Accepted Manuscript Rapidly Progressing Aortic Intramural Hematoma to Aortic Dissection Pierre Olivier Dionne , MD Louis Paul Perrault , MD, PhD PII:
S0828-282X(14)00358-4
DOI:
10.1016/j.cjca.2014.05.015
Reference:
CJCA 1226
To appear in:
Canadian Journal of Cardiology
Received Date: 28 November 2013 Revised Date:
15 May 2014
Accepted Date: 15 May 2014
Please cite this article as: Dionne PO, Perrault LP, Rapidly Progressing Aortic Intramural Hematoma to Aortic Dissection, Canadian Journal of Cardiology (2014), doi: 10.1016/j.cjca.2014.05.015. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Dionne 1
Rapidly Progressing Aortic Intramural
RI PT
Hematoma to Aortic Dissection
Pierre Olivier Dionne, MD, Louis Paul Perrault, MD, PhD
SC
From the Department of Surgery, Montreal Heart Institute and Université de Montréal,
M AN U
Montreal, Quebec, Canada.
TE D
Short title: Progressing aortic intramural hematoma
AC C
_____________
EP
Word count: 517
Corresponding author: Louis P. Perrault, MD, PhD, Department of Surgery, Montreal Heart Institute, 5000 Belanger Street East, Montreal, Quebec, H1T 1C8, Canada. Tel.: (514) 376-3330 #3471; Fax: (514) 376-1355. E-mail: [email protected]
ACCEPTED MANUSCRIPT Dionne 2 Brief summary A 73-year-old man presented with intermittent chest pain irradiating to the back, starting 12 hours earlier. Initial scan showed an acute ascending aorta intramural hematoma. One hour
RI PT
later, the patient had an acute chest pain followed by a loss of consciousness. Two hours after the
AC C
EP
TE D
M AN U
SC
initial scan, a second scan showed a type A aortic dissection.
ACCEPTED MANUSCRIPT Dionne 3 ABSTRACT A 73-year-old man presented with intermittent chest pain irradiating to the back, starting 12 hours earlier. On the day following emergency consultation, thoracic scan showed an acute
RI PT
aortic intramural hematoma starting at the sinotubular junction with an ascending aorta diameter of 5.7 cm. One hour following the initial scan, the patient had an acute chest pain followed by a loss of consciousness. A second scan was done 2 hours after the initial scan and showed a type A
AC C
EP
TE D
M AN U
Key words: Aorta, complications, surgery, tomography
SC
aortic dissection that extended from the sinotubular junction to the descending aorta.
ACCEPTED MANUSCRIPT Dionne 4 We present the case of a 73-year-old man who presented with intermittent chest pain irradiating to the back, starting 12 hours earlier. The pain was partly relieved with sublingual Nitroglyceryn
years prior and a descending aorta replacement for type B dissection..
RI PT
The patient had a past medical history of atrial fibrillation, mildly positive Sestamibi test two
On the day following emergency consultation, contrast computed tomography (CT) showed an acute aortic intramural hematoma (IMH) starting at the sinotubular junction with an ascending
SC
aorta diameter of 5.7 cm.
The patient was asymptomatic and in a stable condition, which motivated the decision to
M AN U
manage the condition medically with a follow-up CT 24 hours later.
One hour following initial CT, the patient had an acute chest pain episode followed by a loss of consciousness. On awakening, the patient complained of left shoulder pain and had total left arm plegia.
TE D
A second contrast CT was done 2 hours after the initial scan and showed a type A aortic dissection that extended from the sinotubular junction to the descending aorta prosthesis, involving the innominate artery, left primitive carotid artery and left subclavian artery. There
EP
was also an 8.5 mm circumferential pericardial collection that was absent on initial CT. The patient was operated emergently but died post-operatively secondary to multiple
AC C
cerebral embolic strokes.
Management of aortic intramural hematoma remains controversial. Medical management seems to be associated with more complications than surgical management.
1,2
Initial aortic
diameter (>55 mm) and intramural hematoma thickness (>16 mm) are associated with more aortic complications (development of aortic dissection, delayed surgery and death). 2,3 As reported in Hata and colleagues’ serie, hospital mortality was higher with medical management than with surgical management (25,8% and 0%, respectively).1 Furthermore, as
ACCEPTED MANUSCRIPT Dionne 5 much as 47% of patients managed medically might require late surgical conversion owing to persistent pain, progression to type A dissection, ruptured aneurysm or aneurysmal enlargement (> 60 mm).4
RI PT
These aortas are highly unstable and should be managed as such. In light of the literature, surgical management of type A IMH should be recommended in patients presenting with aortic complications and probably even in asymptomatic patients.
SC
From this case we learn that clinical deterioration in a patient with a known type A IMH
M AN U
should warrant emergent surgery.
Source of funding: None.
Q:\Secrétariat
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Disclosures: None.
Central\boitin\PUBL\Can
AC C
EP
(unmarked).doc
J
Cardiol\Radiply
progressing_LP_ft\Rapidly
progressing
aortic_May
ACCEPTED MANUSCRIPT Dionne 6
References
1.
Hata M, Hata H, Sezai A, Yoshitake I, Wakui S, Shiono M. Optimal treatment strategy for
RI PT
type A acute aortic dissection with intramural hematoma. The Journal of Thoracic and Cardiovascular Surgery. 2014;147(1):307–311. doi:10.1016/j.jtcvs.2012.11.015.
Song J-K, Yim JH, Ahn J-M, et al. Outcomes of patients with acute type a aortic intramural hematoma. Circulation. 2009;120(21):2046–2052.
3.
M AN U
doi:10.1161/CIRCULATIONAHA.109.879783.
SC
2.
Watanabe S, Hanyu M, Arai Y, Nagasawa A. Initial medical treatment for acute type a intramural hematoma and aortic dissection. The Annals of Thoracic Surgery. 2013;96(6):2142–2146. doi:10.1016/j.athoracsur.2013.06.060.
TE D
Motoyoshi N, Moizumi Y, Komatsu T, Tabayashi K. Intramural hematoma and dissection involving ascending aorta: the clinical features and prognosis. Eur J Cardiothorac Surg.
EP
2003;24(2):237–42– discussion 242.
AC C
4.
ACCEPTED MANUSCRIPT Dionne 7
Figure Legend
Figure 1. Thoracic injected computed tomography showing the strikingly rapid evolution of the
RI PT
intramural hematoma over 2 hours. Arrows show the false lumen. 2 upper rows: sinotubular
AC C
EP
TE D
M AN U
SC
junction, third row: ascending aorta, fourth row: aortic arch.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0828-282X(14)00358-4
DOI:
10.1016/j.cjca.2014.05.015
Reference:
CJCA 1226
To appear in:
Canadian Journal of Cardiology
Received Date: 28 November 2013 Revised Date:
15 May 2014
Accepted Date: 15 May 2014
Please cite this article as: Dionne PO, Perrault LP, Rapidly Progressing Aortic Intramural Hematoma to Aortic Dissection, Canadian Journal of Cardiology (2014), doi: 10.1016/j.cjca.2014.05.015. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Dionne 1
Rapidly Progressing Aortic Intramural
RI PT
Hematoma to Aortic Dissection
Pierre Olivier Dionne, MD, Louis Paul Perrault, MD, PhD
SC
From the Department of Surgery, Montreal Heart Institute and Université de Montréal,
M AN U
Montreal, Quebec, Canada.
TE D
Short title: Progressing aortic intramural hematoma
AC C
_____________
EP
Word count: 517
Corresponding author: Louis P. Perrault, MD, PhD, Department of Surgery, Montreal Heart Institute, 5000 Belanger Street East, Montreal, Quebec, H1T 1C8, Canada. Tel.: (514) 376-3330 #3471; Fax: (514) 376-1355. E-mail: [email protected]
ACCEPTED MANUSCRIPT Dionne 2 Brief summary A 73-year-old man presented with intermittent chest pain irradiating to the back, starting 12 hours earlier. Initial scan showed an acute ascending aorta intramural hematoma. One hour
RI PT
later, the patient had an acute chest pain followed by a loss of consciousness. Two hours after the
AC C
EP
TE D
M AN U
SC
initial scan, a second scan showed a type A aortic dissection.
ACCEPTED MANUSCRIPT Dionne 3 ABSTRACT A 73-year-old man presented with intermittent chest pain irradiating to the back, starting 12 hours earlier. On the day following emergency consultation, thoracic scan showed an acute
RI PT
aortic intramural hematoma starting at the sinotubular junction with an ascending aorta diameter of 5.7 cm. One hour following the initial scan, the patient had an acute chest pain followed by a loss of consciousness. A second scan was done 2 hours after the initial scan and showed a type A
AC C
EP
TE D
M AN U
Key words: Aorta, complications, surgery, tomography
SC
aortic dissection that extended from the sinotubular junction to the descending aorta.
ACCEPTED MANUSCRIPT Dionne 4 We present the case of a 73-year-old man who presented with intermittent chest pain irradiating to the back, starting 12 hours earlier. The pain was partly relieved with sublingual Nitroglyceryn
years prior and a descending aorta replacement for type B dissection..
RI PT
The patient had a past medical history of atrial fibrillation, mildly positive Sestamibi test two
On the day following emergency consultation, contrast computed tomography (CT) showed an acute aortic intramural hematoma (IMH) starting at the sinotubular junction with an ascending
SC
aorta diameter of 5.7 cm.
The patient was asymptomatic and in a stable condition, which motivated the decision to
M AN U
manage the condition medically with a follow-up CT 24 hours later.
One hour following initial CT, the patient had an acute chest pain episode followed by a loss of consciousness. On awakening, the patient complained of left shoulder pain and had total left arm plegia.
TE D
A second contrast CT was done 2 hours after the initial scan and showed a type A aortic dissection that extended from the sinotubular junction to the descending aorta prosthesis, involving the innominate artery, left primitive carotid artery and left subclavian artery. There
EP
was also an 8.5 mm circumferential pericardial collection that was absent on initial CT. The patient was operated emergently but died post-operatively secondary to multiple
AC C
cerebral embolic strokes.
Management of aortic intramural hematoma remains controversial. Medical management seems to be associated with more complications than surgical management.
1,2
Initial aortic
diameter (>55 mm) and intramural hematoma thickness (>16 mm) are associated with more aortic complications (development of aortic dissection, delayed surgery and death). 2,3 As reported in Hata and colleagues’ serie, hospital mortality was higher with medical management than with surgical management (25,8% and 0%, respectively).1 Furthermore, as
ACCEPTED MANUSCRIPT Dionne 5 much as 47% of patients managed medically might require late surgical conversion owing to persistent pain, progression to type A dissection, ruptured aneurysm or aneurysmal enlargement (> 60 mm).4
RI PT
These aortas are highly unstable and should be managed as such. In light of the literature, surgical management of type A IMH should be recommended in patients presenting with aortic complications and probably even in asymptomatic patients.
SC
From this case we learn that clinical deterioration in a patient with a known type A IMH
M AN U
should warrant emergent surgery.
Source of funding: None.
Q:\Secrétariat
TE D
Disclosures: None.
Central\boitin\PUBL\Can
AC C
EP
(unmarked).doc
J
Cardiol\Radiply
progressing_LP_ft\Rapidly
progressing
aortic_May
ACCEPTED MANUSCRIPT Dionne 6
References
1.
Hata M, Hata H, Sezai A, Yoshitake I, Wakui S, Shiono M. Optimal treatment strategy for
RI PT
type A acute aortic dissection with intramural hematoma. The Journal of Thoracic and Cardiovascular Surgery. 2014;147(1):307–311. doi:10.1016/j.jtcvs.2012.11.015.
Song J-K, Yim JH, Ahn J-M, et al. Outcomes of patients with acute type a aortic intramural hematoma. Circulation. 2009;120(21):2046–2052.
3.
M AN U
doi:10.1161/CIRCULATIONAHA.109.879783.
SC
2.
Watanabe S, Hanyu M, Arai Y, Nagasawa A. Initial medical treatment for acute type a intramural hematoma and aortic dissection. The Annals of Thoracic Surgery. 2013;96(6):2142–2146. doi:10.1016/j.athoracsur.2013.06.060.
TE D
Motoyoshi N, Moizumi Y, Komatsu T, Tabayashi K. Intramural hematoma and dissection involving ascending aorta: the clinical features and prognosis. Eur J Cardiothorac Surg.
EP
2003;24(2):237–42– discussion 242.
AC C
4.
ACCEPTED MANUSCRIPT Dionne 7
Figure Legend
Figure 1. Thoracic injected computed tomography showing the strikingly rapid evolution of the
RI PT
intramural hematoma over 2 hours. Arrows show the false lumen. 2 upper rows: sinotubular
AC C
EP
TE D
M AN U
SC
junction, third row: ascending aorta, fourth row: aortic arch.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
