Type a dissection in pregnancy

1. ARTICLE IN PRESS
www.icvts.org
doi:10.1510/icvts.2008.182766
Interactive CardioVascular and Thoracic Surgery 7 (2008) 938–940
Case report - Cardiac general
Repair of an acute type A aortic dissection combined with an
emergency cesarean section in a pregnant woman
Mohammad Shihata, Victor Pretorius, Roderick MacArthur*
Division of Cardiac Surgery, University of Alberta, 3H2.17 Walter Mackenzie Center, 8440-112 Street, Edmonton, Alberta, T6G 2B7, Canada
Received 30 April 2008; received in revised form 4 June 2008; accepted 5 June 2008
Abstract
This case report describes a 35-week pregnant woman presenting with an acute type A aortic dissection. She underwent a successful
emergency surgical repair and a concomitant cesarean section with a favorable outcome for the mother and the child.
2008 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
Keywords: Aortic dissection; Pregnancy; Hypothermic circulatory arrest
1. Introduction
The association between pregnancy and type A aortic
dissection is an uncommon presentation. Risk factors
include a bicuspid aortic valve or a connective tissue
disorder (e.g. Marfan’s syndrome) w1x. In addition to being
a life threatening surgical emergency, management could
be complicated due to the hemodynamic changes that
occur late in pregnancy, and the implications of the man-agement
strategy on fetal survival.
2. Case
The patient is a 36-year-old lady with a history of panhy-popituitarism
following a resection of a pituitary adenoma
on hormonal replacement therapy. She was 35 weeks preg-nant
as a product of in vitro fertilization. She was referred
to a tertiary care center for shortness of breath and chest
pain. She was also known to have gestational hypertension.
A chest computed tomography (CT) scan was performed to
rule out a pulmonary embolism. The CT-scan revealed the
presence of a type A aortic dissection involving the aortic
arch (Fig. 1). It also showed the presence of a large
pericardial effusion (Fig. 2). The patient was urgently
referred to cardiac surgery and was transferred to the
cardiac surgical intensive care unit. A transthoracic echo-cardiogram
was preformed and showed early tamponade
features as well as moderate aortic valve insufficiency. The
patient was hemodynamically stable at that point, but due
to the suspicion of a contained aortic rupture the decision
was to arrange for an emergency combined cesarean sec-tion
and repair of the aortic dissection. Care was taken to
communicate the management plan with all the involved
*Corresponding author. Tel.: q1 (780) 407-2186; fax: q1 (780) 407-2184.
E-mail address: RoderickMacarthur@cha.ab.ca (R. MacArthur).
2008 Published by European Association for Cardio-Thoracic Surgery
teams including the Anesthesia, Obstetrics, and Neonatal
Intensive care unit (NICU) teams. The axillary artery was
exposed and prepared for cannulation. After that, a median
sternotomy was performed and the pericardial effusion was
evacuated. Surprisingly, it was serous in nature with no
evidence of active extravasation. At this point the cesarean
section was performed prior to systemic heparinization.
The neonate was intubated and transferred to the NICU.
The uterus was closed and the incision was packed open
for re-assessment of hemostasis at the end of the procedure
once the systemic heparinization was reversed. Following
that, the aortic repair was performed. The aortic root was
found to be dilated and thin. The dissection flap was
involving the left coronary ostium and the aortic valve
annulus. After thorough assessment of the aortic valve and
root dimensions, we decided it was not suitable for repair.
The aortic repair consisted of replacement of the ascending
aorta and the aortic arch in a bevelled hemiarch fashion
with a Dacron graft (Gelweave Graft, Vascutek USA Inc.,
Ann Arbor, MI) and replacement of the aortic root with a
stentless aortic valve prosthesis (Freestyle Aortic Root
Bioprosthesis, Medtronic Inc., Minneapolis, MN). The origin
of the brachiocephalic artery was involved in the dissection
and it was reimplanted separately to a preformed 8 mm
side branch on the Dacron graft. The aortic arch replace-ment
and the re-implantation of the brachiocephalic artery
were performed under a period of hypothermic circulatory
arrest and selective antegrade cerebral perfusion through
the right axillary artery. The total cardiopulmonary bypass
time was 260 min. The aortic cross-clamp and selective
antegrade cerebral perfusion times were 200 and 49 min,
respectively.
The recovery course was uneventful and both the patient
and her new born were discharged home after a total
hospital stay of ten days.

2. ARTICLE IN PRESS
M. Shihata et al. / Interactive CardioVascular and Thoracic Surgery 7 (2008) 938–940 939
Fig. 1. Type A aortic dissection involving the aortic arch.
Fig. 2. Computed tomography showing a significant pericardial effusion.
3. Discussion
The association between pregnancy and aortic dissection
has been well described in previous reports in the litera-ture.
Acute aortic dissection during pregnancy, particularly
during the third trimester, accounts for half the cases in
women under the age of 40 years w2x. The presence of a
pre-existing aortopathy secondary to a connective tissue
disorder increases the risk for dissection.
Several hemodynamic alterations take place during late
pregnancy, including an increase in the total circulatory
volume and systemic blood pressure. This may give a
sensible explanation for the increased incidence of dissec-tions
during the third trimester. Adding to that risk is the
ultra structural changes that occur in the aortic wall in a
very similar pattern to the medial degeneration found in
other cases of aortic dissection w3, 4x. The hormonal effects
of naturally occurring increments in the levels of estrogen
and progesterone during pregnancy on the aortic tissue
include, fragmentation of the reticulin fibers, diminished
amounts of acid mucopolysaccharides, loss of the normal
corrugation of elastic fibers, and hypertrophy and hyper-plasia
of smooth muscle cells w5, 6x. Since the first report
describing a successful post-partum surgical repair of an
aortic dissection diagnosed in a pregnant woman in 1963
w7x, several reports and small reviews have addressed the
management of this rather challenging group of patients.
The main challenge remains choosing the best strategy to
timely manage the maternal surgical emergency but at the
same time preserve the viability of the term or near-term
fetus. Although a high flow, high pressure, normothermic
flow on cardiopulmonary bypass is probably the safest for
fetal preservation w8x, a hypothermic circulatory arrest will
almost invariably result in fetal loss w9x. Factors that will
dictate the ideal management include, hemodynamic sta-bility
of the mother, gestational age and viability of the
fetus. The extent of the aortic dissection and the presence
of any directly related complications are also key factors
in planning for the best surgical approach. A timely man-agement
plan aiming to optimize the care for both the
mother and the fetus should be pursued whenever feasible,
and especially after 28 weeks of gestation. A cesarean
section followed shortly by aortic repair or performed
concomitantly in the same operative session has been
recommended for an acute type A aortic dissection pre-senting
in a term or near-term pregnancy w1x. In this case,
the patient had a large pericardial effusion with echocar-diographic
features of early tamponade. This raised con-cerns
of serious hemodynamic compromise during the
induction of anesthesia secondary to the loss of negative
intrathoracic pressure and further reduction in the venous
return to the heart. In addition, the rapid increase in
circulatory volume as a result of uterine contraction
imposed the theoretical risk of rupture of the ascending
aorta. For these reasons we elected to expose the axillary
artery and evacuate the pericardial effusion through a
sternotomy prior to proceeding with the cesarean section.
This way, hemodynamic improvement and immediate access
for cannulation were assured. The successful outcome of
this case represented in the complete surgical repair of
the mother’s dissection with an uneventful recovery and
the salvage of the 35-week fetus, has led us to the following
conclusions:
First, the necessity of a multidisciplinary approach in
dealing with similar cases. Secondly, the safety of the
hemodynamically compromised mother takes priority in the
management plan. Finally, it is safe to conduct a combined
approach aiming to save both the mother and the fetus
with careful planning and the availability of immediate
back up measures.

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eComment: Acute type A aortic dissection at seven weeks of gestation
in a Marfan patient
Authors: Mohamed F. Ibrahim, PSHC, King Fahad Medical City, PO Box
59046, Riyadh 11525, Kingdom of Saudi Arabia; Amal A. Refaat
doi:10.1510/icvts.2008.182766A
I read with interest the case report by Shihata and colleagues w1x regarding
combined cesarean section and repair of acute type A aortic dissection.
Acute aortic dissection during pregnancy can be serious for both the mother
and the fetus with a reported mortality of 1% per hour if untreated w2x. This
time-related mortality imposes the need for high degree of suspicion and
reliable diagnostic tools. The bedside transthoracic echocardiogram is used
for initial diagnosis with sensitivity and specificity of 75% and 90%, respec-tively
w2x. The close relation between the aortic dissection and pregnancy
initiated Zeebregts and colleagues w3x to follow these cases over 12 years.
They suggested a guideline for management according to the gestational
age aiming to save two lives. Before 28 weeks gestation, aortic surgery with
the fetus kept in the uterus is recommended. After 32 weeks gestation,
primary cesarean section followed by aortic repair at the same setting is
the management of choice as in the report of Shihata. We encountered
recently a case of pregnant Marfan lady at seven weeks gestation who
presented with acute type A aortic dissection. We performed an emergency
Bentall operation under hypothermic circulatory arrest (circulatory arrest
time was 11 min). The fetus survived the surgery and, at 35 weeks of
gestation, the patient underwent an elective cesarean section and delivered
a healthy baby. To our knowledge, our case is the first to report a favorable
fetal outcome following surgical repair of acute dissection during the first
trimester of pregnancy in a Marfan patient w4x.
References
w1x Shihata M, Pretorius V, MacArthur R. Repair of an acute type A aortic
dissection combined with an emergency cesarean section in a pregnant
woman. Interact CardioVasc Thorac Surg 2008;7:938–940.
w2x Khan AK, Nair CK. Clinical, diagnostic and management perspectives of
aortic dissection. Chest 2002;122:311–328.
w3x Zeebregts CJ, Schepens MA, Hameeteman TM, Morshuis WJ, De la Rivire
AB. Acute aortic dissection complicating pregnancy. Ann Thorac Surg
1997;64:1345–1348.
w4x Shaker WH, Refaat AA, Hakami MA, Ibrahim MF. Acute type A aortic
dissection at 7 weeks of gestation in a Marfan patient. J Cardiothorac
Surg 2008;(in press).