European Heart Journal Advance Access originally published online on May 25, 2005
European Heart Journal 2005 26(13):1342-1343; doi:10.1093/eurheartj/ehi267
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Type A aortic intramural haematoma vs. dissection: reply
Hospital Gen. Universitari Vall D'Hebron
Servei de Cardiología, Paseo Vall d'Hebron 119–129,
Barcelona, Spain
Tel: 34 93 2746212
Fax: 34 93 2746244
E-mail address: aevangel{at}hg.vhebron.es
The letter of Pocar et al.1 underlines important queries regarding the management of aortic intramural haematoma, which have not yet been definitively answered. Mortality in our series of 68 intramural haematoma was high (19%) in the first 3 months of evolution.2 On multivariate analysis, mortality-related variables were diameter >50 mm and ascending aorta involvement. We agree that in this series ascending aorta involvement was low (18%), and similar to that described in other series.3,4 The majority of published studies report type A mortality similar to type A dissection, except in the Asian groups. Intramural haematoma represents 10–15% of acute aortic syndrome; however, in the Asian series the incidence is much higher (20–40%). This greater frequence of intramural haematoma could suggest that these groups have greater sensitivity in the diagnosis of this disease, with mild haematomas and better prognosis being included. In contrast, in the western reference centres, with a high proportion of patients referred from other institutions, the haematomas are more extensive and evident, and probably have worse prognosis. The low incidence of type A haematoma in our series could indicate a group with relatively poor prognosis, with mortality being 37% in the surgically treated group and 75% in the group treated medically. The case reported by Pocar et al.1 shows that a thin type A haematoma, and with no aortic dilatation, may evolve to aortic dissection, although in the case described the dissection was located only at the origin of the left carotid artery. Our group reported that 36% of intramural haematomas evolve with dissection of a more or less extensive aortic segment.5
Our cautious statement that surgery might be indicated in the therapeutic management of type A haematoma refers simply to the fact that our data do not permit this to be confirmed, as this was not the aim of the study. However, Pocar's case1 does not contribute definitive evidence either.
Thus, our study does not provide an answer to the question of whether or not all type A haematomas should be operated on, although we consider that the persistence of symptoms, poor haemodynamic control, aorta diameter >50 mm, and haematoma thickness imply poor prognosis. It is likely that in patients without these poor prognostic factors surgery might not be done on an emergency basis and be performed under the best conditions in the first 24–48 h. In any event, whether or not reabsorption of the haematoma implies that the disease is cured, remains to be defined. In our series, a patient with ascending aorta reabsorption presented a type A dissection at 9 months of follow-up. Regarding endovascular treatment of type B haematoma, there are currently no extensive series in the literature that demonstrate its benefit. However, it could constitute a therapeutic alternative when symptoms persist and the haematoma has an extension shorter than the length of the stent, particularly if accompanied by a large aortic ulcer.
References
- Pocar M, Di Bartolomeo R, Donatelli F. Type A aortic intramural haematoma vs. dissection. Eur Heart J doi:10.1093/eurheartj/ehi266.
- Evangelista A, Dominguez R, Sebastiá C, Salas A, Permayer-Miralda G, Avegliano G, Gómez-Bosch Z, González-Alujas T, García del Castillo H, Soler-Soler J. Prognostic value of clinical and morphologic findings in short-term evolution of aortic intramural haematoma. Therapeutic implications. Eur Heart J 2004;25:81–87.
[Abstract/Free Full Text] - Ganaha F, Miller C, Sugimoto K, Do YS, Minamiguchi H, Saito H, Mitchell S, Dake M. Prognosis of aortic intramural hematoma with and without penetrating atherosclerotic ulcer: a clinical and radiological analysis. Circulation 2002;106:342–348.
[Abstract/Free Full Text] - Nishigami K, Tsuchiya T, Shono H, Horibata Y, Honda T. Disappearance of aortic intramural hematoma and its significance to the prognosis. Circulation 2000;102(Suppl. III):III243–III247.
- Evangelista A, Dominguez R, Sebastia C, Salas A, Permanyer-Miralda G, Avegliano A, Elorz C, González-Alujas T, García del Castillo H, Soler-Soler J. Long-term follow-up of aortic intramural hematoma predictors of outcome. Circulation 2003;108:583–589.
[Abstract/Free Full Text]
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