Comprehensive management of aortic dissection during pregnancy_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

CHEN Suwei , ZHONG Yongliang , LI Chengnan , GE Yipeng , QIAO Zhiyu , SUN Lizhong ,  ZHU Junming

Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing, 100029, P.R China;

Corresponding author：

ZHU Junming, Email: anzhenzjm@126.com

Keywords：

Pregnancy; aortic dissection; cardiopulmonary bypass; comprehensive treatment

DOI：

10.7507/1007-4848.201907061

Video：

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The aortic dissection (AD) carries high mortality which increases by 1%-2% per hour after onset in untreated patients. Fifty percent of patients will die in 48 hours, and 70%-80% patients will die in 2 weeks without treatment. Moreover, acute AD during pregnancy is a rare and much catastrophic disease with high lethality for the mother and fetus simultaneously. At present, AD is so rare that most articles are mainly small cohort studies and case reports. Therefore, we reviewed literatures in order to provide clinical reference for the comprehensive treatment of AD.

Citation： CHEN Suwei, ZHONG Yongliang, LI Chengnan, GE Yipeng, QIAO Zhiyu, SUN Lizhong, ZHU Junming. Comprehensive management of aortic dissection during pregnancy. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2020, 27(9): 1094-1098. doi: 10.7507/1007-4848.201907061 Copy

1.	Mészáros I, Mórocz J, Szlávi J, <italic>et al</italic>. Epidemiology and clinicopathology of aortic dissection. Chest, 2000, 117(5): 1271-1278.
2.	Coady MA, Rizzo JA, Goldstein LJ, <italic>et al</italic>. Natural history, pathogenesis, and etiology of thoracic aortic aneurysms and dissections. Cardiol Clin, 1999, 17(4): 615-635.
3.	Lansman SL, Goldberg JB, Kai M, <italic>et al</italic>. Aortic surgery in pregnancy. J Thorac Cardiovasc Surg, 2017, 153(2): S44-S48.
4.	Sawlani N, Shroff A, Vidovich MI. Aortic dissection and mortality associated with pregnancy in the United States. J Am Coll Cardiol, 2015, 65(15): 1600-1601.
5.	Immer FF, Bansi AG, Immer-Bansi AS, <italic>et al</italic>. Aortic dissection in pregnancy: analysis of risk factors and outcome. Ann Thorac Surg, 2003, 76(1): 309-314.
6.	Donnelly RT, Pinto NM, Kocolas I, <italic>et al</italic>. The immediate and long-term impact of pregnancy on aortic growth rate and mortality in women with Marfan syndrome. J Am Coll Cardiol, 2012, 60(3): 224-229.
7.	Kinney-Ham L, Nguyen HB, Steele R, <italic>et al</italic>. Acute aortic dissection in third trimester pregnancy without risk factors. West J Emerg Med, 2011, 12(4): 571-574.
8.	Segreto A, Chiusaroli A, De Salvatore S, <italic>et al</italic>. Biomarkers for the diagnosis of aortic dissection. J Card Surg, 2014, 29(4): 507-511.
9.	Ohlson L. Effects of the pregnant uterus on the abdominal aorta and its branches. Acta Radiol Diagn (Stockh), 1978, 19(2): 369-376.
10.	Meijboom LJ, Vos FE, Timmermans J, <italic>et al</italic>. Pregnancy and aortic root growth in the Marfan syndrome: a prospective study. Eur Heart J, 2005, 26(9): 914-920.
11.	European Society of Gynecology (ESG), Association for European Paediatric Cardiology (AEPC), German Society for Gender Medicine (DGesGM), <italic>et al</italic>. ESC guidelines on the management of cardiovascular diseases during pregnancy: the task force on the management of cardiovascular diseases during pregnancy of the European Society of Cardiology (ESC). Eur Heart J, 2011, 32(24): 3147-3197.
12.	Smith K, Gros B. Pregnancy-related acute aortic dissection in Marfan syndrome: A review of the literature. Congenit Heart Dis, 2017, 12(3): 251-260.
13.	Smok DA. Aortopathy in pregnancy. Semin Perinatol, 2014, 38(5): 295-303.
14.	Shaker WH, Refaat AA, Hakamei MA, <italic>et al</italic>. Acute type A aortic dissection at seven weeks of gestation in a Marfan patient: case report. J Card Surg, 2008, 23(5): 569-570.
15.	Barrus A, Afshar S, Sani S, <italic>et al</italic>. Acute type A aortic dissection and successful surgical repair in a woman at 21 weeks gestational pregnancy with maternal and fetal survival: a case report. J Cardiothorac Vasc Anesth, 2018, 32(3): 1487-1493.
16.	Taylor KM. SIRS— the systemic inflammatory response syndrome after cardiac operations. Ann Thorac Surg, 1996, 61(6): 1607-1608.
17.	Pomini F, Mercogliano D, Cavalletti C, <italic>et al</italic>. Cardiopulmonary bypass in pregnancy. Ann Thorac Surg, 1996, 61(1): 259-268.
18.	Sakaguchi M, Kitahara H, Seto T, <italic>et al</italic>. Surgery for acute type A aortic dissection in pregnant patients with Marfan syndrome. Eur J Cardiothorac Surg, 2005, 28(2): 280-283.
19.	Becker RM. Intracardiac surgery in pregnant women. Ann Thorac Surg, 1983, 36(4): 453-458.
20.	Mul TF, van Herwerden LA, Cohen-Overbeek TE, <italic>et al</italic>. Hypoxic-ischemic fetal insult resulting from maternal aortic root replacement, with normal fetal heart rate at term. Am J Obstet Gynecol, 1998, 179(3 Pt 1): 825-827.
21.	Kunishige H, Ishibashi Y, Kawasaki M, <italic>et al</italic>. 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.
22.	Buffolo E, Palma JH, Gomes WJ, <italic>et al</italic>. Successful use of deep hypothermic circulatory arrest in pregnancy. Ann Thorac Surg, 1994, 58(5): 1532-1534.
23.	Seeburger J, Mohr FW, Falk V. Acute type A dissection at 17 weeks of gestation in a Marfan patient. Ann Thorac Surg, 2007, 83(2): 674-676.
24.	Easo J, Horst M, Schmuck B, <italic>et al</italic>. Retrograde type a dissection in a 24th gestational week pregnant patient— the importance of interdisciplinary interaction to a successful outcome. J Cardiothorac Surg, 2018, 13(1): 36.
25.	Chen SW, Zhong YL, Ge YP, <italic>et al</italic>. Successful repair of acute type A aortic dissection during pregnancy at 16(th) gestational week with maternal and fetal survival: A case report and review of the literature. World J Clin Cases, 2019, 7(18): 2843-2850.
26.	Zhu JM, Ma WG, Peterss S, <italic>et al</italic>. Aortic dissection in pregnancy: management strategy and outcomes. Ann Thorac Surg, 2017, 103(4): 1199-1206.
27.	Kim WH, Bae J, Choi SW, <italic>et al</italic>. Stanford type A aortic dissection in a patient with Marfan syndrome during pregnancy: a case report. Korean J Anesthesiol, 2016, 69(1): 76-79.
28.	Wanga S, Silversides C, Dore A, <italic>et al</italic>. Pregnancy and thoracic aortic disease: managing the risks. Can J Cardiol, 2016, 32(1): 78-85.
29.	Sato S, Ogino H, Matsuda H, <italic>et al</italic>. Annuloaortic ectasia treated successfully in a pregnant woman with Marfan syndrome: report of a case. Surg Today, 2012, 42(3): 285-287.
30.	Yates MT, Soppa G, Smelt J, <italic>et al</italic>. Perioperative management and outcomes of aortic surgery during pregnancy. J Thorac Cardiovasc Surg, 2015, 149(2): 607-610.
31.	Hiratzka LF, Bakris GL, Beckman JA, <italic>et al</italic>. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Catheter Cardiovasc Interv, 2010, 76(2): E43-E86.
32.	Shu C, Fang K, Dardik A, <italic>et al</italic>. Pregnancy-associated type B aortic dissection treated with thoracic endovascular aneurysm repair. Ann Thorac Surg, 2014, 97(2): 582-587.
33.	Moretti ME, Caprara D, Drehuta I, <italic>et al</italic>. The fetal safety of angiotensin converting enzyme inhibitors and angiotensinⅡreceptor blockers. Obstet Gynecol Int, 2012, 2012: 658310.
34.	Crowley R, Corniea J, Chavez D, <italic>et al</italic>. Intraoperative diagnosis of aortic dissection in pregnancy. J Cardiothorac Vasc Anesth, 2010, 24(1): 116-118.
35.	Boissonnas CC, Davy C, Bornes M, <italic>et al</italic>. Careful cardiovascular screening and follow-up of women with Turner syndrome before and during pregnancy is necessary to prevent maternal mortality. Fertil Steril, 2009, 91(3): 929. e5-e7.
36.	Johnston C, Schroeder F, Fletcher SN, <italic>et al</italic>. Type A aortic dissection in pregnancy. Int J Obstet Anesth, 2012, 21(1): 75-79.
37.	van Hagen IM, Roos-Hesselink JW. Aorta pathology and pregnancy. Best Pract Res Clin Obstet Gynaecol, 2014, 28(4): 537-550.
38.	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.
39.	Yang Z, Yang S, Wang F, <italic>et al</italic>. Acute aortic dissection in pregnant women. Gen Thorac Cardiovasc Surg, 2016, 64(5): 283-285.
40.	阮颖清. 应用子宫填塞球囊导管治疗产后出血的初步经验. 国际医药卫生导报, 2012, 18(9): 1288-1290.
41.	Kim SY, Wolfe DS, Taub CC. Cardiovascular outcomes of pregnancy in Marfan's syndrome patients: A literature review. Congenit Heart Dis, 2018, 13(2): 203-209.
42.	den Hartog AW, Franken R, Zwinderman AH, <italic>et al</italic>. The risk for type B aortic dissection in Marfan syndrome. J Am Coll Cardiol, 2015, 65(3): 246-254.
43.	Judge DP, Dietz HC. Marfan's syndrome. Lancet, 2005, 366(9501): 1965-1976.
44.	Braverman AC, Moon MR, Geraghty P, <italic>et al</italic>. Pregnancy after aortic root replacement in Loeys-Dietz syndrome: High risk of aortic dissection. Am J Med Genet A, 2016, 170(8): 2177-2180.
45.	Gersony DR, McClaughlin MA, Jin Z, <italic>et al</italic>. The effect of beta-blocker therapy on clinical outcome in patients with Marfan's syndrome: a meta-analysis. Int J Cardiol, 2007, 114(3): 303-308.
46.	Lydakis C, Lip GY, Beevers M, <italic>et al</italic>. Atenolol and fetal growth in pregnancies complicated by hypertension. Am J Hypertens, 1999, 12(6): 541-547.
47.	Yetman AT, Bornemeier RA, McCrindle BW. Usefulness of enalapril versus propranolol or atenolol for prevention of aortic dilation in patients with the Marfan syndrome. Am J Cardiol, 2005, 95(9): 1125-1127.

1. Mészáros I, Mórocz J, Szlávi J, <italic>et al</italic>. Epidemiology and clinicopathology of aortic dissection. Chest, 2000, 117(5): 1271-1278.
2. Coady MA, Rizzo JA, Goldstein LJ, <italic>et al</italic>. Natural history, pathogenesis, and etiology of thoracic aortic aneurysms and dissections. Cardiol Clin, 1999, 17(4): 615-635.
3. Lansman SL, Goldberg JB, Kai M, <italic>et al</italic>. Aortic surgery in pregnancy. J Thorac Cardiovasc Surg, 2017, 153(2): S44-S48.
4. Sawlani N, Shroff A, Vidovich MI. Aortic dissection and mortality associated with pregnancy in the United States. J Am Coll Cardiol, 2015, 65(15): 1600-1601.
5. Immer FF, Bansi AG, Immer-Bansi AS, <italic>et al</italic>. Aortic dissection in pregnancy: analysis of risk factors and outcome. Ann Thorac Surg, 2003, 76(1): 309-314.
6. Donnelly RT, Pinto NM, Kocolas I, <italic>et al</italic>. The immediate and long-term impact of pregnancy on aortic growth rate and mortality in women with Marfan syndrome. J Am Coll Cardiol, 2012, 60(3): 224-229.
7. Kinney-Ham L, Nguyen HB, Steele R, <italic>et al</italic>. Acute aortic dissection in third trimester pregnancy without risk factors. West J Emerg Med, 2011, 12(4): 571-574.
8. Segreto A, Chiusaroli A, De Salvatore S, <italic>et al</italic>. Biomarkers for the diagnosis of aortic dissection. J Card Surg, 2014, 29(4): 507-511.
9. Ohlson L. Effects of the pregnant uterus on the abdominal aorta and its branches. Acta Radiol Diagn (Stockh), 1978, 19(2): 369-376.
10. Meijboom LJ, Vos FE, Timmermans J, <italic>et al</italic>. Pregnancy and aortic root growth in the Marfan syndrome: a prospective study. Eur Heart J, 2005, 26(9): 914-920.
11. European Society of Gynecology (ESG), Association for European Paediatric Cardiology (AEPC), German Society for Gender Medicine (DGesGM), <italic>et al</italic>. ESC guidelines on the management of cardiovascular diseases during pregnancy: the task force on the management of cardiovascular diseases during pregnancy of the European Society of Cardiology (ESC). Eur Heart J, 2011, 32(24): 3147-3197.
12. Smith K, Gros B. Pregnancy-related acute aortic dissection in Marfan syndrome: A review of the literature. Congenit Heart Dis, 2017, 12(3): 251-260.
13. Smok DA. Aortopathy in pregnancy. Semin Perinatol, 2014, 38(5): 295-303.
14. Shaker WH, Refaat AA, Hakamei MA, <italic>et al</italic>. Acute type A aortic dissection at seven weeks of gestation in a Marfan patient: case report. J Card Surg, 2008, 23(5): 569-570.
15. Barrus A, Afshar S, Sani S, <italic>et al</italic>. Acute type A aortic dissection and successful surgical repair in a woman at 21 weeks gestational pregnancy with maternal and fetal survival: a case report. J Cardiothorac Vasc Anesth, 2018, 32(3): 1487-1493.
16. Taylor KM. SIRS— the systemic inflammatory response syndrome after cardiac operations. Ann Thorac Surg, 1996, 61(6): 1607-1608.
17. Pomini F, Mercogliano D, Cavalletti C, <italic>et al</italic>. Cardiopulmonary bypass in pregnancy. Ann Thorac Surg, 1996, 61(1): 259-268.
18. Sakaguchi M, Kitahara H, Seto T, <italic>et al</italic>. Surgery for acute type A aortic dissection in pregnant patients with Marfan syndrome. Eur J Cardiothorac Surg, 2005, 28(2): 280-283.
19. Becker RM. Intracardiac surgery in pregnant women. Ann Thorac Surg, 1983, 36(4): 453-458.
20. Mul TF, van Herwerden LA, Cohen-Overbeek TE, <italic>et al</italic>. Hypoxic-ischemic fetal insult resulting from maternal aortic root replacement, with normal fetal heart rate at term. Am J Obstet Gynecol, 1998, 179(3 Pt 1): 825-827.
21. Kunishige H, Ishibashi Y, Kawasaki M, <italic>et al</italic>. 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.
22. Buffolo E, Palma JH, Gomes WJ, <italic>et al</italic>. Successful use of deep hypothermic circulatory arrest in pregnancy. Ann Thorac Surg, 1994, 58(5): 1532-1534.
23. Seeburger J, Mohr FW, Falk V. Acute type A dissection at 17 weeks of gestation in a Marfan patient. Ann Thorac Surg, 2007, 83(2): 674-676.
24. Easo J, Horst M, Schmuck B, <italic>et al</italic>. Retrograde type a dissection in a 24th gestational week pregnant patient— the importance of interdisciplinary interaction to a successful outcome. J Cardiothorac Surg, 2018, 13(1): 36.
25. Chen SW, Zhong YL, Ge YP, <italic>et al</italic>. Successful repair of acute type A aortic dissection during pregnancy at 16(th) gestational week with maternal and fetal survival: A case report and review of the literature. World J Clin Cases, 2019, 7(18): 2843-2850.
26. Zhu JM, Ma WG, Peterss S, <italic>et al</italic>. Aortic dissection in pregnancy: management strategy and outcomes. Ann Thorac Surg, 2017, 103(4): 1199-1206.
27. Kim WH, Bae J, Choi SW, <italic>et al</italic>. Stanford type A aortic dissection in a patient with Marfan syndrome during pregnancy: a case report. Korean J Anesthesiol, 2016, 69(1): 76-79.
28. Wanga S, Silversides C, Dore A, <italic>et al</italic>. Pregnancy and thoracic aortic disease: managing the risks. Can J Cardiol, 2016, 32(1): 78-85.
29. Sato S, Ogino H, Matsuda H, <italic>et al</italic>. Annuloaortic ectasia treated successfully in a pregnant woman with Marfan syndrome: report of a case. Surg Today, 2012, 42(3): 285-287.
30. Yates MT, Soppa G, Smelt J, <italic>et al</italic>. Perioperative management and outcomes of aortic surgery during pregnancy. J Thorac Cardiovasc Surg, 2015, 149(2): 607-610.
31. Hiratzka LF, Bakris GL, Beckman JA, <italic>et al</italic>. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Catheter Cardiovasc Interv, 2010, 76(2): E43-E86.
32. Shu C, Fang K, Dardik A, <italic>et al</italic>. Pregnancy-associated type B aortic dissection treated with thoracic endovascular aneurysm repair. Ann Thorac Surg, 2014, 97(2): 582-587.
33. Moretti ME, Caprara D, Drehuta I, <italic>et al</italic>. The fetal safety of angiotensin converting enzyme inhibitors and angiotensinⅡreceptor blockers. Obstet Gynecol Int, 2012, 2012: 658310.
34. Crowley R, Corniea J, Chavez D, <italic>et al</italic>. Intraoperative diagnosis of aortic dissection in pregnancy. J Cardiothorac Vasc Anesth, 2010, 24(1): 116-118.
35. Boissonnas CC, Davy C, Bornes M, <italic>et al</italic>. Careful cardiovascular screening and follow-up of women with Turner syndrome before and during pregnancy is necessary to prevent maternal mortality. Fertil Steril, 2009, 91(3): 929. e5-e7.
36. Johnston C, Schroeder F, Fletcher SN, <italic>et al</italic>. Type A aortic dissection in pregnancy. Int J Obstet Anesth, 2012, 21(1): 75-79.
37. van Hagen IM, Roos-Hesselink JW. Aorta pathology and pregnancy. Best Pract Res Clin Obstet Gynaecol, 2014, 28(4): 537-550.
38. 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.
39. Yang Z, Yang S, Wang F, <italic>et al</italic>. Acute aortic dissection in pregnant women. Gen Thorac Cardiovasc Surg, 2016, 64(5): 283-285.
40. 阮颖清. 应用子宫填塞球囊导管治疗产后出血的初步经验. 国际医药卫生导报, 2012, 18(9): 1288-1290.
41. Kim SY, Wolfe DS, Taub CC. Cardiovascular outcomes of pregnancy in Marfan's syndrome patients: A literature review. Congenit Heart Dis, 2018, 13(2): 203-209.
42. den Hartog AW, Franken R, Zwinderman AH, <italic>et al</italic>. The risk for type B aortic dissection in Marfan syndrome. J Am Coll Cardiol, 2015, 65(3): 246-254.
43. Judge DP, Dietz HC. Marfan's syndrome. Lancet, 2005, 366(9501): 1965-1976.
44. Braverman AC, Moon MR, Geraghty P, <italic>et al</italic>. Pregnancy after aortic root replacement in Loeys-Dietz syndrome: High risk of aortic dissection. Am J Med Genet A, 2016, 170(8): 2177-2180.
45. Gersony DR, McClaughlin MA, Jin Z, <italic>et al</italic>. The effect of beta-blocker therapy on clinical outcome in patients with Marfan's syndrome: a meta-analysis. Int J Cardiol, 2007, 114(3): 303-308.
46. Lydakis C, Lip GY, Beevers M, <italic>et al</italic>. Atenolol and fetal growth in pregnancies complicated by hypertension. Am J Hypertens, 1999, 12(6): 541-547.
47. Yetman AT, Bornemeier RA, McCrindle BW. Usefulness of enalapril versus propranolol or atenolol for prevention of aortic dilation in patients with the Marfan syndrome. Am J Cardiol, 2005, 95(9): 1125-1127.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Comprehensive management of aortic dissection during pregnancy

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