Acute type A aortic intramural hematoma and type A aortic dissection: correlation between the intimal tear features and pathogenesis

Background —Surgery for acute type A aortic dissection is associated with a high mortality rate and incidence of postoperative complications. This study was designed to explore perioperative risk factors for death in patients with acute type A aortic dissection. Methods and Results —One hundred twenty-four consecutive patients with acute type A aortic dissection between 1984 and 1998 were reviewed. All underwent operation with resection of the intimal tear and open distal anastomosis: 107 patients had surgery within 24 hours and 17 patients had surgery within 72 hours of symptom onset. Median age was 62 years (23 to 89); 89 were men. Forty-three patients had ascending aortic replacement only, 72 had hemiarch repair, in 2 the entire arch was replaced, and in 7 replacement included the proximal descending aorta. The aortic valve was replaced in 54 patients, resuspended in 52, and untouched in 18. Hospital mortality rate was 15.3% (19 of 124): of these, 3 patients died during surgery, 4 had fatal rupture of the distal aorta before discharge, and 2 died of malperfusion-related complications. Multivariate analysis revealed age >60, hemodynamic compromise, and absence of hypertension as preoperative indicators of hospital death ( P <0.05); the presence of new neurological symptoms was a significant preoperative risk factor in univariate analysis. Ominous intraoperative factors included contained hematoma and a comparatively low esophageal temperature but not cerebral ischemic time (mean 32 minutes). The site of the intimal tear did not influence outcome, but mortality rate was higher with more extensive resection: 43% with resection including the descending aorta died versus 14% with only ascending aorta or hemiarch replacement. Overall 5- and 10-year survival was 71% and 54%, respectively; among discharged patients (median follow-up 41 months) survival was 84% and 64% versus expected US survival of 92% and 79%. Conclusions —Immediate surgical treatment of all acute type A dissections with resection of the intimal tear and use of hypothermic circulatory arrest for distal anastomosis results in acceptable early mortality rates and excellent long-term survival.

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Age-related presentation of acute type A aortic dissection

Asian Cardiovascular and Thoracic Annals ◽

10.1177/0218492318810087 ◽

2018 ◽

Vol 26 (9) ◽

pp. 659-666 ◽

Cited By ~ 1

Author(s):

Pietro Giorgio Malvindi ◽

Daniela Votano ◽

Ahmed Ashoub ◽

Amit Modi ◽

Szabolcs Miskolczi ◽

...

Keyword(s):

Aortic Valve ◽

Connective Tissue ◽

Aortic Dissection ◽

Bicuspid Aortic Valve ◽

Type A ◽

Acute Type ◽

Connective Tissue Disorders ◽

Type A Aortic Dissection ◽

Younger Patients ◽

Intimal Tear

Background We evaluated the clinical and anatomic presentations of acute type A aortic dissection according to patient age. Methods We retrospectively reviewed 235 consecutive patients who underwent acute type A dissection repair between January 2000 and December 2014. The influence of age on anatomical and clinical presentation, surgical management in the entire cohort and also after exclusion of patients with known connective tissue disorders was assessed using logistic regression. Results Males presented with type A acute aortic dissection at a younger age than females. Acute onset with signs of myocardial ischemia, connective tissue disorders, or bicuspid aortic valve characterized the younger population. Extension to the coronary sinus(es) ( p = 0.0003), descending thoracic aorta ( p = 0.016), and abdominal aorta ( p = 0.029), and an intimal tear at the level of the aortic root ( p = 0.0017) correlated inversely with patient age. Similar findings were obtained after exclusion of patients with connective tissue disorders or a bicuspid aortic valve. Conclusions More frequent proximal and distal progression of the dissection flap occurs in younger patients with acute type A aortic dissection. Older age is associated with a lower probability of an intimal tear at the level of the sinus of Valsalva. These findings, associated with prognostic implications, account for the choice of more radical proximal procedures for repair of aortic dissection in younger patients.

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Primary repair of re-entry intimal tear in a patient with limited extension of acute type A aortic dissection

Journal of Surgical Case Reports ◽

10.1093/jscr/rjy331 ◽

2018 ◽

Vol 2018 (12) ◽

Author(s):

Yong Zhan ◽

Masashi Kawabori ◽

Mishan Rambukwella ◽

Frederick Cobey ◽

Frederick Y Chen

Keyword(s):

Aortic Dissection ◽

Primary Repair ◽

Type A ◽

Acute Type ◽

Type A Aortic Dissection ◽

Intimal Tear

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Clinical profiles and outcomes of acute type A aortic dissection and intramural hematoma in the current era

Chinese Medical Journal ◽

10.1097/cm9.0000000000001459 ◽

2021 ◽

Vol Publish Ahead of Print ◽

Author(s):

Wei-Xun Duan ◽

Wei-Guang Wang ◽

Lin Xia ◽

Chao Xue ◽

Bo Yu ◽

...

Keyword(s):

Aortic Dissection ◽

Intramural Hematoma ◽

Type A ◽

Acute Type ◽

Type A Aortic Dissection ◽

Clinical Profiles

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Early Results of Modified Aortic-Valve Sparing Partial Root Replacement in Acute Type A Aortic Dissection with an Intimal Tear in the Aortic Sinuses

Journal of Cardiac Surgery ◽

10.1111/jocs.12524 ◽

2015 ◽

Vol 30 (5) ◽

pp. 448-451

Author(s):

Sung Kwang Lee ◽

Ho-Ki Min ◽

Woon Heo ◽

Do Kyun Kang ◽

Hee Jae Jun ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Dissection ◽

Type A ◽

Acute Type ◽

Type A Aortic Dissection ◽

Early Results ◽

Valve Sparing ◽

Intimal Tear

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Reprint of: Early and late outcomes of acute type A aortic dissection with intramural hematoma∗

Journal of Thoracic and Cardiovascular Surgery ◽

10.1016/j.jtcvs.2014.12.036 ◽

2015 ◽

Vol 149 (2) ◽

pp. S110-S115 ◽

Cited By ~ 1

Author(s):

Anthony L. Estrera ◽

Harleen K. Sandhu ◽

Samuel S. Leake ◽

Kristofer M. Charlton-Ouw ◽

Rana O. Afifi ◽

...

Keyword(s):

Aortic Dissection ◽

Intramural Hematoma ◽

Type A ◽

Acute Type ◽

Type A Aortic Dissection

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Initial medical management in acute type A aortic dissection patients with a thrombosed false lumen in the ascending aorta combining intramural hematoma and retrograde dissection from the descending to the ascending aorta

European Heart Journal Acute Cardiovascular Care ◽

10.1177/2048872618777724 ◽

2018 ◽

Vol 9 (3_suppl) ◽

pp. S13-S20 ◽

Cited By ~ 4

Author(s):

Kenji Sadamatsu ◽

Susumu Takase ◽

Shuichiro Sagara ◽

Kensuke Ohe ◽

Jun-ichiro Nishi ◽

...

Keyword(s):

Aortic Dissection ◽

Medical Management ◽

False Lumen ◽

Intramural Hematoma ◽

Type A ◽

Daily Practice ◽

Ascending Aorta ◽

Maximum Diameter ◽

Acute Type ◽

Type A Aortic Dissection

Background: The feasibility of medical management for select patients with acute type A aortic dissection has been reported from a few institutions. In this study, we retrospectively investigated the safety and feasibility of our conservative approach for patients with type A aortic dissection in daily practice. Methods: From January 2013 to December 2017, 131 consecutive patients were admitted to our institution for acute aortic dissection, including 58 patients of type A. Initial medical management was attempted in select patients who were clinically stable and had a thrombosed false lumen of the ascending aorta without ulcer-like projections in the ascending aorta. Results: Except for nine patients contraindicated for surgery, urgent surgery was performed in 26 patients (SRG group), while 23 patients (MED group) were treated with the initial medical management. The maximum diameter of the ascending aorta was significantly larger in the SRG group than in the MED group. In the MED group, the heart rate and blood pressures were well-controlled at admission to the intensive-care unit, and the systolic blood pressure was further reduced at 24 h after. The in-hospital mortality rates of the MED and SRG groups were 0% and 15%, respectively. During the follow-up period, the survival rate was significantly higher in the MED group than in the SRG group, and the aortic event-free survival at one year was 80%. Conclusions: The initial medical management for select patients with a thrombosed false lumen in the ascending aorta was a safe and feasible strategy in real-world practice.

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