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(Circulation. 2009;120:S292-S298.)
© 2009 American Heart Association, Inc.

Surgery for Aortic Disease

Clinical Outcomes of Medical Therapy and Timely Operation in Initially Diagnosed Type A Aortic Intramural Hematoma

A 20-Year Experience

Takeshi Kitai, MD; Shuichiro Kaji, MD; Atsushi Yamamuro, MD; Tomoko Tani, MD; Koichi Tamita, MD; Makoto Kinoshita, MD; Natsuhiko Ehara, MD; Atsushi Kobori, MD; Michihiro Nasu, MD; Yukikatsu Okada, MD; Yutaka Furukawa, MD

From Department of Cardiovascular Medicine (T.K., S.K., A.Y., T.T., K.T., M.K., N.E., A.K., Y.F.) and Cardiovascular Surgery (M.N., Y.O.), Kobe City Medical Center General Hospital, Kobe, Japan.

Correspondence to Shuichiro Kaji, MD, Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan, 4–6 Minatojima-nakamachi Chuo-ku, Kobe, Japan 650-0046. E-mail skaji{at}kcgh.gr.jp

Background— The management of aortic intramural hematoma (IMH) involving the ascending aorta (type A) has not been well-established. The purpose of this study was to clarify the long-term clinical outcomes of patients with type A IMH who were treated with medical therapy and timely operation.

Methods and Results— Clinical data including operative mortality, IMH-related events, and long-term survival were retrospectively reviewed in 66 patients with type A IMH, who were admitted to our institution from 1986 to 2006. Emergent surgical repair was performed in 16 (24%) patients because of severe complications, whereas 50 patients were treated with initial medical therapy. In medically treated patients, 15 (30%) patients who demonstrated progression to classic dissection or increase in hematoma size within 30 days underwent surgical repair except for 2 patients who refused surgery. The 30-day mortality rate was 6% with emergent surgery and 4% with supportive medial therapy. There were 7 late deaths and the actuarial survival rates of all patients were 96±3%, 94±3%, and 89±5% at 1, 5, and 10 years, respectively. In medically treated patients, maximum aortic diameter was the only predictor of early and late progression of ascending IMH (hazard ratio, 4.43; 95% CI, 2.04–9.64; P<0.001). Aortic diameter 50 mm predicted progression of ascending IMH with the positive and negative value of 83% and 84%, respectively.

Conclusions— Combination of medical therapy and timely operation resulted in favorable long-term clinical outcomes in patients with type A IMH.

Key Words: aorta • follow-up studies • mortality • prognosis • and survival