Emergency pericardial drainage without aortic repair for type A intramural haematoma complicated by cardiac tamponade

Abstract

From April 2011 to March 2020, 87 patients with type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta were treated at Kitasato University Hospital. The initial watch-and-wait strategy without emergency aortic repair was taken in 52 cases in which the maximum aortic diameter was ≤50 mm, pain score on arrival at our hospital was ≤3/10 on the numerical rating scale and there was no ulcer-like projection (ULP) in the ascending aorta. Eleven patients who fulfilled the criteria but developed cardiac tamponade underwent emergency pericardial drainage without aortic repair. Among these 11 patients, 3 patients developed an aortic event during the hospitalization; 1 patient developed enlargement of the ULP 18 days later but refused surgery, another patient developed rupture of the dissected brachiocephalic artery 4 days later and underwent emergency repair of the ascending aorta and the brachiocephalic artery and the other patient developed a new ULP in the ascending aorta 14 days later and underwent aortic repair. All 11 patients were discharged home. During follow-up (3.0 ± 2.4 years), 1 patient developed a recurrent type A acute aortic dissection and underwent emergency aortic repair 29 months later. There was no aorta-related death.

INTRODUCTION

Treatment strategy for type A acute aortic dissection (AAD) with a thrombosed false lumen or intramural haematoma (IMH) varies across regions and countries [1, 2], and we have adopted a watch-and-wait strategy to type A IMH and AAD with a thrombosed false lumen in selected cases [3]. IMH is sometimes complicated by sanguineous pericardial effusion, and it is normally considered as a sign of rupture. However, pericardial effusion associated with type A IMH is not definitely caused by the breakdown of the aortic wall. When the false lumen is thrombosed, risk of rupture naturally decreases. Therefore, pericardial drainage may turn IMH complicated by cardiac tamponade into an uncomplicated IMH, yielding time to consider indication for aortic repair.

CASES REPORT

This single-centre retrospective review was approved by the ethics committee at the Kitasato Institute (5 July 2018, B18-020). Because this was an observational retrospective study, the need for informed consent was waived. From April 2011 to March 2020, 87 patients with type A IMH and AAD with thrombosed false lumen of the ascending aorta were treated at Kitasato University Hospital. At the time of presentation, three-phase computed tomography (CT) angiography was performed including plain images, early-phase images with contrast enhancement and delayed-phase images, the last of which were obtained 150 s after the injection of contrast medium (Video 1). The initial watch-and-wait strategy was taken in cases in which the maximum aortic diameter was ≤50 mm, pain score upon arrival at our hospital was ≤3/10 on the numerical rating scale for conscious patients and there was no ulcer-like projection (ULP) in the ascending aorta. Eleven patients who fulfilled the criteria but developed cardiac tamponade underwent emergency pericardial drainage without aortic repair; 3 patients underwent percutaneous drainage performed by the emergency department physicians because of unstable haemodynamics before cardiac surgeons arrived at the emergency department. The remaining patients underwent surgical drainage in the operation theatre designated to cardiac surgery. The approach of the drainage was based on the surgeon’s preference. CT angiography was repeated on days 1, 3, 7 and 14 [3]. Aortic events occurred in 3 patients during the initial hospitalization; 2 of these underwent aortic repair (Fig. 1). Two patients who developed an enlarged or new ULP were asymptomatic (Table 1). All 11 patients were discharged home. All the patients underwent repeated plain CT angiography 3, 6 and 12 months after the onset and yearly thereafter. Contrast enhancement was conducted if CT showed signs of disease progression. Follow-up was ceased if there was no IMH or dissection in 2 consecutive years, unless the patient desired to continue. One patient developed a recurrent type A AAD and underwent emergency aortic repair 29 months later during the mean follow-up period of 3.0 ± 2.4 years (48–2311 days). This patient died of pneumonia 70 months after the initial onset of IMH. All other patients were alive at the end of the study period (Table 1 and Supplementary Material, Table S1).

Figure 1:

Flowchart of the management of type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta.

Table 1:

Profile of the patients

Case	Age	Sex	Primary tear	CPR before arrival	Pericardial drainage	Early event	Late event	Observation period after onset
1	77	M	Zone 4 (ULP)	No	Subxiphoid			6 years 2 months, alive
2	69	F	None (IMH)	No	Subxiphoid		Redissection 29 months later, underwent aortic repair. Died of pneumonia after 41 months more	5 years 10 months, died
3	73	M	None (IMH)	Yes	Subxiphoid			1 year 3 months, alive
4	78	M	None (IMH)	No	Subxiphoid			6 years 4 months, alive
5	78	F	Zone 3 (ULP)	No	Sternotomy	Enlargement of ULP 18 days later, refused surgery		4 years 4 months, alive
6	79	M	Zone 4 (Patent descending false lumen)	No	Sternotomy			3 years 4 months, alive
7	75	M	None (IMH)	No	Centesis			3 years 3 months, alive
8	64	M	Zone 4 (ULP)	No	Centesis			0 years 1 month, alive
9	73	F	None (IMH)	No	Sternotomy	Rupture of dissected right brachiocephalic artery 4 days later, underwent aortic and right brachiocephalic artery repair		1 year 6 months, alive
10	75	F	None (IMH)	No	Centesis			0 years 10 months, alive
11	82	M	None (IMH)	Yes	Subxiphoid	New ULP in the ascending aorta 14 days later, underwent aortic repair		0 years 5 months, alive

CPR: cardiopulmonary resuscitation; CT: computed tomography; F: female; IMH: intramural haematoma; M: male; ULP: ulcer-like projection.

DISCUSSION

Rupture of type A AAD mostly occurs at the false lumen of the ascending aorta where there is less surrounding tissue. We took the watch-and-wait strategy in both type A IMH and AAD with a thrombosed false lumen of the ascending aorta regardless of patent false lumen or ULP of the descending aorta [3]. In a patient who underwent pericardial drainage, dissection of the right brachiocephalic artery occurred 4 days later, and as a result, right haemothorax developed. We speculate that there was a primary entry within the right brachiocephalic artery of this patient, which was not detected by CT angiography. To adopt this strategy, high-resolution CT images are necessary. Signs of rupture, expansion of IMH, development of new ULP and aortic enlargement warrant urgent aortic repair. During pericardial drainage, the adventitia and epicardium remained intact. The source of sanguineous fluid is unclear, but presumably, it was caused by exudate fluid through the pressurized false lumen (Video 2).

During the study period, there were 35 patients with type A IMH and AAD with thrombosed false lumen of the ascending aorta who had indication for emergency aortic repair (Fig. 1). Among these, emergency aortic repair was declined in 13 cases mainly because of neurological deficits and advanced age, with 5 in-hospital mortalities. Conversely, 22 patients wished to have surgery; 1 died of rupture before entering the operation theatre, and 2 died after surgery. Among the remaining 19 early survivors, there were 1 late death and 1 aortic event during the mean follow-up period of 3.3 ± 2.3 years; a patient died of gastrointestinal bleeding 29 months after surgery and another underwent repair of an anastomotic pseudoaneurysm 2 months after surgery. Thus, the early and midterm outcomes with initial pericardial drainage without aortic repair were comparable with those with emergency aortic repair. Early detection of disease progression and prompt aortic repair in response to changes of aortic pathology were the keys to improving outcomes with this strategy.

All the patients in this series were Japanese, and this treatment strategy may not be universally acceptable. Further accumulation of data is required to prove its safety and to make it a general recommendation.

In conclusion, initial emergency pericardial drainage without aortic repair was associated with favourable early and midterm outcomes in patients with type A IMH and AAD with a thrombosed false lumen. It is considered that cardiac tamponade is not necessarily a sign of rupture in type A IMH and AAD with a thrombosed false lumen.

SUPPLEMENTARY MATERIAL

Supplementary material is available at ICVTS online.

Conflict of interest: none declared.

Reviewer information

Interactive CardioVascular and Thoracic Surgery thanks Daniel-Sebastian Dohle and the other, anonymous reviewer(s) for their contribution to the peer review process of this article.