Asian Cardiovasc Thorac Ann 1999;7:156-157
© 1999 Asia Publishing EXchange Pte Ltd
Two Years Survival of Dissecting Ascending Aortic Aneurysm With Medical Treatment
M Kamil Göl, MD,
Ahmet Sarita
, MD,
eref A Küçüker, MD,
O
uz Tademir, MD,
Kemal Bayazit, MD
Department of Cardiovascular Surgery
Türkiye Yüksek  htisas Hospital
Ankara, Turkey
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For reprint information contact: M Kamil Göl, MD Tel: 90 312 310 3080 Fax: 90 312 311 6351 email: nkgol{at}ato.org.tr Department of Cardiovascular Surgery, Türkiye Yüksek htisas Hospital, Sihhiye, Ankara 06100, Turkey.
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Abstract
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Aortic dissections in the acute phase have a dramatic outcome, especially those in the ascending and arcus segments. The fate of these dissections in the chronic phase is not well established. We describe a case treated medically for over two years and then successfully repaired surgically.
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Introduction
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Aortic dissection is probably the most common potentially fatal aortic disease and the most frequent cause of aortic rupture.1,2 Acute dissections end with fatality in almost 80% of patients within two weeks.3 Those who survive the first year (around 10%) may expect reasonable longevity. Late deaths are due to cerebrovascular accidents secondary to hypertension, heart failure due to aortic regurgitation, or rupture of a saccular aneurysm of the residual false channel. We report the case of a patient with a dissecting aneurysm of the ascending and arcus aorta, in whom continual chest pain and palpitation were present. Surgery was offered but the patient refused until the intensity of his symptoms forced him to accept an operation 28 months after his initial diagnosis.
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Case Report
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A 51-year-old man was referred to Türkiye Yüksek htisas Hospital in 1995 with chest pain and palpitation. He was in good health until 5 months prior to admission when he began to experience a continuous dull substernal pain that was aggravated by exercise. On admission, his physical findings included blood pressure of 110/50 mm Hg, pulse rate 80 beats per minute, temperature 37.1°C, respiratory rate 17 per minute, and signs of mild congestive heart failure with a murmur of aortic regurgitation. All peripheral pulses were palpable and symmetrical. Laboratory data were within the normal limits. Electrocardiography showed left ventricular hypertrophy and chest radiography showed some widening of the upper mediastinum. Echocardiography revealed dilatation of the ascending aorta (4.3 cm), an intimal flap, and severe aortic regurgi-tation. Aortography and coronary angiography were performed and these confirmed the diagnosis of ascending aortic dissection and aneurysm with third-degree aortic regurgitation. The patient's coronary vessels were com-pletely normal. The dissection began just above the coronary ostia and extended to the level of the innominate artery (Stanford type A), being 4.3 cm. in diameter at its widest. An operation was offered but the patient refused and was then discharged on medical treatment comprising digitalis, a diuretic, and beta blockers. Four months later, transthoracic echocardiography was performed and the diameter of the aorta was found to have increased to 5.8 cm. The patient again refused the operation and was followed up with medications. Fourteen months later, transthoracic echocardiography gave the same measure-ment for the diameter of ascending aorta (5.8 cm).
As the patient's symptoms worsened, he eventually accepted the surgery and was admitted to our hospital in 1998, 28 months after his initial diagnosis. On admission, his blood pressure was 110/40 mm Hg and other vital signs and physical examination findings were normal except for the murmur of aortic regurgitation that was recorded as more intense. Chest radiography showed marked widening of the upper mediastinum. Transthoracic echocardiography was repeated and the diameter of the ascending aorta was measured as 6.6 cm. A computed tomography scan indicated that the aortic diameter was 7 cm. Aortography showed a double lumen and a 6.6-cm aneurysmatic dilatation of the ascending aorta (Figure 1
). The dissection ended at the level of the left subclavian artery.
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Figure 1. Digital subtraction angiography of the patient. The internal diameter of the aorta was measured as 6.6 cm. The double lumen of the aorta can also be seen.
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Surgery revealed an aneurysm confined to the ascending aorta and the aortic arch with a false lumen and a thick fibrotic septum in between. The primary tear was just above the left coronary ostia and the reentry was near the origin of the left subclavian artery. There was no thrombus in the false lumen. The arch vessels were spared of dissection. A Dacron graft was used to perform supracoronary ascending aorta and hemiarch replacement. Postcardiopulmonary bypass transesophageal echo-cardiography showed minimal aortic regurgitation so no aortic valve intervention was undertaken. The patient had an uneventful postoperative course and was discharged from the hospital on the 8th postoperative day. One month after the operation, echocardiography showed no pathology except for minimal aortic regurgitation. The patient's symptoms subsided and his functional capacity improved rapidly.
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Discussion
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Hirose and colleagues4 found an average annual increase in the diameter of the arcus aorta in 171 patients of 0.56 cm. In our case, the diameter of ascending aorta was 4.3 cm at the initial diagnosis, it reached 5.8 cm 4 months later and 6.6 cm after 28 months. Chronic dissections of the ascending aorta are considered for surgery if the diameter is above 60 mm, if the annual increase in diameter is more than one cm, or if the patient has symptoms. As observed in this case, the annual increase may be less rapid once the dissection finds a reentry. It could also be assumed that anti-impulse therapy, as suggested by Wheat and Palmer5, might have limited the enlargement. It is not clear why the patient had an increase in symptoms after 2 years. We believe this was a warning sign of forthcoming rupture.
The intensity of aortic regurgitation was recorded as increased on admission compared with that at the time of diagnosis. However, this was not a reliable finding since the two observers were different. It would be expected to be the same or decreased because worsening of left ventricular function or dilatation of the left ventricle with a lowered ejection fraction would reduce the intensity of the murmur. There is no controversy regarding the surgical indications in cases of dissecting ascending aortic aneurysm but documentation of unusual cases such as the one described here, might contribute to our understanding of the pathophysiology of rupture and the natural history of dissections.
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References
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Spitnell PC, Spitnell JA Jr, Joyce JW, Tajik AJ, Edwards WD, Schaff HV, et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980–1990). Mayo Clin Proc 1993;68:642–51.[Medline]
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Crawford ES. The diagnosis and management of aortic dissection. JAMA 1990;264:2537–41.[Abstract/Free Full Text]
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Hirst AE Jr, Johns VJ Jr, Kime SW Jr. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine 1958;37:217–79.[Medline]
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Hirose Y, Hamada S, Takamiya M, Imakita S, Naito H, Nishimura T. Aortic aneurysms: growth rates measured with CT. Radiology 1992;185:249–52.[Abstract/Free Full Text]
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Wheat MW, Palmer RF. Dissecting aneurysms of the aorta: present status of drug versus surgical therapy. Progr Cardiovasc Dis 1968;11:198–210.[Medline]
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Abstract
Introduction
