1
|
Chow SCY, Wong RHL, Lakhani I, Wong MV, Tse G, Yu PSY, Ho JYK, Fujikawa T, Underwood MJ. Management of acute type A intramural hematoma: upfront surgery or individualized approach? A retrospective analysis and meta-analysis. J Thorac Dis 2020; 12:680-689. [PMID: 32274133 PMCID: PMC7139001 DOI: 10.21037/jtd.2019.12.109] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Management of acute type A intramural hematoma (IMH) is a controversial topic. In our study, we aim to analyze the survival outcomes in local patients with acute type A IMH and a meta-analysis on survival in type A IMH treated medically versus surgically was performed. Methods From 2014 to 2019, 65 patients with acute type A IMH were selected for analysis. Primary outcome of interest was 1 year all cause survival. The rate of aortic-related events in the medical group was evaluated. PubMed and Embase were searched for meta-analysis. Results The mean age of our cohort was 61.7±9.7 years. Of the 65 patients, 40% had emergency operation. Overall 1-year survival was 96.9%. The 1-year survival was 94.9% for the medical group. 46.2% of the medical group required aortic intervention at a mean duration of 191±168 days. Maximal aortic diameter (MAD) ≥45 mm was predictive of aortic-related events in the medical group (OR: 7.0; 95% CI, 1.7-29.4; P=0.008). For the meta-analysis, 21 studies were identified, and 900 patients were included. Emergent surgery was associated with improved survival in type A IMH (OR: 0.76; 95% CI, 0.29-1.97, P=0.58; I2=27%). Conclusions The 1-year survival after type A IMH was promising, regardless of approach. The conservative-first approach was found to be safe & feasible, and upfront surgery remained the management of choice in general. Patients with MAD ≥45 mm was associated with subsequent aortic intervention in the medical-first group.
Collapse
Affiliation(s)
- Simon C Y Chow
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Randolph H L Wong
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Ishan Lakhani
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Michelle V Wong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Gary Tse
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Peter S Y Yu
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Jacky Y K Ho
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Takuya Fujikawa
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Malcolm J Underwood
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| |
Collapse
|
2
|
Kim JY, Kim KH, Yim YR, Cho JY, Sim DS, Yoon HJ, Yoon NS, Hong YJ, Park HW, Kim JH, Ahn Y, Jeong MH, Cho JG, Park JC. Usefulness of Cardiac Biomarkers in the Evaluation of Prognosis and Cardiac Involvement in Patients with Acute Aortic Syndrome. J Lipid Atheroscler 2016. [DOI: 10.12997/jla.2016.5.1.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Jong Yoon Kim
- The Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Kye Hun Kim
- The Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Yi Rang Yim
- The Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Jae Yeong Cho
- The Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Doo Sun Sim
- The Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Hyun Ju Yoon
- The Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Nam Sik Yoon
- The Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Young Joon Hong
- The Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Hyung Wook Park
- The Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Ju Han Kim
- The Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Youngkeun Ahn
- The Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Myung Ho Jeong
- The Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Jeong Gwan Cho
- The Heart Center, Chonnam National University Hospital, Gwangju, Korea
| | - Jong Chun Park
- The Heart Center, Chonnam National University Hospital, Gwangju, Korea
| |
Collapse
|
3
|
Ho HH, Cheung CW, Jim MH, Miu KM, Siu CW, Lam YM, Chan HW, Lee WL, Tse HF. Type A aortic intramural hematoma: clinical features and outcomes in Chinese patients. Clin Cardiol 2011; 34:E1-5. [PMID: 21400537 DOI: 10.1002/clc.20481] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The purpose of this study was to describe the clinical characteristics and clinical outcomes for Chinese patients with type A intramural hematoma (IMH). METHODS AND RESULTS We studied 90 patients with Stanford type A acute aortic syndrome who presented to our institution from 1998 to 2005 and evaluated the presentation, management, and clinical outcomes of acute IMH by comparing these patients with those diagnosed with classical aortic dissection (AD). A total of 34 patients had IMH and they tended to be older (69.7 ± 12.4 versus 60.5 ± 16.2 years; p=0.006). The development of pericardial effusion was more frequent in patients with IMH than in patients with AD. They were also less likely to receive surgery as compared to AD patients (26.5% versus 73.2%; p<0.0001). Overall mortality of IMH was not significantly higher than that of classic AD (29.4% versus 21.4%; p=0.45). For IMH patients, the mortality rate with medical treatment was 32%. Ten (40%) of the 25 medically treated patients developed adverse outcomes. However, no independent predictors of adverse outcomes were identified in the study. In follow-up imaging studies of 15 patients who survived IMH without surgical repair, 14 patients showed complete resolution of IMH and 1 progressed into classical AD. CONCLUSION Acute type A IMH in Chinese patients showed a high mortality rate with medical treatment. It has a highly unpredictable course with no reliable clinical and anatomical predictors. Surgical therapy should be the treatment of choice for Chinese patients with acute IMH, especially those who are younger and have less comorbidities.
Collapse
Affiliation(s)
- Hee Hwa Ho
- Division of Cardiology, Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong, China.
| | | | | | | | | | | | | | | | | |
Collapse
|
4
|
New classification of aortic dissection during the cardiac cycle as pulsating type and static type evaluated by electrocardiogram-gated multislice CT. Int J Cardiol 2010; 142:177-86. [DOI: 10.1016/j.ijcard.2008.12.194] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Accepted: 12/17/2008] [Indexed: 01/19/2023]
|
5
|
Song JK, Yim JH, Ahn JM, Kim DH, Kang JW, Lee TY, Song JM, Choo SJ, Kang DH, Chung CH, Lee JW, Lim TH. Outcomes of patients with acute type a aortic intramural hematoma. Circulation 2009; 120:2046-52. [PMID: 19901188 DOI: 10.1161/circulationaha.109.879783] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The proper treatment option for patients with type A intramural hematoma (IMH), a variant form of classic aortic dissection (AD), remains controversial. We assessed the outcome of our institutional policy of urgent surgery for unstable patients and initial medical treatment for stable patients with surgery in cases with complications. METHODS AND RESULTS Among 357 consecutive patients with type A acute aortic syndrome, 101 (28.3%) had IMH and 256 had AD. Urgent operations were performed in 224 patients with AD (87.5%) and 16 with unstable IMH (15.8%; P<0.001). The remaining 85 stable IMH patients received initial medical treatment, and adverse clinical events developed in 31 patients (36.5%) within 6 months, which included development of AD (n=25), delayed surgery (n=25), or death (n=6). Initial aorta diameter and hematoma thickness were independent predictors for development of these events, and the best cutoff values were 55 and 16 mm, respectively. The overall hospital mortality was lower in IMH patients than in AD patients (7.9% [8/101] versus 17.2% [44/256]; P=0.0296) and was comparable to that of surgically treated AD patients (7.9% versus 10.7% [24/224]; P=0.56). The 1-, 2-, and 3-year survival rates of IMH patients were 87.6+/-3.6%, 84.9+/-3.7%, and 83.1+/-4.1%, respectively. There was no statistical difference of overall survival rates between patients with IMH and surgically treated AD patients (P=0.787). CONCLUSIONS The clinical outcome of IMH patients receiving treatment by our policy was comparable to that of surgically treated AD patients. However, adverse clinical events were not uncommon with medical treatment alone, and initial aorta diameter and hematoma thickness may identify patients who might benefit from urgent surgery.
Collapse
Affiliation(s)
- Jae-Kwan Song
- Asan Medical Center, University of Ulsan College of Medicine, 388-1 Poongnap-dong Songpa-gu, Seoul, 138-736 South Korea.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Buckley O, Rybicki FJ, Gerson DS, Huether C, Prior RF, Powers SL, Ersoy H. Imaging features of intramural hematoma of the aorta. Int J Cardiovasc Imaging 2009; 26:65-76. [PMID: 19777368 DOI: 10.1007/s10554-009-9504-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2009] [Accepted: 08/28/2009] [Indexed: 11/28/2022]
Abstract
Intramural hematoma (IMH) is defined as localized hemorrhage within the aortic wall and is included in the acute aortic syndrome spectrum with aortic dissection and penetrating aortic ulcer. The mortality from IMH is similar to classic aortic dissection (21%). 16% of patients with IMH will evolve to classic aortic dissection over time. Despite this confusion exists regarding the precise definitions and radiologic features of IMH versus penetrating ulcers with mural thrombus and overt aortic dissection.
Collapse
Affiliation(s)
- Orla Buckley
- Noninvasive Cardiovascular Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.
| | | | | | | | | | | | | |
Collapse
|
7
|
|
8
|
Ryan A, McCook B, Sholosh B, Pryma DA, Jablonowski E, Fuhrman C, Blodgett TM. Acute intramural hematoma of the aorta as a cause of positive FDG PET/CT. Clin Nucl Med 2007; 32:729-31. [PMID: 17710030 DOI: 10.1097/rlu.0b013e318123f7a6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Type A acute intramural hematoma (IMH) of the ascending aorta is defined as hemorrhage in the aortic wall in the absence of intimal disruption. Proximity to the adventitia may explain the higher incidence of rupture in IMH. We present a case of IMH, diagnosed by the presence of linear intense uptake of FDG on PET/CT, in a 70-year-old woman undergoing staging for colorectal cancer. There is no current role for FDG-PET in the diagnosis of IMH. This case demonstrates that incidental focal FDG activity in the wall of the aorta may indicate the life-threatening diagnosis of IMH.
Collapse
Affiliation(s)
- Alex Ryan
- Department of Radiology, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
| | | | | | | | | | | | | |
Collapse
|
9
|
Ryan A, McCook B, Sholosh B, Pryma DA, Jablonowski E, Fuhrman C, Blodgett TM. Acute intramural hematoma of the aorta as a cause of positive fluorodeoxyglucose positron emission tomography/computed tomography. J Thorac Cardiovasc Surg 2007; 134:520-1. [PMID: 17662807 DOI: 10.1016/j.jtcvs.2007.02.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2007] [Accepted: 02/23/2007] [Indexed: 11/19/2022]
Affiliation(s)
- Alex Ryan
- Department of Radiology, University of Pittsburgh, Pittsburgh, Pa, USA.
| | | | | | | | | | | | | |
Collapse
|