Abstract 14126: Aortic Root Involvement in Acute type A Intramural Hematoma: Is it a Risk for Medical Treatment?
Introduction: Controversy exists in the optimal treatment for acute type A aortic intramural hematoma (IMH). We have employed “intensive medical treatment with timely surgery” strategy. Whether the location of IMH affects the outcome with this conservative strategy is unknown.
Hypothesis: We assessed the hypothesis that involvement of aortic root in acute IMH affects the short and long-term outcomes.
Methods: At initial presentation, patients with the maximum diameter of the ascending aorta larger than 50mm or ulcer-like projection (ULP) undergo urgent surgery. Other patients received intensive anti-hypertensive therapy. During follow-up, patients with IMH progression (ascending aorta dilatation, new ULP or aortic dissection) undergo surgery. Since 1991 through 2008, 67 patients (34 male and 33 female; mean age of 67.5±10.5) were treated. Of these, 31 patients (46%) had IMH extended into aortic root (Group AR), while 36 patients (54%) had IMH contained in the ascending aorta above the ST junction (Group AA).
Results: At initial presentation, patients in Group AR had larger maximum diameter of the ascending aorta (53±6 mm vs. 45±6 mm: p<0.0001), thicker intramural hematoma (16±8 mm vs. 10±5mm: p=0.0004), more adverse events such as cardiac tamponade or rupture (52% vs. 6%: p<0.0001), urgent surgery (55% vs. 19%: p= 0.002) and hospital mortality (16% vs. 0%: p=0.02). Without surgery, 43 patients (64%) were medically treated in the follow-up period. Fewer patients in Group AR were medically treated (45% vs. 81%: p=0.002). Follow-up study of adverse events (rupture or IMH progression to surgery) showed less favorable event-free survival in Group AR than Group AA (50%, 36%, 29% and 29% vs. 86%, 76%, 72% and 66% at 1 m, 3 m, 1yr and 5 yr: p=0.006).Eventually, 14 patients (37% of the medically-treated patients) underwent scheduled surgery during the 10-years of follow-up with no mortality. All IMH-related death (n=5: rupture or surgical mortality) was observed in Group AR during the first year after the onset, not in Group AA (16% vs. 0% at 1, 5 and 10 yr: p=0.013).
Conclusions: Acute type A IMH involving aortic root was highly associated with adverse events and mortality at initial presentation, followed by more IMH-related events during the first year of follow-up.
- © 2010 by American Heart Association, Inc.