Clinical treatment of acute aortic dissection in late pregnancy and puerperium_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

JIN Lei , QIAO Fan , CAI Chengliang , LI Bailing , LANG Xilong , HAN Lin , LU Fanglin ,  XU Zhiyun

Department of Cardiovascular Surgery, Shanghai Changhai Hospital, Naval Military Medical University, Shanghai, 200433, P.R.China;

Corresponding author：

XU Zhiyun, Email: ZhiYunX@hotmail.com

Keywords：

Late pregnancy; third trimester pregnancy; puerperium; acute aortic dissection; cardiac surgery

DOI：

10.7507/1007-4848.201801007

Video：

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Objective To study the clinical characteristics, therapy strategies and the outcomes of female patients with acute aortic dissection during late pregnancy and puerperal period. Methods We retrospectively analyzed the clinical data of 7 patients with acute aortic dissection during late pregnancy and puerperal period in Shanghai Changhai Hospital between August 2012 and June 2017. Five of the 7 patients were late stage pregnancy, 2 were puerperal period (1 at the postpartum night, 1 in 18 days after delivery). There were 6 patients of Stanford type A aortic dissection (85.7%), and 1 patient of type B aortic dissection (14.3%). The age of the patients ranged from 26 to 34 (30.8±3.1) years. Cardiac ultrasonography of patients with type A showed that the maximum diameter of the ascending aortas was 4.2–5.7 (4.7±0.6) cm, of which 2 patients were aneurysm of aortic sinus, 3 patients were with Marfan syndrome. Bentall procedure was conducted in 1 patient, Bentall+Sun’s surgery in 2 patients, ascending aorta replacement+Sun’s+coronary artery bypass grafting surgery in 1 patient, aortic root remodeling+ascending aorta replacement+Sun’s surgery in 2 patients. One patient with Stanford type B acute aortic dissection was performed with thoracic endovascular aortic repair (TEVAR) after cesarean section. Results Aortic blocking time ranged from 51 to 129 (85.5±22.9) min. Cardiopulmonary bypass time was 75–196 (159.0±44.0) min. Moderate hypothermic circulation arrest with selective cerebral perfusion time was 20–30 (23.8±3.5) min. All maternal and fetuses survived. The infant whose mother received aortic repair in early stage and then received cesarean section was diagnosed with cerebral palsy. Maternal and fetuses were followed up for 9 months to 4 years. During the follow up period, all the fetuses grew well except the cerebral palsy one, and all maternal recovered well. The patient who received aortic repair in the early stage, had a sigmoid rupture during cesarean section and was treated with sigmoid colostomy. Another patient with Stanford type A dissection was diagnosed as left renal vein entrapment syndrome after 2 years. Conclusion Type A aortic dissection is more common in late pregnancy and puerperal patients. And Marfan syndrome is a high-risk factor for acute aortic dissection in pregnancy women. Early and appropriate surgical treatment strategy based on the type of aortic dissection and gestational age are the key points to achieve good outcomes both for maternal and fetus.

Citation： JIN Lei, QIAO Fan, CAI Chengliang, LI Bailing, LANG Xilong, HAN Lin, LU Fanglin, XU Zhiyun. Clinical treatment of acute aortic dissection in late pregnancy and puerperium. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2018, 25(8): 676-680. doi: 10.7507/1007-4848.201801007 Copy

1.	Mészáros I, Mórocz J, Szlávi J, et al. Epidemiology and clinicopathology of aortic dissection. Chest, 2000, 117(5): 1271-1278.
2.	Ch'ng SL, Cochrane AD, Goldstein J, et al. Stanford type A aortic dissection in pregnancy: a diagnostic and management challenge. Heart Lung Circ, 2013, 22(1): 12-18.
3.	Elliotson J. ST. Thomas’s Hospital: clinical lecture. Lancet, 1832, 19: 129-134.
4.	Maurice A, Charles A. Dissecting aneurysm of the aorta in young individuals, particularly in association with pregnancy. With report of a case. Ann Intern Med, 1944, 20(3): 486-511.
5.	Smok DA. Aortopathy in pregnancy. Semin Perinatol, 2014, 38(5): 295-303.
6.	Immer FF, Bansi AG, Immer-Bansi AS, et al. Aortic dissection in pregnancy: analysis of risk factors and outcome. Ann Thorac Surg, 2003, 76(1): 309-314.
7.	Tan EK, Tan EL. Alterations in physiology and anatomy during pregnancy. Best Pract Res Clin Obstet Gynaecol, 2013, 27(6): 791-802.
8.	Yuan SM. Postpartum aortic dissection. Taiwan J Obstet Gynecol, 2013, 52(3): 318-322.
9.	Collins D. Aetiology and management of acute cardiac tamponade. Crit Care Resusc, 2004, 6(1):54-58.
10.	Rajagopalan S, Nwazota N, Chandrasekhar S. Outcomes in pregnant women with acute aortic dissections: a review of the literature from 2003 to 2013. Int J Obstet Anesth, 2014, 23(4):348-356.
11.	Rossiter JP, Repke JT, Morales AJ, et al. A prospective longitudinal evaluation of pregnancy in the Marfan syndrome. Am J Obstet Gynecol, 1995, 173(5):1599-1606.
12.	Zeebregts CJ, Schepens MA, Hameeteman TM, et al. Acute aortic dissection complicating pregnancy. Ann Thorac Surg, 1997, 64(5):1345-1348.
13.	Weiss BM, von Segesser LK, Alon E, et al. Outcome of cardiovascular surgery and pregnancy: a systematic review of the period 1984-1996. Am J Obstet Gynecol, 1998, 179(6 Pt 1):1643-1653.
14.	John AS, Gurley F, Schaff HV, et al. Cardiopulmonary bypass during pregnancy. Ann Thorac Surg, 2011, 91(4):1191-1196.
15.	于浩, 童光, 颜涛, 等. 优化选择性动脉灌注策略在 Stanford A 型主动脉夹层全弓置换术中的应用. 第二军医大学学报, 2018, 39(4): 404-410.Ref.
16.	Chandrasekhar S, Cook CR, Collard CD. Cardiac surgery in the parturient. Anesth Analg, 2009, 108(3):777-785.
17.	Kunishige H, Ishibashi Y, Kawasaki M, et al. Surgical treatment for acute type A aortic dissection during pregnancy (16 weeks) with Loeys-Dietz syndrome. Gen Thorac Cardiovasc Surg, 2012, 60(11):764-767.
18.	Shu C, Fang K, Dardik A, et al. Pregnancy-associated type B aortic dissection treated with thoracic endovascular aneurysm repair. Ann Thorac Surg, 2014, 97(2):582-587.

1. Mészáros I, Mórocz J, Szlávi J, et al. Epidemiology and clinicopathology of aortic dissection. Chest, 2000, 117(5): 1271-1278.
2. Ch'ng SL, Cochrane AD, Goldstein J, et al. Stanford type A aortic dissection in pregnancy: a diagnostic and management challenge. Heart Lung Circ, 2013, 22(1): 12-18.
3. Elliotson J. ST. Thomas’s Hospital: clinical lecture. Lancet, 1832, 19: 129-134.
4. Maurice A, Charles A. Dissecting aneurysm of the aorta in young individuals, particularly in association with pregnancy. With report of a case. Ann Intern Med, 1944, 20(3): 486-511.
5. Smok DA. Aortopathy in pregnancy. Semin Perinatol, 2014, 38(5): 295-303.
6. Immer FF, Bansi AG, Immer-Bansi AS, et al. Aortic dissection in pregnancy: analysis of risk factors and outcome. Ann Thorac Surg, 2003, 76(1): 309-314.
7. Tan EK, Tan EL. Alterations in physiology and anatomy during pregnancy. Best Pract Res Clin Obstet Gynaecol, 2013, 27(6): 791-802.
8. Yuan SM. Postpartum aortic dissection. Taiwan J Obstet Gynecol, 2013, 52(3): 318-322.
9. Collins D. Aetiology and management of acute cardiac tamponade. Crit Care Resusc, 2004, 6(1):54-58.
10. Rajagopalan S, Nwazota N, Chandrasekhar S. Outcomes in pregnant women with acute aortic dissections: a review of the literature from 2003 to 2013. Int J Obstet Anesth, 2014, 23(4):348-356.
11. Rossiter JP, Repke JT, Morales AJ, et al. A prospective longitudinal evaluation of pregnancy in the Marfan syndrome. Am J Obstet Gynecol, 1995, 173(5):1599-1606.
12. Zeebregts CJ, Schepens MA, Hameeteman TM, et al. Acute aortic dissection complicating pregnancy. Ann Thorac Surg, 1997, 64(5):1345-1348.
13. Weiss BM, von Segesser LK, Alon E, et al. Outcome of cardiovascular surgery and pregnancy: a systematic review of the period 1984-1996. Am J Obstet Gynecol, 1998, 179(6 Pt 1):1643-1653.
14. John AS, Gurley F, Schaff HV, et al. Cardiopulmonary bypass during pregnancy. Ann Thorac Surg, 2011, 91(4):1191-1196.
15. 于浩, 童光, 颜涛, 等. 优化选择性动脉灌注策略在 Stanford A 型主动脉夹层全弓置换术中的应用. 第二军医大学学报, 2018, 39(4): 404-410.Ref.
16. Chandrasekhar S, Cook CR, Collard CD. Cardiac surgery in the parturient. Anesth Analg, 2009, 108(3):777-785.
17. Kunishige H, Ishibashi Y, Kawasaki M, et al. Surgical treatment for acute type A aortic dissection during pregnancy (16 weeks) with Loeys-Dietz syndrome. Gen Thorac Cardiovasc Surg, 2012, 60(11):764-767.
18. Shu C, Fang K, Dardik A, et al. Pregnancy-associated type B aortic dissection treated with thoracic endovascular aneurysm repair. Ann Thorac Surg, 2014, 97(2):582-587.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Clinical treatment of acute aortic dissection in late pregnancy and puerperium

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