. Malperfusion refers to obstruction of the aortic branches from the dissection flap, causing ischemia to other areas of the body. In patients with aortic dissection, dynamic obstruction occurs as a result of occlusion of the suppressed true lumen of the aorta by an enlarged and compressed false lumen. As a result, malperfusion syndrome develops, which is manifested by various clinical syndromes, including transient neurological ones, as well as arrhythmias such as atrial fibrillation. Moreover, type A aortic dissection can cause coronary malperfusion without extension of the dissection to the coronary arteries [12]. In addition, in our patient, hypertension itself is a risk factor for both aortic dissection and atrial fibrillation, causing paroxysmal or chronic events. The chosen first stage of the Bentall-de Bono procedure is based on recommendations developed for the treatment of dilated aorta with concomitant surgery, as well as on recent publications [13; 14] and avoids harmful events in the aortic root, such as dilatation (> 3 mm/year), reoperation, aortic regurgitation and pseudoaneurysm [15].
Since the patient's aortic dissection also extends to the area of the left common iliac artery, the next stage is planned to install a stent graft to repair the aortic dissection in the descending section [8].
Conclusion
In conclusion, we presented a case report of a patient who along with chest pain, had masks of the initial clinical symptoms of dissecting aortic aneurysm, including transient neurological symptoms and atrial fibrillation. Such clinical symptoms resulting from malperfusion syndrome require differential diagnosis with acute coronary syndrome, stroke, abdominal diseases, and arterial occlusion of the lower extremities. It is no coincidence that acute aortic dissection is often called the "great masquerade" because it often mimics other conditions, mainly due to malperfusion syndromes. Timely differential diagnosis and instrumental studies improve clinical outcomes in aortic aneu-rysm dissection.
References
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6. Trimarchi S., Tolenaar J. L., Tsai T. T., Froehlich J., Pegorer M., Upchurch G. R., Fattori R., Sundt T. M. 3rd, Isselbacher E. M., Nienaber C. A., Rampoldi V., Eagle K. A. Influence of clinical presentation on the outcome of acute B aortic dissection: evidences from IRAD // J Cardiovasc Surg (Torino). - 2012.
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8. Erbel R., Aboyans V., Boileau C., Bossone E., Bartolomeo R. D., Eggebrecht H., Evangelista A., Falk V., Frank H., Gaemperli O., Grabenwöger M., Haverich A., Iung B., Manolis A. J., Meijboom F., Nienaber C. A., Roffi M., Rousseau H., Sechtem U., Sirnes P. A., Allmen R. S., Vrints C. J.; ESC Committee for Practice Guidelines. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases // European Heart Journal. - 2014. - Vol. 35. - P. 2873-2926. - DOI:10.1093/eurheartj/ ehu281.
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10. Liu Z. Y., Zou Y. L., Chai B. L. et al. Analysis of clinical features of painless aortic dissection // J Huazhong Univ Sci Technol Med Sci. - 2014. -Vol. 34(4). - P. 582-585.
11. Chew H. C., Lim S. H. Aortic dissection presenting with atrial fibrillation // Am J Emerg Med. - 2006. - Vol. 24. - P. 379-380.
12. Lardi C., Lobrinus J. A., Doenz F. et al. Acute aortic dissection with carotid and coronary malperfusion: from imaging to pathology // Am J Forensic Med Pathol. - 2014. - Vol. 35. - P. 157-162.
13. Baumgartner H., Falk V., Bax J. J., De Bonis M., Hamm C., Holm P. J. et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease // EurHeart J. - 2017. - Vol. 38(36). - P. 2739-2791.
14. Vendramin I., Lechiancole A., Piani D., Deroma L., Tullio A., Sponga S., Milano A. D., Onorati F., Bortolotti U., Livi U. Type A acute aortic dissection with >40-mm aortic root: results of conservative and replacement strategies at long-term follow-up // Eur J Cardiothorac Surg. - 2021. - Vol. 59(5). - P. 1115-1122. - DOI: 10.1093/ejcts/ezaa456.
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References
1. Isselbacher, E. M., Preventza, O., Black, J. H. 3rd, Augoustides, J. G., Beck, A. W., Bolen, M. A., Braverman, A. C., Bray, B.E., Brown-Zimmerman, M. M., Chen, E. P., Collins,, T. J., DeAnda, A. Jr., Fanola, C. L., Girardi, L. N., Hicks, C. W., Hui, D. S., Jones, W. S., Kalahasti, V., Kim, K. M., Milewicz, D. M., Oderich, G. S., Ogbechie, L., Promes, S. B., Ross, E. G., Schermerhorn, M. L., Times, S. S., Tseng, E. E., Wang, G. J., Woo, Y. J. (2022). 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation, 146, 334-482. DOI: 10.1161/ CIR.0000000000001106.
2. Levy, D., Sharma, S., Grigorova, Y. et al. (2024). Aortic Dissection. In: StatPearls. Treasure Island (FL): StatPearls Publishing [Website]. Retrieved
October 10, 2024, from https://www.ncbi.nlm.nih. gov/books/NBK441963.
3. Yee, J., Kendle, A. P. (2022). Aortic Dissection Presenting as a STEMI. J Educ Teach Emerg Med., 7(3), 26-54. DOI: 10.21980/J8W647.
4. Daily, P. O., Trueblood, H. W., Stinson, E. B. et al. (1970). Management of acute aortic dissection. Ann Thorac Surg., 10, 237-247.
5. Hagan, P. G., Nienaber, C. A., Isselbacher, E. M. et al. (2000). The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA, 283, 897-903.
6. Trimarchi, S., Tolenaar, J. L., Tsai, T. T., Froehlich, J., Pegorer, M., Upchurch, G. R., Fattori, R., Sundt, T. M. 3rd, Isselbacher, E. M., Nienaber, C. A., Rampoldi, V., Eagle, K. A. (2012). Influence of clinical presentation on the outcome of acute B aortic dissection: evidences from IRAD. J Cardiovasc Surg (Torino), 53, 161-168.
7. Klompas, M. (2002). Does this patient have an acute thoracic aortic dissection? JAMA, 287, 2262-2272.
8. Erbel, R., Aboyans, V., Boileau, C., Bossone, E., Bartolomeo, R. D., Eggebrecht, H., Evangelista, A., Falk, V., Frank, H., Gaemperli, O., Grabenwöger, M., Haverich, A., Iung, B., Manolis, A. J., Meijboom, F., Nienaber, C. A., Roffi, M., Rousseau, H., Sechtem, U., Sirnes, P. A., Allmen, R. S., Vrints, C. J.; ESC Committee for Practice Guidelines (2014). 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases. European Heart Journal, 35, 28732926. DOI:10.1093/eurheartj/ehu281.
9. Gaul, C., Dietrich, W., Friedrich, I., Sirch, J., Erbguth, F. J. (2007). Neurological symptoms in type A aortic dissections. Stroke, 38(2), 292-297. DOI: 10.1161/01.STR.0000254594.33408.b1.
10. Liu, Z. Y., Zou, Y. L., Chai, B. L. et al. (2014). Analysis of clinical features of painless aortic dissection. J Huazhong Univ Sci Technol Med Sci., 34(4), 582-585.
11. Chew, H. C., Lim, S. H. (2006). Aortic dissection presenting with atrial fibrillation. Am J Emerg Med., 24, 379-380.
12. Lardi, C., Lobrinus, J. A., Doenz, F. et al. (2014). Acute aortic dissection with carotid and coronary malperfusion: from imaging to pathology. Am J Forensic Med Pathol., 35, 157-162.
13. Baumgartner, H., Falk, V., Bax, J. J., De Bonis, M., Hamm, C., Holm, P. J. et al. (2017). 2017 ESC/ EACTS Guidelines for the management of valvular
heart disease. EurHeart J., 38(36), 2739-2791. 14. Vendramin, I., Lechiancole, A., Piani, D., Deroma, L., Tullio, A., Sponga, S., Milano, A. D., Onorati, F., Bortolotti, U., Livi, U. (2021). Type A acute aortic dissection with >40-mm aortic root: results of conservative and replacement strategies
at long-term follow-up. Eur J Cardiothorac Surg., 59(5), 1115-1122. DOI: 10.1093/ejcts/ezaa456. 15. Nishida, H., Tabata, M., Fukui, T., Takanashi, S. (2016). Surgical Strategy and Outcome for Aortic Root in Patients Undergoing Repair of Acute Type A Aortic Dissection. Ann Thorac Surg., 101(4),1464-1469.
К ВОПРОСУ О МНОГООБРАЗИИ КЛИНИЧЕСКИХ МАСОК ПРИ РАССЛОЕНИИ
АНЕВРИЗМЫ АОРТЫ Н. Е. Айдаргалиева1*, А. Ж. Телеушева2, К. Т. Нурманбетова3, Г. С. Айтбай4, С. Т. Шарипова2, А. Сейдхан1, А. Жаксылыков1
1 НУО «Казахстанско-Российский медицинский университет», Казахстан, Алматы 2Медицинский центр «TAN Clinic», Казахстан, Алматы 3Городское Коммунальное Предприятие на правах хозяйственного ведения
«Городская клиническая больница №1», Казахстан, Алматы 4 Городское Коммунальное Предприятие на правах хозяйственного ведения «Городская клиническая больница №7», Казахстан, Алматы *Корренспондирующий автор
Аннотация
Острое расслоение аорты часто называют «большим маскарадом» из-за разнообразия клинических проявлений. В связи с тем, что клинические проявления часто включают симптомы и признаки, связанные с другими заболеваниями, такими, как острый коронарный синдром аритмии сердца, тромбоэмболия легочной артерии и инсульт, первоначальный ошибочный диагноз при расслоении аорты встречается почти в 34 % случаев.
Представляется клинический случай с 54-летним мужчиной с гипертонией, у которого клинические симптомы включают боль в груди и в нижней челюсти в сочетании с преходящими неврологическими симптомами и мерцательной аритмией. Трансторакальная эхокардиограмма выявила расширение восходящей аорты и дуги, мембрану расслоения в восходящей аорте.
Компьютерная томография грудной и брюшной аорты с контрастированием: расслоение аорты типа А и В по Стэнфорду.
Пациенту на первом этапе проведена операция Бенталл-де Боно с положительным эффектом.
Таким образом, своевременное проведение дифференциальной диагностики и инструментальных исследований улучшает клинические результаты при расслаивающей аневризме аорты.
Ключевые слова: расслаивающаяся аневризма аорты, клинические проявления.
АОРТА АНЕВРИЗМАСЫНЬЩ ДИССЕКЦИЯСЫНДАГЫ КЛИНИКАЛЫК; МАСКАЛАРДЬЩ ТУРАЛЫ С¥РАВДА ОРАЛУ
Н. Е. Айдаргалиева1*, А. Ж. Телеушева2, К. Т. Нурманбетова3, Г. С. Айтбай4, С. Т. Шарипова2, А. Сейдхан1, А. Жаксылыков1
1 «^азакстан-Ресей медициналы; университета МЕББМ, ^азакстан, Алматы 2«TAN Clinic» медицинальщ орталыгы, ^азакстан, Алматы 3«№1 калалык клиникалык аурухана» шаруашылык жYргiзу к¥кыгындагы калалык коммуналды;
кэсшорны, ^азакстан, Алматы 4«№7 калалык клиникалык аурухана» шаруашылык жYргiзу к¥кыгындагы калалык коммуналдык
кэсшорны, ^азакстан, Алматы * Корреспондент автор
Ацдатпа
Жедел аорта диссекциясы клиникалык кершютердщ эртYрлiлiгiне байланысты жиi «улы маскарад» деп аталады. Клиникалык KepÍHÍCTep жиi жедел коронарлык синдром, жYрек аритмия-сы, екпе эмболиясы жэне инсульт сиякты баска аурулармен байланысты белгiлер мен белгiлердi камтитындыктан, аорта диссекциясыныц бастапкы кате диагнозы 34 % жагдайда кездеседi.
Бiз гипертензиямен ауыратын 54 жастагы ер адамныц жагдайын усынамыз, оныц клиникалык симптомдары eтпелi неврологиялык симптомдармен жэне жYрекшелердщ фибрилляциясымен байланысты кеуде жэне жак аймагындагы ауырсынуды камтиды.
Трансторакальды эхокардиограммада кетершетш аорта мен доганыц кецею^ кетершу колкасында мембраналык диссекция аныкталды.
Контрасты бар кеуде жэне курсак колкасыныц компьютерлiк томографиясы: Стэнфорд типт А жэне В колка диссекциясы.
Бiрiншi кезецде наукаска оц нэтиже берген Бенталл-де Боно операциясы жасалды. Осылайша, уакытылы дифференциалды диагностика жэне аспаптык зерттеулер аорта анев-ризмасын диссекциялаудагы клиникалык нэтижелердi жаксартады.
Tyüíh свздер: аорта аневризмасыныц диссекциясы, клиникалыц KepiHicmepi.
АВТОРЛАР ТУРАЛЫ
Айдаргалиева Назипа Ермухамбетовна - медицина гылымдарыныц докторы, профессор. «^азакстан-Ресей медициналык университет» МЕББМ, жогары оку орнынан кейiнгi бшм берудщ «Ересектер жэне балалар кардиологиясы» мамандыгы бойынша резидентураныц профессоры; телефон: +7 701 300 1123; email: [email protected]; ORCID: 0000-0002-0688-1318. Телеушева Асель Жаугашты кызы - кардиолог, медицина гылымдарыныц кандидаты, «TAN Clinic» медициналык орталыгы; телефон: +7 701 767 9343; email: [email protected]. Нурманбетова Камила Тургынбеккызы - Алматы каласыныц «№ 1 калалык клиникалык ауруханасы» шаруашылык жYргiзу кукыгындагы калалык коммуналдык казыналык кэсiпорны, ультрадыбыстык диагностика дэрiгерi; телефон: +7 707 310 4553; email: [email protected]. Айтбай Гаухар Саматкызы - Алматы каласыныц «№ 7 калалык клиникалык ауруханасы» шаруашылык жYргiзу кукыгындагы калалык коммуналдык казыналык кэсшорны, радиология бeлiмiнiц мецгерушiсi; телефон: +7 701 192 2228; email: [email protected].
Шарипова Салима Тахтасыновна - терапевт, медицина гылымдарыныц кандидаты, «TAN Clinic» медициналык орталыгы; телефон: +7 777 240 4395; email: [email protected]. Айтолкын Сейдхан - «^азакстан-Ресей медицина университет!» МЕББМ «Ересектер жэне балалар кардиологиясы» мамандыгы бойынша 2^i жыл резиденту телефон:+7 701 604 3210; email: [email protected].
Адильжан Жаксылыков - «^азакстан-Ресей медициналык университета МЕББМ «Ересектер жэне балалар кардиологиясы» мамандыгы бойынша 2^i жыл резиденту телефон: +7 747 341 8085; email: [email protected].
ОБ АВТОРАХ
Айдаргалиева Назипа Ермухамбетовна - доктор медицинских наук, профессор. НУО «Казахстанско-Российский медицинский университет» профессор курса резидентуры по специальности «Кардиология взрослая, детская» последипломного образования; телефон: +7701 300 1123; email: [email protected]; ORCID: 0000-0002-0688-1318.
Телеушева Асель Жаугаштыевна - кардиолог, кандидат медицинских наук Медицинский центр «TAN Clinic»; телефон: +7 701 767 9343; email: [email protected].
Нурманбетова Камила Тургынбековна - врач ультразвуковой диагностики ГКП на ПХВ «Городская клиническая больница №1» УЗ г. Алматы; телефон: +7 707 310 4553; email: [email protected].
Айтбай Гаухар Саматовна - заведующая отделением радиологии ГКП на ПХВ «Городская клиническая больница №7» УЗ г. Алматы; телефон: +7 701 192 2228; email: [email protected]. Шарипова Салима Тахтасыновна - терапевт, кандидат медицинских наук, Медицинский центр «TAN Clinic»; телефон: +7 777 240 4395; email: [email protected].
Айтолкын Сейдхан - резидент 2 года по специальности «Кардиология взрослая, детская» НУО «Казахстанско-Российский медицинский университет»; телефон: +7 701 604 3210; email: aseydkhan@ mail.ru.
Адильжан Жаксылыков - резидент 2 года по специальности «Кардиология взрослая, детская» НУО «Казахстанско-Российский медицинский университет»; телефон: +7 747 341 8085; email: [email protected].
ABOUTAUTHORS
Nazipa Aidargalieva Ermukhambetovna - Doctor of Medical Sciences, Professor. Kazakh-Russian Medical University, professor of the residency course in the specialty «Adult and pediatric Cardiology» of postgraduate education; phone: +7701 300 1123; email: [email protected]; ORCID: 0000-00020688-1318.
Teleusheva Assel Zhaugashtyevna - Cardiologist, Candidate of Medical Sciences, «TAN Clinic» Medical Center; phone: +7 701 767 9343; email: [email protected].
Nurmanbetova Kamila Turgynbekovna - ultrasound diagnostics doctor of the State municipal enterprise under the right of economic management «City Clinical Hospital No.1» Health Department of Almaty; phone: +7 707 310 4553; email: [email protected].
Aytbay Gaukhar Samatovna - Head of the Radiology Department of the State municipal Enterprise under the right of economic management «City Clinical Hospital No.7» Health Department of Almaty; phone: +7 701 192 2228; email: [email protected].
Sharipova Salima Tokhtasynovna - therapist, Candidate of Medical Sciences, «TAN Clinic» Medical Center; phone: +7 777 240 4395; email: [email protected].
Aitolkyn Seidkhan - 2nd year resident specializing in Adult and Pediatric Cardiology at the NEI «Kazakh-Russian Medical University»; phone: +7 701 604 3210; email: [email protected]. Adilzhan Zhaksylykov - 2nd year resident specializing in Adult and Pediatric Cardiology at the NEI «Kazakh-Russian Medical University»; phone: +7 747 341 8085; email: [email protected].
Written informed consent was obtainedfrom the patientfor publication ofthis manuscript and accompanying images. A copy of the written consent is available for review by the First Author of this report. Conflict of interest. All authors declare that there is no potential conflict of interest that requires disclosure in this article.
Authors' contributions. All authors contributed equally to the development of the concept, implementation, processing of results and writing of the article.
We declare that this material has not been previously published and is not under consideration by other
publishers.
Funding. None.
Article submitted: 28.11.2024year Accepted for publication: 20.12.2024year
