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(Circulation. 2009;120:S287-S291.)
© 2009 American Heart Association, Inc.

Surgery for Aortic Disease

Acute Type A Intramural Hematoma

Analysis of Current Management Strategy

Anthony Estrera, MD; Charles Miller, III, PhD; Taek-Yeon Lee, MD; Paola De Rango, MD; Saad Abdullah, MD; Jon-Cecil Walkes, MD; Dianna Milewicz, MD, PhD; Hazim Safi, MD

From the Department of Cardiothoracic and Vascular Surgery, Memorial Hermann Heart and Vascular Institute, and The University of Texas at Houston Medical School, Houston, Tex.

Correspondence to Anthony L. Estrera, MD, Cardiothoracic and Vascular Surgery, University of Texas Houston Medical School, 6400 Fannin, Suite 2850, Houston, TX 77030. E-mail anthony.l.estrera{at}uth.tmc.edu

Background— Management of acute type A intramural hematoma (IMH) remains controversial, varying from immediate surgery to medical management only. Conversion to typical dissection remains a concern. We analyzed our experience managing acute type A IMH.

Methods and Results— Between October 1999 and May 2008, 251 patients with acute type A aortic dissection were treated, including 36 (14.3%) with type A IMH. Seven IMH patients (19%) were repaired immediately, 28 (80%) managed initially with optimal medical management and eventual repair and 1 (3%) with medical management only. End points analyzed were early mortality and conversion to typical dissection (flow in the false lumen of the ascending aorta). Time (hours) from onset of symptoms defined initiation of IMH. Early mortality for acute type A IMH was 8.3% (3/36): 14.3% (1/7) with immediate repair and 7.1% (2/28) when optimal medical management with eventual repair was undertaken (P=0.69). The 1 medically managed Asian patient survived with resolution of the IMH. Conversion to type A IMH to typical dissection occurred in 33% (12/36) of cases. No conversions were observed within 72 hours. Aortic diameter did not predict conversion. In actuarial analysis among the initially medically managed group with eventual repair, the hazard conversion to typical dissection increased significantly at 8 days from the onset of symptoms (P<0.05).

Conclusions— Despite optimal medical management, conversion of type A IMH to typical dissection still remains a concern, with the most significant risk beyond 8 days. In our patient population, timely surgical repair is recommended.

Key Words: aorta • surgery • hematoma

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