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Pregnancy complicated by aortic dissection

Here’s and interesting article about AD’s and pregnancy.

Aortic dissection in pregnancy: analysis of risk factors and outcome

Franz F. Immer, MDa*, Anne G. Bansi, MDa, Alexsandra S. Immer-Bansi, MDb, Jane McDougall, MDc, Kenton J. Zehr, MDd, Hartzell V. Schaff, MDd, Thierry P. Carrel, MDa

a Department of Cardiovascular Surgery, Berne, Switzerland
b Institute of Anesthesiology, Berne, Switzerland
c Division of Neonatology, University Hospital, Berne, Switzerland
d Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA

* Address reprint requests to Dr Immer, Department of Cardiovascular Surgery, University Hospital, 3010 Berne, Switzerland
e-mail: franzimmer@yahoo.de

Aortic dissection during pregnancy is a life-threatening event. Recent studies have revealed similar histologic changes in the wall of the ascending aorta in patients with bicuspid aortic valve disease (BAVD). Based on a review of the literature, including the experience from two institutions, we looked at the patient’s characteristics in patients with thoracic aortic dissection during pregnancy. We found that aortic root enlargement (> 4cm) or an increase of aortic root size during pregnancy in patients with BAVD, and Marfan syndrome is associated with a considerable risk for the occurrence of Type A dissection.

Original Articles: General Thoracic

Acute Aortic Dissection Complicating Pregnancy

Clark J. Zeebregts, MD, Marc A. Schepens, MD, PhD, Ton M. Hameeteman, MD, PhD, Wim J. Morshuis, MD, PhD, Aart Brutel de la Rivière, MD, PhD

Departments of Cardiopulmonary Surgery and Gynecology and Obstetrics, St. Antonius Hospital, Nieuwegein, the Netherlands

Accepted for publication May 23, 1997.

Background. Acute aortic dissection occurring during pregnancy represents a lethal risk to both the mother and fetus. Our purpose was to study the prevalence, treatments, and outcome of this rare problem and to suggest therapeutic guidelines.

Methods. During the past 12 years, 6 pregnant women were admitted with an acute aortic dissection. Four had a type A and 2 had a type B dissection (Stanford classification).

Results. Two of the 4 patients with a type A dissection underwent a combined emergency operation consisting of first cesarean section and then ascending aortic repair. Cesarean section was carried out 5 days after the emergency procedure on the aorta in the third patient, and 16 weeks later in the fourth patient. All 4 fetuses were delivered alive. One fetus died 6 days later, but the other 3 are alive and well at long-term follow-up. Of the 2 patients with a type B dissection, 1 was operated on for celiac ischemia; the other was treated medically. In both cases the fetus died in utero. There were no maternal deaths in either group. Conclusions. Cesarean section with concomitant aortic repair is recommended for pregnant women with a type A dissection, depending on the gestational age. The maternal hemodynamic status will determine the sequence of the two procedures. Medical treatment is advised for patients with a type B dissection, but surgical repair is indicated if complications such as bleeding or malperfusion of major side branches occur.

Surgery for acute type A aortic dissection in pregnant patients with Marfan syndrome

Abstract 

Objective: Acute type A aortic dissection during pregnancy can be fatal to both the mother and the fetus. The goal of the present study was to characterize the prevalence, treatment and outcomes of this dangerous condition in an effort to determine optimal management. Methods: A retrospective study was conducted using data from four Marfan patients with acute type A aortic dissection during pregnancy at our institution between 1991 and 2003. Results: The mean gestational period at the time of operative repair was 31 weeks, with a range of 26–34 weeks, and the aortic root diameter ranged from 35 to 85mm. Two of the four patients underwent a combined operation with cesarean section followed by aortic repair. One patient underwent operative aortic repair following spontaneous delivery. The final patient underwent aortic repair with the fetus remaining in situ. Median sternotomy and cardiopulmonary bypass were established via the femoral artery with direct right atria drainage and left atrial venting in all patients. Composite graft replacement combined with re-implantation of the coronary artery and aortic valve replacement were performed in three patients, and aortic valve replacement with coronary artery bypass grafting of the right coronary artery was performed in one patient. Three of four patients underwent aortic arch repair utilizing antegrade cerebral perfusion and deep hypothermia with total circulatory arrest. The patient that underwent operative correction with the fetus remaining in situ experienced fetal demise with miscarriage just after cardiac surgery, and the patient died 4 days later secondary to disseminated intravascular coagulation and multi-organ failure. The remaining three cases recovered uneventfully, and the mothers and babies were discharged in good condition. Conclusions: Based on these data, we advocate cesarean section with concomitant aortic repair for patients with Marfan syndrome and acute type A aortic dissection during pregnancy. Minimization of deep hypothermic circulatory arrest time is also recommended for cases in which the fetus remains in situ.

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