Corresponding Author
Key Words: aortic intramural hematoma, ascending aorta, cardiac surgical procedures, cardiovascular surgical procedures, thoracic aorta
Acute type A aortic intramural hematoma (IMH), along with aortic dissection and penetrating aortic ulcer, is a life-threatening condition on the spectrum of acute aortic syndromes requiring surgical intervention. 11,2,3,4,5 IMH is predominantly located in the descending aorta (60%-70%) and is classified as type B aortic IMH, rather than in the ascending aorta (30%), which is classified as type A IMH.6
In this issue of JACC: Case Reports, Tabesh et al7 present the case of a patient with IMH extending from the aortic root to the suprarenal arteries. An important distinguishing factor of this case report is that the patient was managed conservatively with medical management. The patient, a 50-year-old woman, presented with substernal chest pain. Subsequent computed tomography angiography (CTA) demonstrated type A IMH that originated from the aortic root, above the right coronary artery, and extended to the ascending aorta, aortic arch, and origin of the left subclavian artery and subsequently to the abdominal aorta, superior to the level of the renal artery. Additionally, the ascending aorta was dilated, measuring 45.1 mm. The heart team decided to manage the patient with control of blood pressure and heart rate. Subsequent CTA at 14 days revealed no change in aortic size, and the patient was discharged. A 3-month follow-up scan revealed no IMH present, a finding that was confirmed by another CTA scan at 12 months. Tabesh et al7 defend the reasons for their approach by stating that medical management and follow-up studies were chosen for this patient in the absence of risk factors for mortality.
Despite this anecdotal success, type A aortic IMH carries a high risk of mortality when treated medically. Type A aortic IMH is inherently unstable,1,3, 4, 5,8 with the majority of events taking place during the acute or subacute phase and 14% to 37% of patients progressing to aortic dissection, rupture, or other aorta-related adverse events.9 The unpredictability of IMH makes it unsuitable to rely solely on monitoring and medical management for its management.10 In the absence of high-risk features, it may be reasonable to pursue expectant management of acute type A IMH in patients who have significant comorbidities. However, although acute type A IMH can regress spontaneously with medical therapy alone,9,11 this strategy is associated with a 37% rate of complications and a 29% to 46% risk of conversion to surgery.9,11
A meta-analysis evaluating comparatively the effects of both strategies on the overall survival of patients with type A IMH on the basis of nonrandomized and observational studies revealed that surgery was associated with better late survival and lifetime gain in comparison with medical therapy alone.10 Another meta-analysis, by Chow et al,11 looked at factors allowing conservative management of IMH. The study revealed that a maximal aortic diameter ≥45 mm was predictive of aortic-related events in the medical group. Chow et al,11 also stated that some of these cases could be retrograde dissections arising from the descending aorta with a thrombosed false lumen. In their analysis, 61.5% of patients who did not undergo surgery had a penetrating aortic ulcer or ulcer-like projection in the aortic arch or descending aorta on the presenting scan. Chow et al,11 concluded that, although the initial conservative approach was safe and feasible, emergency surgery was associated with improved survival in type A aortic IMH.
Surgical intervention provides definitive treatment by addressing the hematoma and the structural vulnerability in the aortic wall,3,5 and some important documents should be mentioned here:
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1.
The joint guidelines of the European Association for Cardio-Thoracic Surgery and The Society of Thoracic Surgeons state that, for patients without high-risk features, medical therapy should be considered to stabilize these patients; close imaging follow-up is mandatory to detect early progression and re-evaluate the conservative treatment approach on an individual basis; the guidelines mention a high rate (30%-40%) of progression to surgical repair or interventions after initial conservative therapy.3
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2.
The joint guidelines of the American College of Cardiology and the American Heart Association mention varied approaches to the timing of surgery, with a low mortality rate within 24 hours and slightly delayed repair (between 24 and 72 hours) when feasible.5
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3.
Results from the International Registry of Acute Aortic Dissection registry and further analysis of their database indicated that earlier surgical management of type A IMH resulted in lower mortality.4
Tabesh et al7 report that medical management in the Asian population results in lower morbidity and mortality compared with European and American populations. In 2011, the Japanese Circulation Society guidelines for the diagnosis and treatment of aortic aneurysm and aortic dissection advocated medical rather than surgical management of uncomplicated type A IMH provided there are no ulcer-like projections in the ascending aorta, the hematoma thickness is <11 mm, and the aortic diameter is <50 mm.12 These guidelines were followed by a 2020 report from Japan that adhered to these guidelines with favorable outcomes.13 However, those investigators considered their strategy more of “watch and wait” than medical management, by highlighting that they repeated CTA on days 1, 3, 7, and 14 following admission.13 A study conducted in China that randomized 124 patients to medical vs surgical management found that, over a mean follow-up of 3.3 years, late mortality was notably higher in the conservatively treated group.14 Actuarial survival at 5 years was 90.4% in the surgical group compared with 74.3% in the conservatively managed group.14
The prognosis of patients with a type A IMH who are conservatively treated is debatable. Considering the Japanese experience, there may be a subgroup group of patients who may benefit from a conservative approach coupled with intensive follow-up, with the caveat that these patients may require urgent surgery in the future and this approach mandates several repeat imaging studies (both during initial hospitalization and follow-up), which increase radiation exposure, stress to the patient, and resource use. Be that as it may, the international guidelines continue to endorse urgent aortic surgery in type A aortic IMH as in all acute aortic syndromes (Figure 1).
Figure 1.
Type A Aortic Intramural Hematoma
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
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References
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