European Heart Journal (2005) 26, 1342–1344
Letters to the Editor doi:10.1093/eurheartj/ehi266 Online publish-ahead-of-print 25 May 2005
Type A aortic intramural haematoma vs. dissection
References 1. Evangelista A, Dominguez R, Sebastia C, Salas A, Permanyer-Miralda G, Avegliano G, Gomez-Bosh Z, Gonzalez-Alujas T, Garcı´a del Castillo H, Soler-Soler J. Prognostic value of clinical and morphologic findings in short-term evolution of aortic intramural haematoma. Therapeutic implications. Eur Heart J 2004;25:81–87. 2. Moizumi Y, Komatsu T, Motoyoshi N, Tabayashi K. Clinical features and long-term outcome of type A and type B intramural hematoma of the aorta. J Thorac Cardiovasc Surg 2004;127: 421–427.
Marco Pocar Cattedra di Cardiochirurgia ` degli Studi di Milano Universita Policlinico MultiMedica Milano, Italy Tel: þ39 335 6804757 Fax: þ39 02 24209085 Email address:
[email protected] Roberto Di Bartolomeo Cattedra di Cardiochirurgia ` degli Studi di Bologna Universita Policlinico Sant’Orsola-Malpighi Bologna, Italy Francesco Donatelli Cattedra di Cardiochirurgia ` degli Studi di Milano Universita Policlinico MultiMedica Milano, Italy
doi:10.1093/eurheartj/ehi267 Online publish-ahead-of-print 25 May 2005
Type A aortic intramural haematoma vs. dissection: reply The letter of Pocar et al.1 underlines important queries regarding the management of
aortic intramural haematoma, which have not yet been definitively answered. Mortality in our series of 68 intramural haematoma was high (19%) in the first 3 months of evolution.2 On multivariate analysis, mortality-related variables were diameter .50 mm and ascending aorta involvement. We agree that in this series ascending aorta involvement was low (18%), and similar to that described in other series.3,4 The majority of published studies report type A mortality similar to type A dissection, except in the Asian groups. Intramural haematoma represents 10–15% of acute aortic syndrome; however, in the Asian series the incidence is much higher (20–40%). This greater frequence of intramural haematoma could suggest that these groups have greater sensitivity in the diagnosis of this disease, with mild haematomas and better prognosis being included. In contrast, in the western reference centres, with a high proportion of patients referred from other institutions, the haematomas are more extensive and evident, and probably have worse prognosis. The low incidence of type A haematoma in our series could indicate a group with relatively poor prognosis, with mortality being 37% in the surgically treated group and 75% in the group treated medically. The case reported by Pocar et al.1 shows that a thin type A haematoma, and with no aortic dilatation, may evolve to aortic dissection, although in the case described the dissection was located only at the origin of the left carotid artery. Our group reported that 36% of intramural haematomas evolve with dissection of a more or less extensive aortic segment.5 Our cautious statement that surgery might be indicated in the therapeutic management of type A haematoma refers simply to the fact that our data do not permit this to be confirmed, as this was not the aim of the study. However, Pocar’s case1 does not contribute definitive evidence either. Thus, our study does not provide an answer to the question of whether or not all type A haematomas should be operated on, although we consider that the persistence of symptoms, poor haemodynamic control, aorta diameter .50 mm, and haematoma thickness imply poor prognosis. It is likely that in patients without these poor prognostic factors surgery might not be done on an emergency basis and be performed under the best conditions in the first 24–48 h. In any event, whether or not reabsorption of the haematoma implies that the disease is cured, remains to be defined. In our series, a patient with ascending aorta reabsorption presented a type A dissection at 9 months of follow-up. Regarding endovascular treatment of type B haematoma, there are currently no
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We read with interest the recent article by Evangelista et al.,1 regarding the 3-month history of patients with aortic intramural haematoma (IMH). The authors state that they made the diagnosis when haematoma thickness was 7 mm; however, smaller IMHs can be encountered in clinical practice. The population described (68 patients) included 12 type A (18%) and 56 type B (82%) IMHs with an A/B ratio of 1:4.7. This may imply a different natural history before arrival at the hospital, that is, in untreated patients (more favourable to type B IMH as for classic dissection). Because medical stabilization was attempted in the absence of haemodynamic instability, persistent pain or peri-aortic bleeding, this also reflects the incidence of emergency operations in these patients; six type A patients (50%, two deaths) and only two type B patients (3.6%) were treated surgically during the acute phase. Furthermore, among the remaining six patients with type A IMH who underwent a medical 3-month follow-up, four died (one during hospitalization, and three others after discharge, of whom one died after an emergency operation). This policy yielded a 67% mortality rate in untreated, that is, relatively stable at onset and lower-risk, patients, and a 37% mortality after emergency surgery (unstable and higher-risk patients). The authors conclude that patients with type A lesions might benefit from surgery and that endovascular treatment of selected type B IMH should be considered. We attempted medical stabilization in a similar patient with type A IMH in view of some apparently favourable conditions, namely, the disappearance of symptoms within 2 h, minimal haematoma thickness (3–4 mm), a relatively non-aneurysmal ascending aorta (maximal diameter 40 mm) with no aortic regurgitation and no pericardial effusion. The patient also had optimal blood pressure and heart rate control. Despite these considerations, mild symptoms (chest discomfort) relapsed after 13 days from onset, that is, during the acute phase of the disease. An intimal tear was visualized at the left carotid origin and the patient successfully underwent urgent total arch replacement with a branched graft. In summary, we strongly believe that type A IMH should represent an indication for primary surgery. The high mortality rates
reported in untreated patients, and the potential for an early, spontaneous, almost asymptomatic, early trend toward dissection as in the case described earlier is a clear example of what the natural history of type A IMH may imply, and a more complex operation in critically ill higher-risk patients is often necessary. The only exception may be represented by Asian populations.2 Owing to the relative uncommonness of type A IMH, we believe that large numbers are probably unjustified to define indications for a relatively low-risk operation in a lifethreatening condition. Caution is also advised in patients with complicated type B IMH, because endovascular treatment may lessen the probability of aortic rupture, but unlike dissection or penetrating ulcer, does not ‘exclude’ the bleeding source.
