Acute Type A Intramural Hematoma: Analysis of Current ...

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.