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Wang X, Liu X, Liao E, Ge N, Hu Y. Pregnancy complicated with aortic dissection: Two cases report. Medicine (Baltimore) 2022; 101:e31487. [PMID: 36343070 PMCID: PMC9646651 DOI: 10.1097/md.0000000000031487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
RATIONALE This study aims to investigate the characteristics of pregnancy complicated with aortic dissection (AD), diagnosis and treatment plan, and maternal and infant outcomes. PATIENT CONCERNS Two pregnant women suffered persistent back pain were admitted to Hubei Maternal and Child Health Hospital from December 2019 to December 2020. DIAGNOSIS Pregnant women with chest and back pain and especially hypertension should be highly suspected of AD. However, to confirm diagnosis results, laboratory tests such as D-dimer, fibrinogen and white blood cells, and even some Special examination, cardiac ultrasound, computed tomographic angiography (CTA), magnetic resonance angiography (MRA), are required. Early diagnosis and intervention can improve maternal and infant outcomes. INTERVENTIONS Cesarean sections were performed in both patients. Case 1 underwent thoracic aortic stent implantation one day after the onset of AD symptoms. Case 2 received endovascular repair of AD 4 days after the onset of AD symptoms. OUTCOMES In these two cases, good maternal and infant outcomes were obtained through effective early identification and treatment. LESSONS AD is characterized with an acute onset, and the rates of misdiagnosis and missed diagnosis are high, which seriously endangers the life of mother and child. Hypertension is one of the high-risk factors causing AD. Good maternal and infant outcomes can be achieved by early identification, multidisciplinary collaboration and timely cardiac surgical intervention.
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Affiliation(s)
- Xiaoli Wang
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xi Liu
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - E. Liao
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ning Ge
- Radiology Department, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yaping Hu
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- * Correspondence: Yaping Hu, Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, No. 745, Wuluo Road, Hongshan District, Wuhan 430070, China (e-mail: )
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Fernando RJ, Johnson SD, Richardson K. Intraoperative Transesophageal Echocardiographic Detection of a Gerbode Defect in a Patient Referred for Aortic Valve Endocarditis: A Case Report. Semin Cardiothorac Vasc Anesth 2022; 26:245-252. [PMID: 35412867 DOI: 10.1177/10892532221080920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This clinical challenge discusses a case in which a patient was referred for aortic valve repair or replacement due to severe aortic regurgitation from infective endocarditis. In addition to discovering a previously unknown tricuspid valve vegetation, the intraoperative echocardiographic evaluation was instrumental in revealing an undiagnosed Gerbode defect. The flow through this Gerbode defect was previously mistaken for tricuspid regurgitation, and the patient was misdiagnosed as exhibiting severe pulmonary hypertension. This case highlights the importance of reviewing preoperative echocardiographic imaging, as well as diligence in completing a thorough intraoperative transesophageal echocardiographic exam prior to cardiopulmonary bypass. In addition, while flow typically occurs in Gerbode defects during systole, this case demonstrates that flow can also occur during diastole, which was most likely due to the severe aortic regurgitation. Fortunately, the patient was able to undergo successful treatment for the unexpected sequalae of the infective endocarditis, including repair of the Gerbode defect, tricuspid valve repair, and aortic valve and root replacement. Importantly, the incorrect diagnosis of severe pulmonary hypertension was removed.
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Affiliation(s)
- Rohesh J Fernando
- Department of Anesthesiology, Cardiothoracic Division, 12279Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Sean D Johnson
- Department of Anesthesiology, Cardiothoracic Division, 12279Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Karl Richardson
- Department of Cardiology, 12279Wake Forest School of Medicine, Winston Salem, NC, USA
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Ayati A, Sarraf S, Asl Fallah S, Bagheri J, Ahmadi Tafti H, Same K, Hosseini K. Aortic dissection in the first trimester; is it a dead end? A narrative review of recent articles. J Card Surg 2022; 37:1705-1711. [PMID: 35352396 DOI: 10.1111/jocs.16451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/13/2022] [Accepted: 02/17/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Acute-type aortic dissection (AD) during pregnancy is considered a rare and potentially fatal complication for both mother and fetus. Although the definite treatment for an acute-type AD is considered to be open-heart surgery, the decision to perform such a surgery during pregnancy requires a multidisciplinary approach and carries significant risks. METHODS In the present review of the literature, we have discussed various challenges in the management of acute-type AD during pregnancy, including therapeutic approaches, choosing the preferred imaging modalities, surgical techniques, and medication challenges. We have also reported an 8-week pregnant woman with Marfan syndrome who presented with chest pain and was diagnosed with acute AD. RESULTS The patient underwent a Bentall operation and was discharged in good condition with her fetus alive. The medical team's various decisions during preoperative, operative, and postoperative treatments were discussed. CONCLUSIONS Type A AD is considered infrequent in the second and third trimester of pregnancy and rare in the first trimester. Performing a CMR study without contrast in stable patients can help evaluate the extension of the flap. Urgent surgery in the hands of a skilled surgeon may prove lifesaving for the mother while maximizing the likelihood of preserving the fetus.
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Affiliation(s)
- Aryan Ayati
- Tehran Heart Center, Tehran Heart Center Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Syna Sarraf
- Tehran Heart Center, Tehran Heart Center Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sahar Asl Fallah
- Rajaie Cardiovascular Medical And Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Jamshid Bagheri
- Tehran Heart Center, Tehran Heart Center Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Ahmadi Tafti
- Tehran Heart Center, Tehran Heart Center Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Research Center for Advanced Technologies in Cardiovascular Medicine, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Kaveh Same
- Tehran Heart Center, Tehran Heart Center Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kaveh Hosseini
- Tehran Heart Center, Tehran Heart Center Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Augoustides JG. Protecting the Central Nervous System During Cardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00022-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Liu LW, Luo L, Li L, Li Y, Jin M, Zhu JM. Combined cesarean delivery and repair of acute aortic dissection at 34 weeks of pregnancy during COVID-19 outbreak: A case report. World J Clin Cases 2021; 9:3644-3648. [PMID: 34046464 PMCID: PMC8130093 DOI: 10.12998/wjcc.v9.i15.3644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/16/2021] [Accepted: 04/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, the exclusion of a patient from COVID-19 should be performed before surgery. However, patients with type A acute aortic dissection (AAD) during pregnancy can seriously endanger the health of either the mother or fetus that requires emergency surgical treatment without the test for COVID-19.
CASE SUMMARY A 38-year-old woman without Marfan syndrome was admitted to the hospital because of chest pain in the 34th week of gestation. She has diagnosed as having a Stanford type-A AAD involving an aortic arch and descending aorta via aortic computed tomographic angiography. The patient was transferred to the isolated negative pressure operating room in one hour and underwent cesarean delivery and ascending aorta replacement. All medical staff adopted third-level medical protection measures throughout the patient transfer and surgical procedure. After surgery, the patient was transferred to the isolated negative pressure intensive care unit ward. The nucleic acid test and anti-COVID-19 immunoglobulin (Ig) G and IgM were performed and were negative. The patient and infant were discharged without complication nine days later and recovered uneventfully.
CONCLUSION The results indicated that the procedure that we used is feasible in patients with a combined cesarean delivery and surgery for Stanford type-A AAD during the COVID-19 outbreak, which was mainly attributed to rapid multidisciplinary consultation, collaboration, and quick decision-making.
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Affiliation(s)
- Li-Wei Liu
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Lan Luo
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Lu Li
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Yu Li
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Mu Jin
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Jun-Ming Zhu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
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Rimmer L, Heyward-Chaplin J, South M, Gouda M, Bashir M. Acute aortic dissection during pregnancy: Trials and tribulations. J Card Surg 2020; 36:1799-1805. [PMID: 32996191 DOI: 10.1111/jocs.15068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Type A acute aortic dissection (TAAD) during pregnancy is a life-threatening event for both the mother and the unborn baby. Pregnancy has been recognized as an independent risk factor for TAAD, postulated to be due to physiological changes that cause hyperdynamic circulation. This review seeks to outline the current controversies around this unique group. METHODS A comprehensive literature search was carried out across large databases to assimilate relevant papers regarding acute aortic dissection in pregnant women. RESULTS The presentation can be atypical in many cases and further concern from clinicians of fetal radiation exposure can result in missed or delayed diagnoses. Investigation via the quickest form of imaging, whether computed tomography, magnetic resonance imaging, or transesophageal echocardiography, should be carried out promptly due to the high risk of mortality. Surgical management of TAAD in pregnancy revolves primarily around the decision to deliver the fetus concomitantly or to perform the aortic repair with the fetus in utero. CONCLUSIONS Management of this group includes rapid and dynamic assessment without delay. From conception to postpartum, there are multiple stages in which to manage these women. Challenges in carrying out management in the form of operative techniques and cardiopulmonary bypass place the fetus at risk and must be approached with caution, particularly as there is little evidence-base for many of these decisions. Further research into reducing maternal and fetal mortality is necessary.
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Affiliation(s)
- Lara Rimmer
- Vascular Surgery Department, Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Jessica Heyward-Chaplin
- Vascular Surgery Department, Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Matthew South
- Vascular Surgery Department, Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Mohamed Gouda
- Department of Vascular and Endovascular Surgery, Mataria Teaching Hospital, Cairo, Egypt
| | - Mohamad Bashir
- Vascular Surgery Department, Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
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Ma WG, Zhu JM, Chen Y, Qiao ZY, Ge YP, Li CN, Zheng J, Liu YM, Sun LZ. Aortic dissection during pregnancy and postpartum in patients with Marfan syndrome: a 21-year clinical experience in 30 patients. Eur J Cardiothorac Surg 2020; 58:294-301. [PMID: 32259204 DOI: 10.1093/ejcts/ezaa048] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 01/14/2020] [Accepted: 01/31/2020] [Indexed: 01/15/2023] Open
Abstract
Abstract
OBJECTIVES
Pregnancy-related aortic dissection (AoD) in Marfan syndrome is a lethal catastrophe. Due to its rarity and limited clinical experience, there is no consensus regarding the optimal management strategy. We seek to present our 21-year experience in such patients , focusing on management strategies and early and late outcomes.
METHODS
Between 1998 and 2019, we managed 30 pregnant women with Marfan syndrome (mean age 30.7 ± 4.3 years) who sustained AoD at a mean of 28.3 ± 8.8 weeks of gestation (GWs). AoD was acute in 21 (70%), type A (TAAD) in 24 (80%) and type B (TBAD) in 6 (20%). Fourteen TAADs (58.3%, 14/24) and 2 TBADs (33.3%, 2/6) occurred in the third trimester or postpartum. The maximal aortic size was < 45 mm in 26.7% (8/30; 3 TAADs, 5 TBADs). Management strategy was based on the types of dissection and GWs (i.e. surgical versus medical treatment, surgery or delivery first).
RESULTS
TAADs were treated medically in 1 and surgically in 23. The timing of delivery and surgery were caesarean first at 35.4 ± 6.1 GWs in 7 (29.2%), followed by surgery after mean 46 days; single-stage C-section and surgery at 32.0 ± 5.0 GWs in 10 (41.7%); and surgery first at 18.0 ± 5.8 GWs in 6 (25%), followed by C-section after 20 days. Maternal and foetal mortality were 28.6% (2/7) and 14.3% (1/7), 10.0% (1/10) and 20.0% (2/10) and 16.7% (1/6) and 83.3% (5/6), respectively. Five TBADs (83.3%) were managed with C-section followed by surgery in 2 and medical treatment in 3. The respective maternal and foetal mortality were 50% (1/2) and 100% (2/2) and 33.3% (1/3) and 33.3% (1/3), respectively. One TBAD was managed surgically first followed by C-section, resulting in maternal survival and foetal death. Follow-up was complete in 95.8% (23/24) at 3.7 ± 2.9 years. Four late deaths occurred and reoperation was performed in 1 patient. Maternal and foetal survival were 64.3% and 54.1% at 6 years, respectively.
CONCLUSIONS
Management of AoD in pregnant women with Marfan syndrome should be based on types of dissection (surgical versus medical) and gestational age (delivery or surgery first), which largely determine maternal and foetal survival. Aortic repair should be considered prior to conception in women with Marfan syndrome even at diameters smaller than recommended by current guidelines.
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Affiliation(s)
- Wei-Guo Ma
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Jun-Ming Zhu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Yu Chen
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Zhi-Yu Qiao
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Yi-Peng Ge
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Cheng-Nan Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Jun Zheng
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Yong-Min Liu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
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Tran TQ. Successful emergency management for aortic arch rupture in pregnancy at first trimesters: A case report. Int J Surg Case Rep 2019; 64:28-30. [PMID: 31593914 PMCID: PMC6796710 DOI: 10.1016/j.ijscr.2019.09.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/31/2019] [Accepted: 09/17/2019] [Indexed: 01/02/2023] Open
Abstract
The report about aortic arch rupture occurring during first-trimester pregnancy was very rare. It is the emergency condition with high mortality and the fetal loss is common. Emergency surgery for total aortic arch replacement in first-trimester pregnancy was safe for both mother and fetus.
Background The aortic dissection and rupture in pregnancy are uncommon clinical situation, but they are emergency condition with high mortality for both mother and fetus. Here, we report a successful emergency management for pregnancy at first trimesters with aortic arch rupture in Vietnam. Case presentation A young pregnant woman (20-year-old) at 12-week’s gestation was transferred to our hospital due to chest pain (last 7 days on treatment) in severe medical condition: conscious responses to stimuli, oxygen 2 l/min directly through endotracheal tube, and hypertension (170/90 mmHg). The chest computed tomography scanner showed aortic arch aneurysm with the image of rupture. An urgent surgery for total aortic arch replacement with cardiopulmonary bypass (185 min) including heart arrest period (cross clamp time 80 min), and general hypothermia (25 °C) performed. She was discharged after 20 days with a normal pregnancy development. Discussion Aortic arch dissection occurring during 1st trimester was very rare. The mortality of aortic dissection without any treatments increased up to 70% at one week after presentation. The aortic arch replacement surgery was successful recuse her, and fortunately, the fetus was safe. Conclusion An emergency surgery for aortic arch replacement was safety for both mother and fetus at 12-week’s gestation.
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Affiliation(s)
- Tien Quyet Tran
- Cardiovascular Center, Cho Ray Hospital, Ho Chi Minh City, Viet Nam; Department of Cardiovascular Thoracic Surgery, University of Medical and Pharmacy at Ho Chi Minh City, Viet Nam.
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Aortic dissection in the third trimester pregnancy without risk factors. Taiwan J Obstet Gynecol 2019; 58:723-724. [DOI: 10.1016/j.tjog.2019.07.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2018] [Indexed: 12/26/2022] Open
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Lei Y, Jiang Z, Chen J, Wang D, Hong G, Chen S. Type A aortic dissection in pregnant patients with fibrillin-1 gene mutations: Two case reports and a literature review. Exp Ther Med 2018; 16:4407-4414. [PMID: 30542390 PMCID: PMC6257332 DOI: 10.3892/etm.2018.6761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 07/20/2018] [Indexed: 01/03/2023] Open
Abstract
In acute aortic dissection (AD) in pregnancy, increased cardiovascular stress due to pregnancy is an important factor leading to an emergent aortic event. It is rare but often results in a devastating event for both the pregnant patient and the foetus. Two cases of acute AD (Stanford type A) in pregnant females are presented in the present study. The patients were diagnosed via echocardiography, and the diagnosis was confirmed with computed tomography angiography prior to aortic surgery. Up to 50% of ADs in pregnancy occur in patients with fibrillin-1 (FBN1) gene mutations. The FBN1 gene was sequenced in both patients, and notable, novel pathogenic mutations of FBN1 were identified in both patients. A literature review was also performed on available diagnostic imaging and other measurements regarding AD during pregnancy. The authors suggest that the relevant content may have important clinical implications in raising disease awareness, arranging test rationally and choosing an intervention method.
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Affiliation(s)
- Yuanli Lei
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Zhelong Jiang
- Department of Emergency Medicine, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, Zhejiang 310000, P.R. China
| | - Jiaozhen Chen
- Department of Electrocardiogram, Wenzhou People's Hospital, Wenzhou, Zhejiang 325000, P.R. China
| | - Dongsheng Wang
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Guangliang Hong
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Shouquan Chen
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
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