///2017 Abstract Details
2017 Abstract Details2019-08-02T15:54:53-05:00

Type A Aortic Dissection in Pregnancy: A Case Report

Abstract Number: SUN-59
Abstract Type: Case Report/Case Series

Houry Kahwajian M.D.1 ; Jim Nguyen M.D.2; Alexander Bailey M.D.3; Nicola D'Attellis M.D.4; Andrew Geller M.D.5; Mark Zakowski M.D.6

Introduction: Acute aortic dissection is a rare but potentially devastating complication of pregnancy. A 32 year-old pregnant female with gestational hypertension presented with acute type A aortic dissection.

Case: A 32 y.o. female at 32 1/7 weeks gestation, PMH gestational hypertension on no medications, arrived from an outside hospital via helicopter. She presented earlier in the day with severe chest pain radiating to the abdomen and back, shortness of breath, diarrhea, and vomiting. CT of the chest/abdomen/pelvis at the outside hospital showed a Type A aortic dissection with a dissection flap extending from the aortic root to iliac arteries. She arrived on an esmolol drip and in our ICU had BP 97/71 and HR 93. She was awake, mentally alert, and moving all extremities. Multidisciplinary team planning occurred. Within an hour she was brought to the Cardiac OR for an emergency cesarean section and Type A aortic dissection repair.

In OR, she was placed supine in LUD and arterial line and central venous access obtained. General anesthesia was induced RSI with propofol, succinylcholine and fentanyl. TEE showed the aortic tear to be directly above the sinotubular junction extending into the noncoronary sinus. OB team performed Cesarean delivery. NICU team performed resuscitation; Apgars were 1, 2 and 3 at 10 min. Oxytocin infusion was started upon delivery, and continued during the cardiac portion of the case. After uterine closure and packing the pelvis, the cardiothoracic surgery team established cardiopulmonary bypass, deep hypothermic circulatory arrest, retrograde cerebral perfusion, and replacement of ascending aorta and aortic hemi-arch with a gelweave graft, with re-suspension and reconstruction of the sinotubular junction. Total circulatory arrest time was 30 minutes. Patient tolerated the procedure well and went to ICU. She was extubated the following day and was neurologically intact. She was discharged home on POD#8 and baby on POD#32.

Discussion: Acute aortic dissection is a rare but potentially devastating complication that is magnified when pregnant, most commonly associated with hypertension, connective tissue disorders, bicuspid aortic valve, or trauma. However our patient’s only risk factor was her history of gestational hypertension. In women <40 y.o, half of the aortic dissections are associated with pregnancy, most frequently in the third trimester or immediate postpartum period. During pregnancy, the rate of aortic dissection was 0.0004% in the United Sates, and represented 0.1% of all dissection cases. Prompt multidisciplinary collaboration is necessary for optimal outcome.

References:

Aortic dissection in pregnancy: analysis of risk factors and outcome. Ann Thorac Surg. 2003; 76:309–314.

Aortic dissection and mortality associated with pregnancy in the United States. J Am Coll Cardiol. 2015;65:1600–1601.

Thoracic aortic aneurysm and dissection. J Am Coll Cardiol. 2014 Oct 21;64(16):1725-39.

SOAP 2017