Abstract 4277: Acute Type A Intramural Hematoma: Analysis of Current Management Strategy
Introduction: Management of Acute Type A intramural hematoma (IMH) remains controversial varying from immediate surgery to medical management only. Conversion to classic dissection remains a primary concern. We analyzed our experience managing acute Type A intramural hematoma.
Methods: Between 10/99 and 5/08, 251 patients with acute Type A aortic dissection were treated, including 36 (14.3%) with Type A IMH. Seven IMH patients (19%) were repaired immediately, 28 (80%) managed initially with optimal medical management and eventual repair, and 1 (3%) with medical management only. Endpoints analyzed were early mortality and conversion to classic dissection (flow in the false lumen of the ascending aorta). Time (hours) from onset of symptoms defined the initiation of IMH.
Results: Early mortality for acute type A IMH was 8.3% (3/36): 14.3% (1/7) with immediate repair, and 7.1% (2/28) when optimal medical management with eventual repair was undertaken. The one medically managed Asian patient survived with resolution of the IMH. Conversion from Type A IMH to classic dissection occurred in 34% (12/36) of cases. No conversions were observed within 72 hours. Aortic diameter did not predict conversion. In actuarial analysis among the initially medically managed group with eventual repair, the hazard of conversion to classic dissection increased significantly at 8 days from the onset of symptoms. (p<0.05) (Figure 1)
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, timely surgical repair is recommended.