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Conservative management and resolution of iatrogenic type A aortic dissection in a patient with previous cardiac surgery

2012; Elsevier BV; Volume: 144; Issue: 2 Linguagem: Inglês

10.1016/j.jtcvs.2012.05.007

1097-685X

Tomasz A. Timek, Robert L. Hooker, Lawrence H. Patzelt, Gregory Bernath,

Cardiac Structural Anomalies and Repair

Treatment of iatrogenic acute type A aortic dissections (TAAD) remains controversial, with both surgical and percutaneous repairs advocated. We present the clinical course of a patient with previous cardiac surgery and catheter-induced acute iatrogenic TAAD that was successfully treated with conservative management. A 55-year-old morbidly obese woman with a history of diabetes mellitus, tobacco abuse, dyslipidemia, and coronary artery disease treated twice by coronary artery bypass grafting in 2002 presented to an outside hospital with acute chest pain. She reported a 6- to 7-month period of progressive unstable angina with severe substernal chest pain uncontrolled by sublingual nitroglycerin on the night of presentation. In the emergency room, the patient was diaphoretic and short of breath, with the electrocardiogram showing T-wave inversions in leads II, III, and aVF, and 2 negative serial troponin measurements. Chest radiography showed no acute cardiopulmonary process, and computed tomography of the chest with contrast did not reveal a pulmonary embolus or vascular abnormality. The patient's pain resolved in the emergency room, and coronary catheterization was performed 6 hours after admission. Coronary catheterization revealed a patent left internal mammary artery to the left anterior descending graft and a patent saphenous vein graft to the posterior descending artery. An 85% stenosis in the native second obtuse marginal artery was treated with placement of a bare metal stent. During the obtuse marginal intervention, contrast injection in the aortic root was performed, and acute TAAD was diagnosed, with suspicion of contrast injection into the aortic wall. Although the patient complained of chest pain, no evidence was found of cardiac ischemia, and the hemodynamics remained stable. The patient was immediately taken for computed tomography of the chest. The findings confirmed TAAD, with dense contrast within the false lumen (Figure 1). Because of the patient's clinical stability, morbid obesity, previous sternotomy, and mechanism of dissection, conservative management with blood pressure control, analgesics, and close observation was instituted. Echocardiography performed the following day showed normal left ventricular function with no aortic insufficiency or pericardial effusion. A computed tomography scan was repeated 2 and 6 days after the diagnosis and revealed rapid and progressive improvement in the vascular injury (Figure 2, B and C). The patient was discharged on postadmission day 9 without an event. A computed tomography scan 2 months after the event showed an essentially normal ascending aorta (Figure 2, D).Figure 2Cross-sectional computed tomography view of the ascending aorta at the level of the pulmonary artery (A) on admission, and (B) 2, (C) 6, and (D) 58 days after initial presentation. Near complete healing of the vascular injury was observed after 2 months.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Aortic root dissection induced at coronary catheterization has a reported incidence of only 0.02%1Dunning D.W. Kahn J.K. Hawkins E.T. O'Neill W.W. Iatrogenic coronary artery dissections extending into and involving the aortic root.Catheter Cardiovasc Interv. 2000; 51: 387-393Crossref PubMed Scopus (176) Google Scholar; however, it represents a potentially lethal complication. Both surgical repair and stenting of the coronary ostia to seal the entry site have been reported as treatment options.1Dunning D.W. Kahn J.K. Hawkins E.T. O'Neill W.W. Iatrogenic coronary artery dissections extending into and involving the aortic root.Catheter Cardiovasc Interv. 2000; 51: 387-393Crossref PubMed Scopus (176) Google Scholar However, the indications for surgical repair in otherwise hemodynamically stable patients without malperfusion or tamponade but with a history of previous cardiac surgery have not been clearly defined. Surgical repair of acute TAAD in patients with previous cardiac surgery has been associated with a mortality rate of greater than 50%.2Stanger O. Oberwalder P. Dacar D. Knez I. Rigler B. Late dissection of the ascending aorta after previous cardiac surgery: risk, presentation and outcome.Eur J Cardiothorac Surg. 2002; 21: 453-458Crossref PubMed Scopus (44) Google Scholar Even in centers of excellence, the mortality for these patients exceeds 30% and is more than twofold of that for patients with acute TAAD without previous surgery; the incidence of major cerebrovascular accidents is 4 times as high (10% vs 2.5%).3Estrera A.L. Miller C.C. Kaneko T. Lee T.Y. Walkes J.C. Kaiser L.R. et al.Outcomes of acute type A aortic dissection after previous cardiac surgery.Ann Thorac Surg. 2010; 89: 1467-1474Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar In contrast, in a small group of consecutive patients with TAAD and previous cardiac surgery, conservative medical management was associated with no in-hospital mortality and a 20% (2 of 10 patients) death rate at 14 months of mean follow-up.4Hassan M. Carvalho E.M. Macedo F.I. Gologorsky E. Salerno T.A. Paradigm change in the management of patients with acute type A aortic dissection who had prior cardiac surgery.J Card Surg. 2010; 25: 387-389Crossref PubMed Scopus (14) Google Scholar Our patient experienced an iatrogenic catheter-induced TAAD, which might portend a different prognosis than spontaneous TAAD, because the injury is often retrograde and will seal with anterograde aortic flow. A recent review of catheter-induced TAAD has confirmed this idea and revealed that expectant management for patients who did not receive a coronary stent (39% of study population) was not associated with adverse outcomes.5Geomez-Moreno S. Sabate M. Jimenez-Quevedo P. Vazquez P. Alfonso F. Hernandez-Antolin R. et al.Iatrogenic dissection of the ascending aorta following heart catheterization: incidence, management, and outcome.EuroIntervention. 2006; 2: 197-202PubMed Google Scholar As such, the etiology of TAAD, as well as patient comorbidites, hemodynamic status, and previous surgical interventions, should be factored into the surgical decision-making process. In this context, we chose to pursue conservative management with very close observation and radiologic surveillance. Even after only 2 days, marked improvement in TAAD was demonstrated in our patient, with additional progress at 6 days and near complete healing of the aortic injury at 2 months. Similar resolution of an iatrogenic TAAD has been reported recently, although with aid of right coronary artery ostial stenting to seal the primary entry.6Garg P. Buckley O. Rybicki F.J. Resnic F.S. Resolution of iatrogenic aortic dissection illustrated by computed tomography.Circ Cardiovasc Interv. 2009; 2: 261-263Crossref PubMed Scopus (12) Google Scholar This injury had nearly resolved at 30 days but was less extensive than that found in the present patient. Our report has demonstrated that resolution of this iatrogenic vascular complication is feasible without identifying or treating the primary site of injury in a selected, closely monitored patient. As such, in high-risk patients with previous cardiac surgery and iatrogenic catheter-induced TAAD who do not exhibit signs of myocardial ischemia, tamponade, or malperfusion, conservative management with close observation represents a potential treatment option. Should iatrogenic type A aortic dissection in patients with previous cardiac surgery be managed conservatively?The Journal of Thoracic and Cardiovascular SurgeryVol. 145Issue 2PreviewShould iatrogenic type A aortic dissection (AD) in patients with previous cardiac surgery (CS) be managed conservatively? We read with interest the report by Timek and colleagues1 presenting the clinical course of a 55-year-old patient with a history of coronary artery bypass grafting and coronary catheter–induced acute type A AD. This hemodynamically stable patient was treated conservatively, and the vascular injury healed uneventfully. Full-Text PDF