Management strategies and outcomes in pregnancy-related acute aortic dissection: a multicentre cohort study in China.
Heart (British Cardiac Society)
BACKGROUND:Acute aortic dissection (AD) in pregnancy poses a lethal risk to both mother and fetus. However, well-established therapeutic guidelines are lacking. This study aimed to investigate clinical features, outcomes and optimal management strategies for pregnancy-related AD. METHODS:We conducted a retrospective multicentre cohort study including 67 women with acute AD during pregnancy or within 12 weeks postpartum from three major cardiovascular centres in China between 2003 and 2021. Patient characteristics, management strategies and short-term outcomes were analysed. RESULTS:Median age was 31 years, with AD onset at median 32 weeks gestation. Forty-six patients (68.7%) had type A AD, of which 41 underwent immediate surgery. Overall maternal mortality was 10.4% (7/67) and fetal mortality was 26.9% (18/67). Compared with immediate surgery, selective surgery was associated with higher risk of composite maternal and fetal death (adjusted RR: 12.47 (95% CI 3.26 to 47.73); p=0.0002) and fetal death (adjusted RR: 8.77 (95% CI 2.33 to 33.09); p=0.001). CONCLUSIONS:Immediate aortic surgery should be considered for type A AD at any stage of pregnancy or postpartum. For pregnant women with AD before fetal viability, surgical treatment with the fetus in utero should be considered. Management strategies should account for dissection type, gestational age, and fetal viability. TRIAL REGISTRATION NUMBER:NCT05501145.
10.1136/heartjnl-2024-324009
Management and outcomes of aortic dissection type B in late pregnancy: A retrospective case series.
BJOG : an international journal of obstetrics and gynaecology
OBJECTIVE:Pregnancy complicated with type B aortic dissection is a rare but devastating condition. Guidelines for managing this condition are lacking. We present our observation and experiences in managing five pregnant women with complicated type B aortic dissection in the second or third trimesters, aiming to gain insights that can aid in proposing an appropriate management strategy. DESIGN:A retrospective study. SETTING:Zhongnan Hospital of Wuhan University. POPULATION:Pregnant women with complicated type B aortic dissection. METHODS:Clinical data of five pregnant women with complicated type B aortic dissection admitted to Zhongnan Hospital of Wuhan University from January 2022 to June 2023 were collected. The clinical characteristics, treatment strategies, and corresponding maternal and infant outcomes were retrospectively analysed. MAIN OUTCOME MEASURES:Survival of mothers and foetuses. RESULTS:All five study participants were diagnosed with complicated type B aortic dissection by computed tomography angiography (CTA). The range of gestational weeks at admission was 27 weeks + 3 days to 36 weeks + 6 days. The first patient, planning a caesarean section (C-section) followed by thoracic endovascular aortic repair (TEVAR), died of aortic dissection rupture during C-section. Her neonate was successfully rescued. In contrast, the remaining four patients who underwent TEVAR first survived. Among them, three patients underwent single-stage aortic repair and delivery, while one patient received C-section 31 days after TEVAR. Three preterm live births were recorded among these surviving mothers. Neonatal death occurred in one case with a gestational age of 29 weeks + 5 days, who had foetal distress before surgery. During the follow-up period of up to 3 months, no maternal or infant death occurred. No device-related or systemic complications were observed in the surviving mothers after discharge. Routine physical examinations of the four live births showed no abnormalities. CONCLUSIONS:For pregnant women with thoracic back pain and high suspicion of aortic dissection, CTA should be conducted promptly to prevent missed or delayed diagnosis. Maternal survival should be prioritised over foetal outcome once diagnosed. TEVAR was demonstrated to be safe and feasible for such patients. For women with complicated type B aortic dissection in late pregnancy, TEVAR followed by C-section may be a promising treatment strategy.
10.1111/1471-0528.17923
Aortic surgery in pregnancy.
Lansman Steven L,Goldberg Joshua B,Kai Masashi,Tang Gilbert H L,Malekan Ramin,Spielvogel David
The Journal of thoracic and cardiovascular surgery
Pregnancy engenders changes in hemodynamics and the aortic wall that make a woman more susceptible to aortic dilatation and dissection. This is particularly true of women with aortic dilatation and an aortopathy, including the inherited fibrillinopathies, bicuspid aortic valve, and Turner syndrome. Women in these risk groups may be served best by undergoing elective aortic surgery before becoming pregnant. However, some women present during pregnancy with significant aortic dilatation, rapid expansion, or aortic dissection, and strategies to deal with these situations, while optimizing maternal and fetal outcomes, change as gestation progresses. This review summarizes the approaches to the management of aortic diseases and the conduct of aortic surgery in pregnancy.
10.1016/j.jtcvs.2016.06.015
2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines.
Circulation
AIM:The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS:A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
10.1161/CIR.0000000000001106
2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines.
Journal of the American College of Cardiology
AIM:The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS:A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE:Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
10.1016/j.jacc.2022.08.004
Rupture of a Type B Aortic Dissection in a Postpartum Patient with Marfan Syndrome.
Patberg Elizabeth,Duffy Jennifer,Hameed Afshan B
AJP reports
Pregnant women with Marfan syndrome (MFS) are known to be at increased risk of aortic dissection; however, cases of aortic rupture are extremely rare. There is lack of consensus on the exact site and size of aortic diameter measurement that increases this risk, and whether this applies to both Type A and Type B dissections. A 23-year-old G2P1001 with known Marfan syndrome who underwent an uncomplicated antepartum and intrapartum course. She experienced persistent backache 10 days postpartum that led to the diagnosis of Stanford Type B dissection. The patient was hospitalized for close observation. Dissection progressed to aortic rupture within 24 hours that required emergent thoracic endovascular aortic repair. She had an uncomplicated postoperative course. Our report demonstrates rupture of a known aortic dissection within a very short time in the postpartum period. The case highlights the importance of patient education and close surveillance especially in the postpartum period. It also brings home the value of imaging of the whole aorta rather than focusing on the ascending alone. Multidisciplinary care and timely diagnosis and intervention likely led to the favorable outcome in our case.
10.1055/s-0039-1692712
Delivery-First Strategy Followed by Endovascular Repair to Treat Pregnant Woman With Acute Complicated Type B Aortic Dissection.
Clinical medicine insights. Case reports
Objective:Aortic dissection, a rare but serious condition, requires timely diagnosis and treatment. Case report:A case report involving a 33-year-old female with Stanford type B aortic dissection at 32 + 3 weeks gestational age highlights the importance of being alert to the symptoms and signs of this condition, particularly in patients with hypertension or a history of connective tissue disorders. The case report suggests a delivery first strategy followed by TEVAR procedure as the preferred approach for managing aortic dissection in pregnancy. This approach can alleviate pressure on the aorta, reduce the risk of rupture, and provide time for stabilization and preparation for the TEVAR procedure. Conclusion:The case report emphasizes the criticality of recognizing and treating aortic dissection in pregnant patients promptly, given its potential life-threatening impact on both mother and fetus.
10.1177/11795476241265270
Postpartum Acute Aortic Dissection in a Patient Without a Connective Tissue Disorder: A Case Report.
A&A practice
Type A acute aortic dissection is a rare life-threatening event that occurs most commonly in the third trimester or early postpartum and in women with connective tissue disorders. However, this case describes a type A aortic dissection diagnosed on postpartum day 2 in a woman with preeclampsia without a history of a connective tissue disease. The case emphasizes the importance of considering dissection in any parturient complaining of chest pain, especially in the setting of hypertension and a new murmur. Emergent imaging must be considered to decrease delays in surgical repair and to minimize maternal morbidity and mortality.
10.1213/XAA.0000000000001629
Successful treatment of a gravida with acute type A aortic dissection in the third trimester: A case report.
Medicine
RATIONALE:Acute type A aortic dissection is a rare and catastrophic complication of pregnancy with a very high mortality rate for both the mother and the fetus. PATIENT CONCERNS:A 40-year-old female who was 31 weeks pregnant was transferred to our hospital due to "chest and back pain for 7 hours." Enhanced computed tomography (CT) of the aorta revealed a Standford A dissection, involving 3 branches of the aortic arch and the opening of the right coronary artery. The aortic root and ascending aorta were significantly widened. DIAGNOSES:Acute type A aortic dissection. INTERVENTIONS:After multidisciplinary discussions, we decided to perform cesarean section first and then cardiac surgery. A live male infant was delivered successfully by Obstetrician and Gynecologist. And then, we performed the Betalls procedure with the use of a mechanical 23# aortic-valve vessel for the patient. The innominate artery openings were reinforced with felt pads. OUTCOMES:The procedure was successful. CT examination at 2 months after operation showed that the true lumen of the aorta was enlarged, and no dissection was found in the 3 branches of the aortic arch. LESSONS:Type A aortic dissection during pregnancy is a rare event that carries a high risk of death for both mother and fetus. An optimal outcome can be achieved through early and accurate diagnosis, safe imaging techniques, timely and effective multidisciplinary discussion, and precise and individualized treatment.
10.1097/MD.0000000000033423
Type A Aortic Dissection in a Previously Healthy Pregnant Patient: A Challenging Dilemma, Case Report, and Literature Review.
Case reports in cardiology
Aortic dissection (AoD) is a rare fatal condition in which tearing in the intima causes a false channel in the aorta and can lead to rupture. AoD is classified as the DeBakey classification (Types I, II, III) and Stanford classification (Types A and B). Women with underlying risk factors such as hypertension, smoking, bicuspid aortic valve, and connective tissue disorders are at risk for pregnancy-related AoD. These risk factors may not be recognized until the AoD occurs during pregnancy. We describe an acute incidence of type A AoD in the second trimester of pregnancy. A multiparous woman with no previously known risk factor presented with nonspecific chest pain. She was found to have AoD and underwent successful surgical intervention. This case demonstrates the importance of vigilance in the evaluation of pregnant women with new cardiopulmonary symptoms. A multidisciplinary approach can save the mother and the fetus.
10.1155/cric/6971509
Aortic Dissection in a Pregnant Patient without Other Risk Factors.
Case reports in obstetrics and gynecology
An aortic dissection is a life-threatening condition in which the intima of the artery tears causing separation of the intima and media. Pregnancy places women at a significantly increased risk of common vascular events including venous thromboembolism, myocardial infarction, and stroke, while also increasing the risk of rarer vascular events such as aortic dissection and aortic rupture. A 30-year-old previously healthy multiparous woman presenting at 36 weeks of pregnancy with a Type A aortic dissection. She underwent a combined emergent cesarean delivery followed by repair of her aortic root. Aortic dissection should be high on the differential for pregnant patients presenting with the characteristic complaints and physical exam findings given the high mortality rate associated with this vascular event. (1) This report reviews the characteristic presentation, risk factors, and physical exam findings in a patient with an aortic dissection. (2) The report includes treatment options for pregnant patients based on the classification of the dissection.
10.1155/2019/1583509
Acute type B aortic dissection in a pregnant woman with undiagnosed Marfan syndrome: A case report and review of the literature.
Miyazaki Yumiko,Orisaka Makoto,Kato Masataka,Kawamura Hiroshi,Kurokawa Tetsuji,Yoshida Yoshio
Case reports in women's health
Aortic dissection during pregnancy is rare but can be life-threatening to both the mother and the foetus. Marfan syndrome is a major risk factor for acute aortic dissection during pregnancy. Here, we present the case of a woman who had not been diagnosed with Marfan syndrome prior to pregnancy and who developed acute type B dissection at 32 weeks of gestation. The maternal hemodynamic status was stable, and foetal well-being was ensured. However, under conservative treatment, the dissection extended to the descending aorta, reaching the bilateral iliac artery 2 days later. Due to foetal distress, preterm delivery was performed via caesarean section. The primary treatment of type B aortic dissection is conservative medical treatment, with the goals of hemodynamic stabilisation, minimising the extent of the dissection and decreasing the risk of rupture. However, type B aortic dissection, even the uncomplicated type, in pregnant women may require early and aggressive obstetric interventions to improve maternal and foetal prognoses.
10.1016/j.crwh.2021.e00342
Maternal and fetal outcomes in pregnancies complicated by Marfan syndrome.
Cauldwell Matthew,Steer Philip J,Curtis Stephanie L,Mohan Aarthi,Dockree Samuel,Mackillop Lucy,Parry Helen M,Oliver James,Sterrenberg Monique,Wallace Suzanne,Malin Gemma,Partridge Gemma,Freeman Leisa J,Bolger Aidan P,Siddiqui Farah,Wilson Dirk,Simpson Margaret,Walker Niki,Hodson Ken,Thomas Katherine,Bredaki Foteini,Mercaldi Rebecca,Walker Fiona,Johnson Mark R
Heart (British Cardiac Society)
OBJECTIVES:Information to guide counselling and management for pregnancy in women with Marfan syndrome (MFS) is limited. We therefore conducted a UK multicentre study. METHODS:Retrospective observational study of women with MFS delivering between January 1998 and March 2018 in 12 UK centres reporting data on maternal and neonatal outcomes. RESULTS:In total, there were 258 pregnancies in 151 women with MFS (19 women had prior aortic root replacements), including 226 pregnancies ≥24 weeks (two sets of twins), 20 miscarriages and 12 pregnancy terminations. Excluding miscarriages and terminations, there were 221 live births in 139 women. Only 50% of women received preconception counselling. There were no deaths, but five women experienced aortic dissection (1.9%; one type A and four type B-one had a type B dissection at 12 weeks and subsequent termination of pregnancy). Five women required cardiac surgery postpartum. No predictors for aortic dissection could be identified. The babies of the 131 (65.8%) women taking beta-blockers were on average 316 g lighter (p<0.001). Caesarean section rates were high (50%), particularly in women with dilated aortic roots. In 55 women, echocardiographic aortic imaging was available prepregnancy and postpregnancy; there was a small but significant average increase in AoR size of 0.84 mm (Median follow-up 2.3 months) CONCLUSION: There were no maternal deaths, and the aortic dissection rate was 1.9% (mainly type B). There with no identifiable factors associated with aortic dissection in our cohort. Preconception counselling rates were low and need improvement. Aortic size measurements increased marginally following pregnancy.
10.1136/heartjnl-2019-314817
Cardiac operation under cardiopulmonary bypass during pregnancy.
Liu Yanli,Han Fengzhen,Zhuang Jian,Liu Xiaoqing,Chen Jimei,Huang Huanlei,Wang Sheng,Zhou Chengbin
Journal of cardiothoracic surgery
BACKGROUND:Certain pregnant women suffer from cardiac pathology,and a few of them need cardiac operations under cardiopulmonary bypass during pregnancy. Feto-neonatal and maternal outcomes have not been sufficiently described. METHODS:We conducted a retrospective review of 22 cases of women undergoing cardiac operations under cardiopulmonary bypass during pregnancy in our hospital from Jan.2014 to Mar.2019. RESULTS:All 22 patients were alive after treatment. The types of cardiac disorders included congenital heart defects, rheumatic heart disease,infective endocarditis,aortic dissection, obstruction and/or thrombosis of a prosthetic valve. Only one case was a twin pregnancy,and the other 21 cases were singletons. Four fetuses died in the utero after surgery. Three patients chose termination of the pregnancy after the cardiac operations: one fetus was detected abnormity of the brain and the other two patients abandoned pregnancy. Fourteen fetuses were alive and born without any abnormity. Two fetuses suffered from neonatal intracranial hemorrhage and died after birth. CONCLUSIONS:Cardiac operation under cardiopulmonary bypass during pregnancy is a challenge for physicians in multidisciplinary teams. Strictly evaluating the indication is vital. On the other hand, some patients can benefit from this management.
10.1186/s13019-020-01136-9
Surgical treatment of acute aortic dissection Stanford type A in the third trimester of pregnancy: A case report.
Case reports in women's health
BACKGROUND:Aortic dissection is rare in pregnancy, but it is often life-threatening. Thus, early diagnosis and optimal treatment are crucial. In addition, regular multidisciplinary care plays an important role in improving the therapeutic outcome. CASE:A 31-year-old pregnant woman (gravida 2, para 1, abortus 0) was transferred to our centre at 34 weeks of gestation with onset of dyspnoea and serious chest pain radiating to her back. Ultrasonography unexpectedly revealed a dilation of the aortic root with a sign of dissection. Computed tomography confirmed a type A aortic dissection based on the Stanford classification. She was successfully treated by caesarean section prior to open repair of acute type A dissection and received multidisciplinary care. The patient was discharged on the 16th postoperative day, and the baby is still alive without adverse events. CONCLUSION:Aortic dissection in pregnancy is relatively rare, but physicians should be on high alert for the condition when a pregnant woman has chest pain. Early diagnosis and adequate treatment in addition to regular multidisciplinary care are crucial to achieve favourable results.
10.1016/j.crwh.2019.e00163
Successful repair of acute type A aortic dissection during pregnancy at 16 gestational week with maternal and fetal survival: A case report and review of the literature.
Chen Su-Wei,Zhong Yong-Liang,Ge Yi-Peng,Qiao Zhi-Yu,Li Cheng-Nan,Zhu Jun-Ming,Sun Li-Zhong
World journal of clinical cases
BACKGROUND:Aortic dissection during pregnancy is a rare but life-threatening event for mothers and fetuses. It often occurs in the third trimester of pregnancy and the postpartum period. Most patients have connective tissue diseases such as Marfan syndrome. Thus, the successful repair of a sporadic aortic dissection with maternal and fetal survival in the early second trimester is extremely rare. CASE SUMMARY:A 28-year-old woman without Marfan syndrome presented with chest pain at the 16 gestational week. Aortic computed tomographic angiography confirmed an acute type A aortic dissection (TAAD) with aortic arch and descending aorta involvement. Preoperative fetal ultrasound confirmed that the fetus was stable in the uterus. The patient underwent total arch replacement with a frozen elephant trunk using moderate hypothermic circulatory arrest with the fetus . The patient recovered uneventfully and continued to be pregnant after discharge. At the 38 gestational week, she delivered a healthy female infant by cesarean section. After 2.5 years of follow-up, the patient is uneventful and the child's development is normal. CONCLUSION:A fetus in the second trimester may have a high possibility of survival and healthy growth after aortic arch surgery.
10.12998/wjcc.v7.i18.2843
[Clinical analysis of 11 cases of pregnancy with aortic dissection].
Zhonghua fu chan ke za zhi
To investigate the treatment and maternal and fetal outcomes of pregnant women with aortic dissection (AD). The clinical data of 11 pregnant women with AD treated at the First Affiliated Hospital of Air Force Military Medical University from January 1st, 2011 to August 1st, 2022 were collected, and their clinical characteristics, treatment plans and maternal and fetal outcomes were analyzed retrospectively. (1) Clinical characteristics: the age of onset of 11 pregnant women with AD was (30±5) years old, and the week of pregnancy of onset was (31.4±8.0) weeks. Clinical manifestations: the main symptoms were sudden onset of chest and back pain or low back pain. Type of AD: 8 cases of Stanford type A, and 3 cases of type B. The aortic width was (42±11) mm. Diagnostic methods: the diagnosis of AD was confirmed by transthoracic echocardiography (TTE), computed tomography angiography (CTA) or enhanced CT examination, among which 4 cases were confirmed by CTA examination, 4 cases by TTE examination, and 3 cases by enhanced CT examination. Laboratory results: white blood cell count was (15.4±8.7) ×10/L, neutrophil count was (13.5±8.5) ×10/L, the median D-dimer level was 2.7 mg/L (2.1-9.2 mg/L), and the median fibrin degradation products level was 12.0 mg/L (5.4-36.1 mg/L). (2) Treatments: all 11 patients were admitted to hospital in emergency. Before operation, the departments of cardiac surgery, obstetrics, pediatrics and anesthesiology cooperated to develop individualized treatment plan. Aortic surgery was performed in 11 pregnant women with AD. In 6 of them, pregnancy termination was performed at the same time as aortic surgery, and aortic surgery was performed after cesarean section. Four cases of pregnancy termination and aortic operation were performed by stages, including aortic operation after cesarean section in 2 cases, and cesarean section after aortic operation in 2 cases. One case (12 weeks of gestation) had spontaneous abortion on the day after aortic surgery. The gestational age of the 11 patients on pregnancy termination was (32.9±7.4) weeks. Aorta surgical methods: 7 patients received under extracorporeal circulation ascending aorta replacement ± aortic valve replacement ± coronary artery transplantation (or coronary artery bypass transplantation)± left and right coronary Cabrol + total arch replacement (or aortic arch replacement)± stent implantation, 1 patient received under extracorporeal circulation aortic root replacement, and 3 patients underwent aortic endoluminal isolation. (3) Maternal and fetal outcomes: among the 11 pregnant women with AD, 9 (9/11) survived, 2 (2/11) died with lower limb ischemia before the onset of the disease. A total of 10 newborns were born in 9 pregnant women after delivery (1 of them was twins), and the 2 cases were spontaneous abortion after aortic surgery in the first trimester (12 weeks) and fetal death after hysterotomy in the second trimester (26 weeks), respectively. Among the 10 surviving neonates, 3 were full-term infants and 7 were premature infants. The birth weight of newborn was (2 651±784) g. Respiratory distress syndrome was found in 6 cases. The newborns were followed up for (5.6±3.6) years after birth, and the infants developed well during the follow-up period. Pregnancy complicated with AD is dangerous, and chest and back pain is the main clinical manifestation of this disease. With early identification and selection of appropriate diagnostic methods, multidisciplinary diagnosis and treatment, mother and children could obtain good outcomes.
10.3760/cma.j.cn112141-20221130-00724
In-hospital outcomes and long-term survival of women of childbearing age with aortic dissection.
Rommens Kenton L,Sandhu Harleen K,Miller Charles C,Cecchi Alana C,Prakash Siddharth K,Saqib Naveed U,Charlton-Ouw Kristofer M,Milewicz Dianna M,Estrera Anthony L,Safi Hazim J,Afifi Rana O
Journal of vascular surgery
OBJECTIVE:In the present study, we defined the outcomes and effects of pregnancy in a cohort of women of childbearing age with acute aortic dissection (AAD). METHODS:We reviewed our database of AAD to identify all eligible female patients. Women aged <45 years were included. Data on pregnancy timing with respect to the occurrence of dissection, the demographic data, dissection extent, dissection treatment, dissection-related outcomes, overall maternal and fetal mortality, and genetic testing results were analyzed. RESULTS:A total of 62 women aged <45 years had presented to us with AAD from 1999 to 2017. Of the 62 women, 37 (60%) had had a history of pregnancy at AAD. Of these 37 patients, 10 (27%) had had a peripartum aortic dissection, defined as dissection during pregnancy or within 12 months postpartum. Of the 10 AADs, 5 were type A and 5 were type B. Three patients had presented with AAD during pregnancy (one in the second and two in the third trimester). Five patients (50%) had developed AAD in the immediate postpartum period (within 3 months) and two (20%) in the late postpartum period. For the immediate postpartum AADs (<3 months), four of the five patients delivered via cesarean section. Of these 10 peripartum AADs, 3 (30%) had occurred in patients with known Marfan syndrome. In-hospital mortality for those with peripartum AAD was 10% (1 of 10). Fetal mortality was 20% (2 of 10). CONCLUSIONS:The frequency of aortic dissection in women of childbearing age at our institution was low. However, pregnancy might increase the risk of those young women genetically predisposed to dissection events. From these data, this risk appears to be greatest in the immediate postpartum period, even for those who undergo cesarean section. Close clinical and radiographic surveillance is required for all women with suspected aortopathy, especially in the third trimester and early postpartum period.
10.1016/j.jvs.2021.03.028
Successful Outcomes following Repair of a Type A Aortic Dissection during Pregnancy.
Akhmerov Akbarshakh,D'Attellis Nicola,Shah Aamir S
Aorta (Stamford, Conn.)
Type A aortic dissections during pregnancy are rare but lethal events, with reported mortalities as high as 60%. Unique changes in hemodynamics, hormone-related alterations in aortic tissue, and preexisting risk factors place patients at an elevated risk for dissection. We report a successful repair of a Type A aortic dissection at 32 weeks of gestation, with excellent outcomes in both mother and child. This report highlights the importance of gestational age and multidisciplinary effort.
10.1055/s-0040-1701605
Pregnancy complicated with aortic dissection: Two cases report.
Medicine
RATIONALE:This study aims to investigate the characteristics of pregnancy complicated with aortic dissection (AD), diagnosis and treatment plan, and maternal and infant outcomes. PATIENT CONCERNS:Two pregnant women suffered persistent back pain were admitted to Hubei Maternal and Child Health Hospital from December 2019 to December 2020. DIAGNOSIS:Pregnant women with chest and back pain and especially hypertension should be highly suspected of AD. However, to confirm diagnosis results, laboratory tests such as D-dimer, fibrinogen and white blood cells, and even some Special examination, cardiac ultrasound, computed tomographic angiography (CTA), magnetic resonance angiography (MRA), are required. Early diagnosis and intervention can improve maternal and infant outcomes. INTERVENTIONS:Cesarean sections were performed in both patients. Case 1 underwent thoracic aortic stent implantation one day after the onset of AD symptoms. Case 2 received endovascular repair of AD 4 days after the onset of AD symptoms. OUTCOMES:In these two cases, good maternal and infant outcomes were obtained through effective early identification and treatment. LESSONS:AD is characterized with an acute onset, and the rates of misdiagnosis and missed diagnosis are high, which seriously endangers the life of mother and child. Hypertension is one of the high-risk factors causing AD. Good maternal and infant outcomes can be achieved by early identification, multidisciplinary collaboration and timely cardiac surgical intervention.
10.1097/MD.0000000000031487
[The treatment strategy and outcome of pregnancy complicated with Stanford type A aortic dissection].
Lin P R,Zhao L Y,Ma J
Zhonghua yi xue za zhi
To summarize the clinical characteristics and surgical treatment experience of pregnant women with acute Stanford type A aortic dissection.We collected the clinical data of 12 cases with acute aortic dissection during pregnancy and puerperal period from June 2010 to July 2020 in Beijing Anzhen Hospital and analyzed retrospectively, and summarize the clinical characteristics, treatment and outcomes for both mother and fetus. The age of these patients was(29±5)years old, and the onset time was from 16 weeks of gestation and 1 month after delivery. All the 12 patients underwent surgical treatment. The patients in the puerperium received aortic surgery after delivery. Four of them received the aortic surgery and continued pregnancy. Five of them underwent aortic repair and cesarean section simultaneously. Surgical treatment should be actively considered in pregnancy complicated with acute Stanford type A aortic dissection. Multi-disciplinary team cooperation can effectively improve the safety of the patients and fetus.
10.3760/cma.j.cn112137-20210124-00230
Acute Aortic Dissection during Pregnancy: Hideous Clinical Quandaries with Young Lives on the Line-The Role of Hereditary Genetic Syndromes.
Journal of clinical medicine
Acute aortic dissection is a rare but frequently fatal aortic catastrophe with high morbidity and mortality. Especially in pregnant patients, acute dissection is often misdiagnosed putting two lives on the line. Due to its scarcity, only case reports have been reported. The aim of this study is to analyze the time of aortic dissection during the course of pregnancy and the outcome of emergency surgery in pregnant women with and without hereditary connective tissue disorder. We retrospectively reviewed all acute aortic dissections (type A and B) who underwent emergency aortic surgery at our institution between 1994 and 2022 and identified 13 patients with acute aortic dissection during pregnancy or directly postpartum. Mann-Whitney U and Fisher's exact tests were used for statistical analysis. Of the 13 included patients, 5 had a genetic syndrome. These patients were significantly younger at the time of dissection and at an earlier stage of pregnancy (second trimester). Even though operative and in-house mortality was zero, we lost one patient on postoperative day 14 due to rupture of the aortic root after transfer to another hospital. Survival of neonates was 77% including two aborted pregnancies. : Surgical treatment of acute aortic dissection during pregnancy can be performed with excellent operative mortality for the mothers and satisfying survival of their neonates. In patients with genetic syndrome, dissection occurs during the early second trimester, whereas non-syndromic patients experience acute dissection in the late third trimester. Long-term follow-up is essential for timely re-intervention, if needed.
10.3390/jcm13164901
Postpartum aortic dissection. A case report and review of literature.
Silvestri Valeria,Mazzesi Giuseppe,Mele Rita
International journal of surgery case reports
INTRODUCTION:Aortic dissection is a rare cardiovascular complication in pregnancy. Most of the cases occur during the third trimester of pregnancy, whilst 33% of cases are reported during the postpartum period. PRESENTATION OF CASE:We report the case of a multiparous 35-year-old patient with gestational hypertension treated for a type A aortic dissection on the second postpartum day. A review of literature on non-syndromic sporadic aortic dissection during the postpartum period is presented. DISCUSSION:Aortic complications in pregnancy have been described in genetic syndromes or congenital aortic malformations but may also be non -syndromic and occur in the absence of any other risk factor. Pregnancy carries a 25-fold increase in relative risk for dissection. A review of the 16 cases published in literature from 1995 to December 2016 of non-syndromic, sporadic aortic dissections in pregnancy showed that the event may occur more frequently in the first week post-partum, be symptomatic for thoracic pain or dyspnoea. Type A aortic dissection accounts to 75% of cases. Mortality, despite surgical treatment, has been reported in 4 cases. CONCLUSIONS:Even though rarely reported, given the increasing incidence and the high mortality of aortic dissection in pregnancy, along with the potential challenge for two lives, clinician must consider aortic dissection in post-partum while dealing with differential diagnosis in post-partum patients in the emergency setting.
10.1016/j.ijscr.2019.02.018
Cardiopulmonary bypass of acute type A aortic dissection during pregnancy at the 20th gestational week with maternal and foetal survival: A case report.
Perfusion
BACKGROUND:Type A acute aortic dissection, an aggressive and highly fatal disease, is particularly common among pregnant women and foetuses. This disease often occurs during the third trimester of pregnancy and the postpartum period. CASE REPORT:This case involves a female who was 20 weeks pregnant with type A acute aortic dissection. While maintaining pregnancy, the patient underwent Bentall surgery and Sun's procedure. The duration of circulatory arrest was a brief 4 min. The patient fully recovered 40 days after surgery and remained pregnant post-discharge. At the 38th gestational week, she delivered a healthy male infant via caesarean section. CLINICAL DISCUSSION:Gestational morbidity can have a serious impact on the safety of mothers and children. Currently, the shortest time reported for hypothermic circulatory arrest is 5 min. In this case, the lower body circulatory arrest was controlled to approximately 4 min during cardiopulmonary bypass while simultaneously safeguarding both individuals. Ideal strategies for cardiopulmonary bypass to reduce foetal risk include shorter cardiopulmonary bypass times, higher flow rates, and higher perfusion pressures. A reduction in the duration of hypothermic circulatory arrest further increases foetal survival rates. CONCLUSIONS:The development of a rational cardiopulmonary bypass plan should be tailored to the physiological characteristics of the pregnant woman to ensure the safety of both the pregnant woman and the foetus, reduce complications, and improve the success rate of the operation.
10.1177/02676591241297319
Aortic aneurysm and dissection in pregnancy: A case report.
Case reports in women's health
We describe a 24-year-old pregnant woman at 34 weeks of gestation who presented to a community hospital with sharp chest pain radiating to her back. She was found to have a 6 cm ascending aortic aneurysm despite not having any established risk factors. She was transported by air ambulance to a tertiary-care hospital. She delivered a live female neonate via cesarean delivery. Her postpartum course was notable for multiple episodes of chest pain and multiple imaging studies that were read as negative for aortic dissection. Definitive valve surgery was postponed by the cardiothoracic surgeons to allow for recovery from severe preeclampsia, treatment of endometritis, and due to concerns for uterine bleeding while on anticoagulation during cardiopulmonary bypass. She was eventually transferred to another hospital in another state for valve-sparing surgery. During transport, she developed a pulmonary embolism, and after arrival an aortic dissection was confirmed. She received a mechanical aortic valve replacement and the aneurysm was repaired. She returned home and recovered without complication. A gene panel revealed a heterozygous pathogenic variant of the Filamin A gene. Aortic aneurysms during pregnancy are rare, and aortic dissections are more rare. We recommend expeditious surgical treatment, a heightened index of suspicion, and testing for a genetic cause of aneurysm when diagnosed in a pregnant or postpartum woman with no known risk factors.
10.1016/j.crwh.2020.e00261
Outcomes of acute type A aortic dissection repair during pregnancy.
International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics
OBJECTIVE:To evaluate the efficacy and safety of performing cesarean section surgery before aortic repair after acute type A aortic dissection (ATAAD) during pregnancy. METHODS:A total of six patients who received ATAAD repair during their pregnancies were retrospectively identified in the hospital database from January 2002 to December 2021. RESULTS:The mean gestational period at the time of aortic repair was 35.3 ± 2.7 weeks, and the aortic root diameter ranged from 40 to 60 mm. The mean time from disease onset to arrival at the operation room was 20.3 ± 10.8 h (range 10-36 h). All patients successfully received aortic repair operations following cesarean section and survived the peri-surgery period without developing major complications. All fetuses were successfully delivered. After an average follow up of 25.8 months, all patients and their children had survived without developing major complications except for one mother who committed suicide 6 months after discharge as a result of postpartum depression. CONCLUSION:The present study suggested that ATAAD repair can be safely performed in the third-trimester.
10.1002/ijgo.14586
Type A aortic dissection during in pregnancy: Confront without aversion or delay.
Idhrees Mohammed,Jubouri Matti,Bashir Mohamad,Velayudhan Bashi V
Journal of cardiac surgery
Type A aortic dissection (TAAD) is a life-threatening clinical emergency requiring timely surgical intervention. Concomitant with pregnancy at any stage, it adds an additional level of complexity which mandates careful planning for the management strategy that will yield the optimal outcomes. It is life-threatening pathology to both the mother and fetus, with mortality rates of up to 30% and 50% reported, respectively. Safe imaging modalities that do not expose the fetus to radiation and contrast are recommended to reach an accurate diagnosis. In addition, meticulous multidisciplinary team planning is pivotal to ensure optimal outcomes are achieved through careful choice of surgical technique as well as strict control of medications. Although TAAD in pregnancy is associated with high mortality and morbidity to both the mother and her fetus, success in the treatment of this small subset of patients can certainly be achieved.
10.1111/jocs.16446
Acute Type A Aortic Dissection and Late Pregnancy: What Should We Do?
Brazilian journal of cardiovascular surgery
INTRODUCTION:Acute type A aortic dissection (AAAD) in late pregnancy is a rare but severe disease. Lack of clinical experience is the main cause of high mortality. This study tries to investigate the multidisciplinary therapeutic strategy for these patients. CASE PRESENTATION:We reported three patients with AAAD in late pregnancy. Sudden chest pain was the main clinical symptom before operation. All three patients and their newborns survived through multidisciplinary approach in diagnosis and treatment. No serious complications occurred during the mid-term follow-up. CONCLUSION:Multidisciplinary diagnosis and treatment strategy play a crucial role in saving the lives of pregnant women with AAAD.
10.21470/1678-9741-2020-0670
Pregnancy, aortic events, and neonatal and maternal outcomes.
European heart journal
BACKGROUND AND AIMS:This study aimed to evaluate the association between pregnancy and aortic complications and determine related maternal and neonatal outcomes. METHODS:Records of pregnancies and neonatal deliveries from the Taiwan National Health Insurance Research Database from 2000 to 2020 were retrieved. The incidence rate ratio (IRR) was calculated to evaluate the risk factors for aortic events. Survival analysis was conducted to compare maternal and neonatal mortality with and without aortic events. RESULTS:A total of 4 785 266 pregnancies were identified among 2 833 271 childbearing women, and 2 852 449 delivered neonates. In the vulnerable and control periods, 57 and 20 aortic events occurred, resulting in incidence rates of 1.19 and 0.42 aortic events per 100 000 pregnancies, respectively. Pregnancy was established as a risk factor for aortic events (IRR: 2.86, P < .001). The 1-year maternal mortality rate was significantly higher in pregnancies with aortic events than in those without such events (19.3% vs. 0.05%, P < .001). Neonates whose mothers experienced aortic events had a higher late mortality (6.3% vs. 0.6%, P < .001). CONCLUSIONS:The association between pregnancy and aortic events was established in this study. The results revealed that women are at risk of aortic events from the gestational period to 1-year postpartum. Maternal mortality was significantly higher in pregnancies with aortic events than in those without. A higher late mortality and more complications were noted for neonatal deliveries with maternal aortic events. Early awareness of pregnant women at risk of aortic events-especially those with concomitant hypertensive disorders of pregnancy, contributive family histories, or aortopathy-is crucial.
10.1093/eurheartj/ehae757
Obstetric considerations for aortopathy in pregnancy.
Annals of cardiothoracic surgery
Aortic dissection (AD) associated with pregnancy can have catastrophic consequences for the mother and/or fetus. AD occurs in 4-5 per 1,000,000 pregnancies and, despite its rarity, is the third most frequent maternal cardiovascular cause of death. AD associated with pregnancy is most likely to occur in the third trimester or postpartum period. In individuals with genetic aortopathy, pregnancy is considered a high-risk time for AD. There are management strategies in the preconception, antepartum, delivery and postpartum periods to optimize patient care. A multi-disciplinary team that includes capability to perform cardiovascular surgery is critical. Imaging modalities including maternal echocardiogram and magnetic resonance imaging can be safely performed in pregnancy for surveillance of the aortic size. Computed tomography (CT) scan is reserved for scenarios where there is a high index of suspicion for AD in a pregnant person to limit fetal exposure to radiation. After counseling about the potential risks of a pregnancy, the decision to pursue pregnancy is ultimately at the discretion of the individual. The duty of the cardio-obstetric team is to ensure that the patient and their family understand the risks of a pregnancy and the plan of care.
10.21037/acs-2023-adw-0164
Aortic dissection during pregnancy and puerperium: A Japanese nationwide survey.
Tanaka Hiroaki,Kamiya Chizuko A,Horiuchi Chinami,Morisaki Hiroko,Tanaka Kayo,Katsuragi Shinji,Hayata Eijiro,Hasegawa Junichi,Nakata Masahiko,Sekizawa Akihiko,Ishiwata Isamu,Ikeda Tomoaki
The journal of obstetrics and gynaecology research
AIM:This study aimed to characterize the incidence and clinical significance of pregnancy-related aortic dissection using a large-scale survey in Japan. METHODS:A questionnaire requesting the detailed information included in the clinical charts of pregnancy-related aortic dissection cases (without any personally identifying information) was designed between 2013 and 2017 and administered to 407 perinatal centers in Japan. The response rate was 70.5%. Seventeen cases of pregnancy-related aortic dissection were identified. RESULTS:Maternal death due to aortic dissection was observed in nine patients (56.2%) while seven survived (43.8%). Dissection occurred during the postpartum period in 10 cases (62.5%), the third trimester in 4 (25.0%), labor in 1 (6.2%), and the second trimester in 1 (6.2%). The most common underlying diseases were: Marfan syndrome (25.0%), Loeys-Dietz syndrome (6.2%), hypertension (6.2%), and Takayasu aortitis (6.2%). Stanford type A aortic dissection was associated with maternal death during both pregnancy and the postpartum period. However, deceased patients showed lower rates of pre-diagnosed connective tissue disease than did survivors. CONCLUSIONS:The mortality rate of aortic dissection that occurred during pregnancy or postnatal periods was more than 50%. Aortic dissection occurred more frequently in the postnatal period than during pregnancy, and less frequently in women previously diagnosed with connective tissue disease than in women without any medical history of aortic disorders. If symptoms suggestive of aortic dissection, such as severe back pain, are observed, even after the end of pregnancy, exhaustive diagnostic examinations should be carried out.
10.1111/jog.14657
Aortopathy in pregnancy.
Heart (British Cardiac Society)
Aortic dissection is one of the most common causes of death in pregnancy. Most cases are caused by hereditary thoracic aortopathy (HTA), and women are often unaware they are at risk. Awareness, early recognition and involvement of senior clinicians from the expert cardio-obstetric team are essential to facilitate early diagnosis and carefully planned and coordinated antenatal and postnatal care. Frequent imaging antenatally and good blood pressure control are key. Delivery needs particular attention with optimal pain control and techniques to minimise maternal effort. Dissection is most common post partum and a period of close surveillance with meticulous blood pressure control after delivery is crucial, as well as follow-up of the baby in paediatric services. All women with a family history of aortic dissection or sudden death should be investigated. Women with known HTA should be offered specialist individualised pre-pregnancy counselling, including advice about genetics and inheritance, before starting a family. Future research is directed towards more individualised risk assessment, pre-pregnancy advice and pharmacological options to reduce dissection risk.
10.1136/heartjnl-2021-319828
Acute aortic dissection during pregnancy: Trials and tribulations.
Rimmer Lara,Heyward-Chaplin Jessica,South Matthew,Gouda Mohamed,Bashir Mohamad
Journal of cardiac surgery
BACKGROUND:Type A acute aortic dissection (TAAD) during pregnancy is a life-threatening event for both the mother and the unborn baby. Pregnancy has been recognized as an independent risk factor for TAAD, postulated to be due to physiological changes that cause hyperdynamic circulation. This review seeks to outline the current controversies around this unique group. METHODS:A comprehensive literature search was carried out across large databases to assimilate relevant papers regarding acute aortic dissection in pregnant women. RESULTS:The presentation can be atypical in many cases and further concern from clinicians of fetal radiation exposure can result in missed or delayed diagnoses. Investigation via the quickest form of imaging, whether computed tomography, magnetic resonance imaging, or transesophageal echocardiography, should be carried out promptly due to the high risk of mortality. Surgical management of TAAD in pregnancy revolves primarily around the decision to deliver the fetus concomitantly or to perform the aortic repair with the fetus in utero. CONCLUSIONS:Management of this group includes rapid and dynamic assessment without delay. From conception to postpartum, there are multiple stages in which to manage these women. Challenges in carrying out management in the form of operative techniques and cardiopulmonary bypass place the fetus at risk and must be approached with caution, particularly as there is little evidence-base for many of these decisions. Further research into reducing maternal and fetal mortality is necessary.
10.1111/jocs.15068
Pregnancy and cardiovascular disease.
Ramlakhan Karishma P,Johnson Mark R,Roos-Hesselink Jolien W
Nature reviews. Cardiology
Cardiovascular disease complicates 1-4% of pregnancies - with a higher prevalence when including hypertensive disorders - and is the leading cause of maternal death. In women with known cardiovascular pathology, such as congenital heart disease, timely counselling is possible and the outcome is fairly good. By contrast, maternal mortality is high in women with acquired heart disease that presents during pregnancy (such as acute coronary syndrome or aortic dissection). Worryingly, the prevalence of acquired cardiovascular disease during pregnancy is rising as older maternal age, obesity, diabetes mellitus and hypertension become more common in the pregnant population. Management of cardiovascular disease in pregnancy is challenging owing to the unique maternal physiology, characterized by profound changes to multiple organ systems. The presence of the fetus compounds the situation because both the cardiometabolic disease and its management might adversely affect the fetus. Equally, avoiding essential treatment because of potential fetal harm risks a poor outcome for both mother and child. In this Review, we examine how the physiological adaptations during pregnancy can provoke cardiometabolic complications or exacerbate existing cardiometabolic disease and, conversely, how cardiometabolic disease can compromise the adaptations to pregnancy and their intended purpose: the development and growth of the fetus.
10.1038/s41569-020-0390-z
Acute Type-B Aortic Dissection in Pregnancy: Therapeutic Challenges in a Multidisciplinary Setting.
Patel Prakash A,Fernando Rohesh J,Augoustides John G,Yoon Jeongae,Gutsche Jacob T,Feinman Jared W,Zhou Elizabeth,Weiss Stuart J,Hamburger Joshua,Evans Adam S,Aljure Oscar,Fabbro Michael
Journal of cardiothoracic and vascular anesthesia
10.1053/j.jvca.2017.03.011
Aortic Dissection During Pregnancy and Puerperium: Contemporary Incidence and Outcomes in the United States.
Journal of the American Heart Association
Background Aortic dissection (AD) during pregnancy and puerperium is a rare catastrophe with devastating consequences for both parent and fetus. Population-level incidence trends and outcomes remain relatively undetermined. Methods and Results We queried a US population-based health care database, the National Inpatient Sample, and identified all patients with a pregnancy-related AD hospitalization from 2002 to 2017. In total, 472 pregnancy-related AD hospitalizations (mean age, 30.9±0.6 years) were identified from 68 514 000 pregnancy-related hospitalizations (0.69 per 100 000 pregnancy-related hospitalizations), with 107 (22.7%) being type A and 365 (77.3%) being type B. The incidence of AD appeared to increase over the 16-year study period but was not statistically significant ( for trend >0.05). Marfan syndrome, primary hypertension, and preeclampsia/eclampsia were found in 21.9%, 14.4%, and 11.5%, respectively. On multivariable logistic regression analysis, Marfan syndrome was associated with the highest risk of developing AD during pregnancy and puerperium (adjusted odds ratio, 3469.36 [95% CI, 1767.84-6831.75]; <0.001). The in-hospital mortalities of AD, type A AD, and type B AD were 7.3%, 4.3%, and 8.1%, respectively. Length of hospital stay for the AD, type A AD, and type B AD groups were 7.7±0.8, 10.4±1.9, and 6.9±0.9 days, respectively. Conclusions We quantified population-level incidence and in-hospital mortality in the United States and observed an increase in the incidence of pregnancy-related AD. In contrast, its in-hospital mortality appears lower than that of non-pregnancy-related AD.
10.1161/JAHA.122.028436
A patient with Marfan's syndrome who developed an acute aortic dissection at 28 weeks of pregnancy treated with aortic root replacement.
General thoracic and cardiovascular surgery
The patient was a 31-year-old pregnant woman who gave birth to her first child by vaginal delivery 7 years ago. She was diagnosed with Marfan's syndrome based on physical findings; however, the condition was not diagnosed before the onset. The patient developed acute aortic dissection at 28 weeks of pregnancy. A cesarean section was first performed to save the patient's life; then, a total hysterectomy was performed to prevent the risk of postpartum hemorrhage. Furthermore, aortic root replacement was performed using a temporary mechanical valve. The patient and her child have survived without any complications.
10.1007/s11748-021-01596-3
Pernicious pregnancy: Type B aortic dissection in pregnant women.
Rimmer Lara,Mellor Sophie,Harky Amer,Gouda Mohamed,Bashir Mohamad
Journal of cardiac surgery
BACKGROUND:Type B aortic dissection (TBAD) occurs seldomly, particularly in pregnancy, but has disastrous consequences for both mother and fetus. The focus of immediate surgical repair of type A aortic dissection due to higher mortality of patients is less clear in its counterpart, TBAD, in which management is controversial and debated. This article collates knowledge so far on this rare event during pregnancy. METHODS:A comprehensive literature search was performed in PubMed, Scopus, Google Scholar, Embase, and Medline. Key search terms included "type B aortic dissection," "pregnancy," and corresponding synonyms. Non-English papers were excluded. RESULTS:Risk factors for TBAD include aortic wall stress due to hypertension, previous cardiac surgery, structural abnormalities (bicuspid aortic valve, aortic coarctation), and connective tissue disorders. In pregnancy, pre-eclampsia is a cause of increased aortic wall stress. Management of this condition is often conservative, but this is dependent on a number of factors, including gestation, cardiovascular stability of the patient, and symptomology. In most cases, a cesarean section before intervention is carried out unless certain indications are present. CONCLUSIONS:Due to a scarce number of cases across the decades, it is difficult to determine which management is optimal. The gold-standard management of TBAD has traditionally been the medical treatment for uncomplicated cases and open surgery for those needing urgent intervention, but with the advent of techniques, such as thoracic endovascular aortic repair, the management of these group of patients continues to develop.
10.1111/jocs.15354
Aortic dissection during pregnancy and postpartum in patients with Marfan syndrome: a 21-year clinical experience in 30 patients.
Ma Wei-Guo,Zhu Jun-Ming,Chen Yu,Qiao Zhi-Yu,Ge Yi-Peng,Li Cheng-Nan,Zheng Jun,Liu Yong-Min,Sun Li-Zhong
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery
OBJECTIVES:Pregnancy-related aortic dissection (AoD) in Marfan syndrome is a lethal catastrophe. Due to its rarity and limited clinical experience, there is no consensus regarding the optimal management strategy. We seek to present our 21-year experience in such patients , focusing on management strategies and early and late outcomes. METHODS:Between 1998 and 2019, we managed 30 pregnant women with Marfan syndrome (mean age 30.7 ± 4.3 years) who sustained AoD at a mean of 28.3 ± 8.8 weeks of gestation (GWs). AoD was acute in 21 (70%), type A (TAAD) in 24 (80%) and type B (TBAD) in 6 (20%). Fourteen TAADs (58.3%, 14/24) and 2 TBADs (33.3%, 2/6) occurred in the third trimester or postpartum. The maximal aortic size was < 45 mm in 26.7% (8/30; 3 TAADs, 5 TBADs). Management strategy was based on the types of dissection and GWs (i.e. surgical versus medical treatment, surgery or delivery first). RESULTS:TAADs were treated medically in 1 and surgically in 23. The timing of delivery and surgery were caesarean first at 35.4 ± 6.1 GWs in 7 (29.2%), followed by surgery after mean 46 days; single-stage C-section and surgery at 32.0 ± 5.0 GWs in 10 (41.7%); and surgery first at 18.0 ± 5.8 GWs in 6 (25%), followed by C-section after 20 days. Maternal and foetal mortality were 28.6% (2/7) and 14.3% (1/7), 10.0% (1/10) and 20.0% (2/10) and 16.7% (1/6) and 83.3% (5/6), respectively. Five TBADs (83.3%) were managed with C-section followed by surgery in 2 and medical treatment in 3. The respective maternal and foetal mortality were 50% (1/2) and 100% (2/2) and 33.3% (1/3) and 33.3% (1/3), respectively. One TBAD was managed surgically first followed by C-section, resulting in maternal survival and foetal death. Follow-up was complete in 95.8% (23/24) at 3.7 ± 2.9 years. Four late deaths occurred and reoperation was performed in 1 patient. Maternal and foetal survival were 64.3% and 54.1% at 6 years, respectively. CONCLUSIONS:Management of AoD in pregnant women with Marfan syndrome should be based on types of dissection (surgical versus medical) and gestational age (delivery or surgery first), which largely determine maternal and foetal survival. Aortic repair should be considered prior to conception in women with Marfan syndrome even at diameters smaller than recommended by current guidelines.
10.1093/ejcts/ezaa048
Pregnancy-associated arterial dissections: a nationwide cohort study.
Beyer Sebastian E,Dicks Andrew B,Shainker Scott A,Feinberg Loryn,Schermerhorn Marc L,Secemsky Eric A,Carroll Brett J
European heart journal
AIMS:Pregnancy is a known risk factor for arterial dissection, which can result in significant morbidity and mortality in the peripartum period. However, little is known about the risk factors, timing, distribution, and outcomes of arterial dissections associated with pregnancy. METHODS AND RESULTS:We included all women ≥12 years of age with hospitalizations associated with pregnancy and/or delivery in the Nationwide Readmissions Database between 2010 and 2015. The primary outcome was any dissection during pregnancy, delivery, or the postpartum period (42-days post-delivery). Secondary outcomes included timing of dissection, location of dissection, and in-hospital mortality. Among 18 151 897 pregnant patients, 993 (0.005%) patients were diagnosed with a pregnancy-related dissection. Risk factors included older age (32.8 vs. 28.0 years), multiple gestation (3.6% vs. 1.9%), gestational diabetes (14.3% vs. 0.2%), gestational hypertension (6.0% vs. 0.6%), and pre-eclampsia/eclampsia (2.7% vs. 0.4%), in addition to traditional cardiovascular risk factors. Of the 993 patients with dissection, 150 (15.1%) dissections occurred in the antepartum period, 232 (23.4%) were diagnosed during the admission for delivery, and 611 (61.5%) were diagnosed in the postpartum period. The most common locations for dissections were coronary (38.2%), vertebral (22.9%), aortic (19.8%), and carotid (19.5%). In-hospital mortality was 3.7% among pregnant patients with a dissection vs. <0.001% in patients without a dissection. Deaths were isolated to patients with an aortic (8.6%), coronary (4.2%), or supra-aortic (<2.5%) dissection. CONCLUSION:Arterial dissections occurred in 5.5/100 000 hospitalized pregnant or postpartum women, most frequently in the postpartum period, and were associated with high mortality risk. The coronary arteries were most commonly involved. Pregnancy-related dissections were associated with traditional risk factors, as well as pregnancy-specific conditions.
10.1093/eurheartj/ehaa497
Is female sex impactful in the pathophysiology, presentation, management, and outlook of type A acute aortic dissection?
European journal of preventive cardiology
Acute aortic dissection (AAD) is the most common acute aortic syndrome. It is a life-threatening condition and surgical emergency associated with high mortality if not treated promptly. While it is well established that cardiovascular disease recognises different pathophysiological pathways between men and women, there is limited evidence of sex differences in AAS, especially in type A AAD. According to a recent synthesis of clinical studies on gender differences in type A AAD, women were found to have different baseline characteristics, presentation and outcomes, and thus sex should be considered relevant for diagnosis, risk-stratification and management of type A AAD.
10.1093/eurjpc/zwad043
Aortic dissection during pregnancy - obstetric perspective.
Poniedzialek-Czajkowska Elzbieta,Sadowska Agata,Mierzynski Radzislaw,Leszczynska-Gorzelak Bozena
Ginekologia polska
The risk of vascular events during pregnancy is substantially increased. Beyond comparatively frequent vascular diseases, pregnancy may lead also to the development of exceptionally rare vascular events such as the aortic dissection and aortic rupture which are conceivably endangering life conditions. Women with the connective tissue disorders and with a family history of the aorta diseases are especially prone to the aortic complications which may also develop in the absence of these risk factors due to the pregnancy-induced structural changes of the aortic wall. The preconception counselling is vital for patients with aortopathies to assess the risk of the aortic dissection and to establish the most appropriate care plan including the surgical intervention. This review presents the management guidelines in patients with the aortic dissection risk during pregnancy.
10.5603/GP.2019.0052
[Clinical characteristics and placental pathology analysis of 14 cases of pregnancy with aortic dissection/aortic aneurysm].
Zhonghua bing li xue za zhi = Chinese journal of pathology
To investigate the pathological changes of placenta in pregnant women with aortic dissection/aneurysm and their relationship with clinical features. The placental samples of 14 pregnant women with aortic dissection/aneurysm diagnosed from January 2012 to October 2021 and 10 normal placental samples of pregnant women from January 2021 to December 2021 at Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, China were selected. Routine H&E staining and immunohistochemistry were used to analyze the histological features under light microscope. The clinical data were also analyzed. The age of 14 pregnant patients with aortic dissection/aneurysm for placental examination ranged from 22 to 38 years (median, 28 years). The gestational ages ranged from 22 to 39 weeks (median, 34 weeks). The pregnancy of second trimester was noted in 2 cases, and the third trimester in 12 cases. All cases were singleton pregnancy. Seven cases were Stanford type A aortic dissection, 6 cases were Stanford type B aortic dissection, and one case was aortic root aneurysm. Four of the pregnant women underwent aortic dissection surgery after caesarean section, three underwent caesarean section after aortic dissection surgery, and seven underwent both caesarean section and aortic dissection procedures. Among the newborns, 2 cases were full-term birth, and 12 cases were premature birth. Twelve cases had alive newborns, and 2 cases stillbirths. Fetal/placental weight ratio (FPR)<10th percentile was in 5 cases and FPR>90th percentile in one case. Compared with the normal group, accelerated villus maturation and distal villus dysplasia were more frequently found in pregnancy with aortic dissection group (0.05). There was no significant difference in villi infarction and decidua vascular lesions between the two groups (0.05), nor was there correlation between the type of aortic dissection and distal villus dysplasia and accelerated villus maturation of placentas (0.05). The number of villous interstitial blood vessels in the placentas of pregnancy with aortic dissection group was significantly fewer than that in the normal control group (0.01). There are considerable pathological changes in the placentas of pregnant women with aortic dissection/aneurysm. The main histological features are accelerated villus maturation and distal villus dysplasia, which are manifestations of villous ischemia and hypoxia, and also a part of the placental pathological manifestations of maternal vascular dysperfusion.
10.3760/cma.j.cn112151-20230129-00078
Differences among sexes in presentation and outcomes in acute type A aortic dissection repair.
The Journal of thoracic and cardiovascular surgery
OBJECTIVE:Female sex is a known risk factor in most cardiac surgery, including coronary and valve surgery, but unknown in acute type A aortic dissection repair. METHODS:From 1996 to 2018, 650 patients underwent acute type A aortic dissection repair; 206 (32%) were female, and 444 (68%) were male. Data were collected through the Cardiac Surgery Data Warehouse, medical record review, and National Death Index database. RESULTS:Compared with men, women were significantly older (65 vs 57 years, P < .0001). The proportion of women and men inverted with increasing age, with 23% of patients aged less than 50 years and 65% of patients aged 80 years or older being female. Women had significantly less chronic renal failure (2.0% vs 5.4%, P = .04), acute myocardial infarction (1.0% vs 3.8%, P = .04), and severe aortic insufficiency. Women underwent significantly fewer aortic root replacements with similar aortic arch procedures, shorter cardiopulmonary bypass times (211 vs 229 minutes, P = .0001), and aortic crossclamp times (132 vs 164 minutes, P < .0001), but required more intraoperative blood transfusion (4 vs 3 units) compared with men. Women had significantly lower operative mortality (4.9% vs 9.5%, P = .04), especially in those aged more than 70 years (4.4% vs 16%, P = .02). The significant risk factors for operative mortality were male sex (odds ratio, 2.2), chronic renal failure (odds ratio, 3.4), and cardiogenic shock (odds ratio, 6.8). The 10-year survival was similar between sexes. CONCLUSIONS:Physicians and women should be cognizant of the risk of acute type A aortic dissection later in life in women. Surgeons should strongly consider operations for acute type A aortic dissection in women, especially in patients aged 70 years or more.
10.1016/j.jtcvs.2021.03.078
Correlation between Sex and Prognosis of Acute Aortic Dissection in the Chinese Population.
Chinese medical journal
BACKGROUND:The prevalence, presentation, management, and prognosis of coronary heart disease differ according to sex. Greater understanding on the differences between men and women with acute aortic dissection (AAD) is needed. We aimed to investigate whether sex disparities are found in patients with AAD, and to study sex differences in complications, mortality in-hospital, and long-term. METHODS:We included 884 patients enrolled in our institute between June 2002 and May 2016. Considering psychosocial factors, treatments, and the outcomes in men versus those in women with AAD, we explored the association of sex with psychosocial characteristics and mortality risk. For categorical variables, significant differences between groups were assessed with the Chi-square test or Fisher's exact test, and continuous parameters were assessed with Student's t-test. Univariate and stratified survival statistics were computed using Kaplan-Meier analysis. RESULTS:A total of 884 patients (76.1% male, mean age 51.4 ± 11.8 years) were included in this study. There were fewer current smokers in female compared with male (17.5% vs. 67.2%, χ = 160.06, P < 0.05). The percentage of men who reported regular alcohol consumption was significantly higher than that in women (40.6% vs. 3.8%, χ = 100.18, P < 0.05). About 6.2% (55 of 884) of patients with AAD died before vascular or endovascular surgery was performed, 34.4% (304 of 884) of patients underwent surgical procedures, and 52.7% (466 of 884) and 12.8% (113 of 884) of patients received endovascular treatment and medication. Postoperative mortality similar (6.0% vs. 5.6%, respectively, χ = 0.03, P = 0.91) between men and women. Follow-up was completed in 653 of 829 patients (78.8%). Adjustment for age, history of coronary disease, hypertension, smoking and drinking, Type A and use of beta-blocker, angiotensin II receptor blockers, angiotensin converting enzyme (ACE) inhibitor, calcium-channel blockers and statins by multivariate logistic regression analysis suggested that age (odds ratios [OR s], 1.04; 95% confidence interval [CI], 1.01-1.07; P < 0.05), using of calcium-channel blockers (OR, 0.37; 95% CI, 0.18-0.74; P < 0.05), at discharge were independent predictors of late mortality, ACE inhibitors (OR, 1.91; 95% CI, 1.03-3.54; P = 0.04) was independent risk factor of late mortality. CONCLUSIONS:In Chinese with AAD, sex is not independently associated with long-term clinical outcomes. Age, the intake of calcium-channel blockers at discharge might help to improve long-term outcomes.
10.4103/0366-6999.233943
Clinical Features and Outcomes of Pregnancy-Related Acute Aortic Dissection.
Braverman Alan C,Mittauer Eric,Harris Kevin M,Evangelista Arturo,Pyeritz Reed E,Brinster Derek,Conklin Lori,Suzuki Toru,Fanola Christina,Ouzounian Maral,Chen Edward,Myrmel Truls,Bekeredjian Raffi,Hutchison Stuart,Coselli Joseph,Gilon Dan,O'Gara Patrick,Davis Melinda,Isselbacher Eric,Eagle Kim
JAMA cardiology
Importance:Women with aortopathy conditions are at risk for pregnancy-related aortic dissection, and these conditions may not be recognized until after the aortic dissection occurs. Objective:To examine the clinical characteristics, imaging features, and outcomes in women with pregnancy-related acute aortic dissection. Design, Setting, and Participants:A cohort study, comprising data from the International Registry of Acute Aortic Dissection (IRAD) (February 1, 1998, to February 28, 2018). The multicenter referral center study included 29 women with aortic dissection during pregnancy or less than 12 weeks post partum in IRAD from 1998 to 2018. Main Outcomes and Measures:Clinical features of pregnancy-related aortic dissection to be studied included underlying aortopathy, aortic size, type of aortic dissection, timing of dissection, hypertension, and previous aortic surgery. Results:A total of 29 women (mean [SD] age, 32 [6] years) had pregnancy-related aortic dissection, representing 0.3% of all aortic dissections and 1% of aortic dissection in women in the IRAD. Among women younger than 35 years, aortic dissection was related to pregnancy in 20 of 105 women (19%). Thirteen women (45%) had type A aortic dissection, and 16 women (55%) had type B. Aortic dissection onset was known in 27 women (93%): 15 during pregnancy, 4 in the first trimester, and 11 in the third trimester; 12 were post partum, occurring a mean (SD) of 12.5 (14) days post partum. At type A aortic dissection diagnosis, the mean (SD) aortic diameters were sinus of Valsalva, 54.5 (5) mm and ascending aorta, 54.7 (6) mm. At type B aortic dissection diagnosis, the mean (SD) descending aortic diameter was 32.5 (5) mm. Twenty women (69%) had an aortopathy condition or a positive family history: 13 women (65%) with Marfan syndrome, 2 women (10%) with Loeys-Dietz syndrome, 2 women (10%) with bicuspid aortic valves, 2 women (10%) with a family history of aortic disease, and 1 woman (5%) with familial thoracic aortic aneurysm. Aortopathy was not recognized until after aortic dissection in 47% of the women. Twenty-eight women (97%) survived aortic dissection hospitalization. Conclusions and Relevance:Aortic dissection complicating pregnancy is rare. Most pregnancy-related aortic dissection is due to an aortopathy often not diagnosed until after aortic dissection. In this study, type A aortic dissections were associated with a dilated aorta, and type B aortic dissections often were not. Recognition of underlying conditions and risks for aortic dissection may improve management of pregnancy in women with aortopathy.
10.1001/jamacardio.2020.4876
Antepartum acute Stanford type A aortic dissection: a case report and literature review.
Journal of cardiothoracic surgery
BACKGROUND:Aortic dissection in pregnancy is a life-threatening event that is associated with high maternal and foetal mortality. Most cases occur during the third trimester of pregnancy, Herein, we describe a case of a pregnant woman with acute type A aortic dissection at 28 weeks of gestation. CASE PRESENTATION:A previously healthy, 24-year-old gravida 2 para 1 woman was brought to the emergency department during at the 28 weeks of gestation and diagnosed with acute type A aortic dissection. Cesarean section was performed with the cardiac surgical team on standby for cardiopulmonary bypass and the patient delivered a baby weighing 1000 g. After the operation, we performed the Beatall procedure and total arch replacement with FET using the deep hypothermic circulatory arrest technique. Both the mother and child survived and recovered well. A review of the literature on antepartum acute aortic dissection during pregnancy is also presented. CONCLUSION:Women should have a comprehensive, systematic physical examination before getting pregnant. Women at high risks of aortic dissection must undergo multidisciplinary evaluation and be counseled before pregnancy, once they become pregnant, their consistent aortic root diameter should be consistently monitored, and their blood pressure strictly controlled.
10.1186/s13019-022-01817-7
Acute aortic dissection.
Lancet (London, England)
Although substantial progress has been made in the prevention, diagnosis, and treatment of acute aortic dissection, it remains a complex cardiovascular event, with a high immediate mortality and substantial morbidity in individuals surviving the acute period. The past decade has allowed a leap forward in understanding the pathophysiology of this disease; the existing classifications have been challenged, and the scientific community moves towards a nomenclature that is likely to unify the current definitions according to morphology and function. The most important pathophysiological pathway, namely the location and extension of the initial intimal tear, which causes a disruption of the media layer of the aortic wall, together with the size of the affected aortic segments, determines whether the patient should undergo emergency surgery, an endovascular intervention, or receive optimal medical treatment. The scientific evidence for the management and follow-up of acute aortic dissection continues to evolve. This Seminar provides a clinically relevant overview of potential prevention, diagnosis, and management of acute aortic dissection, which is the most severe acute aortic syndrome.
10.1016/S0140-6736(22)01970-5
Aortic dissection in pregnancy and the postpartum period.
Seminars in vascular surgery
Pregnancy-associated aortic dissection (AD) is a rare event, with an incidence of 0.0004% per pregnancy. The work of the Aortic Dissection Collaborative identified pregnancy-associated AD as a high-priority topic, despite its rarity. The Pregnancy Working Group, which included physicians and patient stakeholders, performed a systematic literature review of pregnancy-associated AD from 1960 to 2021 and identified 6,333 articles through PubMed, OVID MEDLINE, Cochrane, Embase, CINAHL and Web of Science. The inclusion criterion was AD in pregnant populations and exclusion criteria were case reports, conference abstracts, and languages other than English. Assessment of full-text articles for eligibility after removal of duplicates from all databases yielded 68 articles to be included in the final review. Topics included were timing of AD in pregnancy, type of AD, and management considerations of pregnancy-associated AD. The Pregnancy Working Group identified gaps in knowledge and future areas of research for pregnancy-associated AD, including clinical management, mental health outcomes post AD, reproductive and genetic counseling, and contraception after AD. Future collaborative projects could be a multicenter, international registry for all pregnancy-associated AD to refine the risk factors, best practice and management of AD in pregnancy. In addition, future mixed methodology studies may be useful to explore social, mental, and emotional factors related to pregnancy-associated AD and to determine support groups' effect on anxiety and depression related to these events in the pregnancy and postpartum period.
10.1053/j.semvascsurg.2022.02.010
Aortic dissection during pregnancy and postpartum.
Meng Xiangli,Han Jijing,Wang Li,Wu Qingqing
Journal of cardiac surgery
BACKGROUND:Patients with aortic dissection during pregnancy and postpartum period exhibit a high mortality. At present, a complete overview of aortic dissection during pregnancy and postpartum period is lacking. Methods: This systematic review included 80 reports published from 2000 to 2020, comprising a total study population of 103 patients with aortic dissection. Results: We found that Stanford Type A aortic dissection was more common in prepartum cases, especially in the third trimester, while postpartum cases of aortic dissection were more common in Stanford Type B. The most common risk factor was connective tissue disease, with no other known risk factors. The mode of delivery had no significant effect on the type of postpartum aortic dissection. Reduced maternal and fetal mortality was observed when patients with Stanford Type A aortic dissection occurring after 28 gestational weeks underwent cesarean section followed by aortic replacement. Patients with Stanford Type B aortic dissection were treated mainly with medication and/or endovascular repair. Conclusion: Contemporary management of patients during pregnancy and within 12 weeks postpartum requires multidisciplinary cooperation and includes serial, noninvasive imaging, biomarker testing, and genetic risk profiling for aortopathy. Early diagnosis and accurate treatment are essential to reduce maternal and fetal mortality.
10.1111/jocs.15575