Cattedra di Cardiochirurgia
Università degli Studi di Milano
Policlinico MultiMedica
Milano, Italy
Tel: +39 335 6804757
Fax: +39 02 24209085
Email address: mpocar{at}milanocuore.org
Cattedra di Cardiochirurgia
Università degli Studi di Bologna
Policlinico Sant'Orsola-Malpighi
Bologna, Italy
Cattedra di Cardiochirurgia
Università degli Studi di Milano
Policlinico MultiMedica
Milano, Italy
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 (34 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 life-threatening 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.
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