Definitive treatment

Definitive treatment involves segmental resection of the dissection, with interposition of a synthetic graft.

When thoracic dissections are associated with aortic valvular disease, replace the defective valve.

With combined reconstruction–valve replacement, the operative mortality rate is approximately 5%, with a late mortality rate of less than 10%.

Operative repair of the transverse aortic arch is technically difficult, with an operative mortality rate of 10% despite induction of hypothermic cardiocirculatory arrest.

Repair of the descending aorta is associated with a higher incidence of paraplegia than repair of other types of dissections because of interruption of segmental blood supply to the spinal cord.

The operative mortality rate is approximately 5%.

In a study by Mimoun et al of patients with Marfan syndrome who had acute aortic dissection, the patients were found to have a better event-free survival when there were no dissected portions of the aorta remaining after surgery.^[3]

Consultations

Once a thoracic dissection is suspected, consult a thoracic surgeon. Because many patients with this disorder have concomitant medical illness, consult the patient's primary care provider to expedite preoperative preparation. Early consultation is encouraged when ordering further imaging studies if the patient requires rapid operative intervention.

Consult a radiologist prior to obtaining aortography.

Inpatient Care

Patients with symptomatic dissection should undergo immediate repair, especially if it is leaking or expanding.

Symptomatic patients require admission to a center experienced in cardiopulmonary bypass and operative care.

Completely asymptomatic patients may have their repair performed electively but may require admission to expedite their evaluation or for preoperative stabilization of their condition.

Patients with chest pain should undergo serial echocardiograms (ECGs) and creatine kinase (CK) determinations if acute myocardial infarction (AMI) is indicated.

Outpatient Care

Follow-up examinations with radiologic studies are recommended at 3-month intervals for the first year and every 6 months for the next 2 years.

After this, follow up annually.

Transfer

Symptomatic patients require care at a facility equipped to perform cardiopulmonary bypass with aortic and/or valvular repair.

Contact the receiving physician as soon as possible to transfer patients before their condition deteriorates.

Early airway management is indicated in the presence of hemoptysis or stridor.

If coronary insufficiency is suspected, nitrates may be used, but therapy with thrombolytic agents and aspirin should be avoided.

Patients should be monitored and accompanied by personnel capable of resuscitation.

If a prolonged ground transport time is anticipated, consider air transport.

Date: 2015-12-11; view: 1013