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Acute Type A Intramural Hematoma: Analysis of Current ...
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Aortic Surgery Symposium 2010 New York, NY April, 2010 Department of Cardiothoracic and Vascular Surgery The University of Texas Medical School at Houston Memorial Hermann Heart & Vascular Institute Anthony Estrera, MD, Charles Miller, III, PhD, Taek-Yeon Lee, MD, Paola De Rango, MD, MD, T. Kaneko, MD, Hazim Safi, MD Acute Type A Intramural Hematoma: Analysis of Current Management Strategy
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Aortic Surgery Symposium 2010
New York, NYApril, 2010
Department of Cardiothoracic and Vascular Surgery
The University of Texas Medical School at HoustonMemorial Hermann Heart & Vascular Institute
Anthony Estrera, MD, Charles Miller, III, PhD, Taek-Yeon Lee, MD, Paola De Rango, MD, MD, T. Kaneko, MD, Hazim Safi, MD
Acute Type A Intramural Hematoma: Analysis of Current Management Strategy
Unstable, Tamponade
Acute Type A IMH
Emergent Surgery(pericardial window)
Stable
Initial Medical OptimizeUrgent Surgery
Background
Purpose
Analyze our experience managing acute
Type A intramural hematoma
Compare outcomes with Typical Acute
Type A dissection
Validate our treatment approach
Methods
251 Acute Type A Aortic Dissection
Oct. 1999 – May 2008
Median age: 62 (21-91)
64%
36%
36 IMH (14%)
Methods
28 Patients (78%)
Managed With Optimal Medical Management With Eventual Surgical
Treatment
1 Patient (3%)Medical Management Only
7 Patients (19%) Repaired On Presentation
36 Patients (IMH)
Methods
IMH vs. Typical
Variable IMH (n=36)
Typical (n=215)
P-Value
Age (yr) 63 ± 14 58 ± 15 0.06
Male 66% 71% 0.72
Chest pain 100% 88% 0.04
Abdominal Pain 6% 10% 0.59
Hypotension (<90) 8% 22% 0.07
Tamponade 6% 16% 0.16
Aortic insuff (>mod) 11% 38% 0.002
Asc. Diameter (cm) 5.2 ± 0.8 5.0 ± 0.8 0.17
PreoperativePreoperative
IMH vs. Typical
Variable IMH (n=36)
Typical (n=215)
P-Value
Total Arch 14% 6% 0.07
Aortic Root 3% 6% 0.45
Cannulation(Fem/Asc/Axilla)
32/1/2 206/3/6 0.08
Peripheral bypass 3% 1% 0.73
CABG 9% 5% 0.34
Intra-operativeIntra-operative
IMH vs. Typical
Variable IMH (n=36)
Typical (n=215)
P-Value
Myocardial Infarct 6% 7% 0.78
Stroke 0% 1% 0.99
Temp Neuro Dysfunct 9% 10% 0.73
Bleeding 0% 7% 0.13
Mortality 8% 13% 0.68
Conversion to Typical 33% NA NA
Post-operativePost-operative
Results by Approach
Variable Immediate (n=7)
Medical then Repair (n=28)
Medical only
(n=1)
P-Value
Mortality 14% 7% 0% 0.69
Conversion to Typical
14% 39% 0% 0.70
Time Sx to OR (Days)
0.8 ± 0.8 6.5 ± 4.1 NA 0.001
Admit to OR(Days)
0.6 ± 0.8 5.3 ± 3.6 NA 0.002
Aortic Size (cm)
5.3 ± 1.1 5.2 ± 0.7 4.8 0.99
Risk of Conversion
Conclusions
Despite optimal medical management, conversion of Type A IMH to typical dissection still remains a concern with the most significant risk beyond 8 days.
In our patient population, although
purposeful delay can be safely achieved in certain patients, timely surgical repair is recommended.
