Острый аортальный синдром магистр второго года обучения по специальности «Кардиология»

Острый аортальный синдром - общее понятие для описания состояний, вызванных острым прогрессирующим нарушением целостности стенки аорты.

Pathophysiology Medial degeneration Intimal tear

Epidemiology Knowledge regarding the incidence of aortic dissection in the general population is limited. Studies suggest an incidence of 2.6 to 3.5 cases per 100000 person-years. In a review of 464 patients from the International Registry of Acute Aortic Dissection (IRAD), two thirds were male, with a mean age for all patients of 63 years. Although less frequently affected by acute aortic dissection, women were significantly older than men, with a mean age of 67 years.

Risk Conditions for Aortic Dissection 3. Vascular inflammation Giant cell arteritis Takayasu arteritis Behcet’s disease Syphilis Ormond’s disease 4. Deceleration trauma Car accident Fall from height 5. Iatrogenic factors Catheter/instrument intervention Valvular/aortic surgery Side or cross-clamping/aortotomy Graft anastomosis Patch aortoplasty Aortic wall fragility 1. Long-standing arterial hypertension Smoking, dyslipidemia, cocaine/crack 2. Connective tissue disorders Hereditary vascular disease Marfan syndrome Vascular Ehlers-Danlos syndrome (type 4) Bicuspid aortic valve Coarctation of the aorta Hereditary thoracic aortic aneurysm/dissection

Demographics and history of patients with acute aortic dissection (N=464) Variable n* (%) Type A, n (%) (N=289) Type B, n (%) (N=175) P, Type A vs B Demographics   Age, mean (SD), y 63.1 (14.0) 61.2 (14.1) 66.3 (13.2) <0.001 Male 303 (65.3) 182 (63.0) 121 (69.1) 0.18 Patient history Marfan syndrome 22/449 (4.9) 19 (6.7) 3 (1.8) 0.02 Hypertension 326/452 (72.1) 194 (69.3) 132 (76.7) 0.08 Atherosclerosis 140/452 (31.0) 69 (24.4) 71 (42) Prior aortic dissection 29/453 (6.4) 11 (3.9) 18 (10.6) 0.005 Prior aortic aneurysm 73/453 (16.1) 35 (12.4) 4 (2.3) 0.006 Diabetes 23/451 (5.1) 12 (4.3) 11 (6.6) 0.29 Prior cardiac surgery 83 (17.9) 46 (15.9) 37 (21.1) 0.16 Adapted with permission from Reference 12, Copyright 2000, American Medical Association.

Independent predictors of in-hospital death Overall Model Variable Overall Type A, % Among Survivors, % Among Deaths, % Parameter Coefficient P OR for Death (95% CI) Age >70 y 35.2 30.0 46.1 0.53 0.03 1.70 (1.05–2.77) Female 34.5 30.7 42.7 0.32 0.20 1.38 (0.85–2.27) Abrupt onset pain 84.5 82.3 89.0 0.96 0.01 2.60 (1.22–5.54) Abnormal ECG 69.6 65.2 79.5 0.57 1.77 (1.06–2.95) Any pulse deficit 30.1 24.7 41.1 0.71 0.004 2.03 (1.25–3.29) Kidney failure 5.6 2.9 11.9 1.56 0.002 4.77 (1.80–12.6) Hypotension/shock/tamponade 29.0 20.1 47.1 1.09 <0.0001 2.97 (1.83–4.81)

Острый аортальный синдром Острое расслоение аорты Острый аортальный синдром Интрамуральная гематома Пенетрирующая язва

The most common classification systems of thoracic aortic dissection: Stanford and DeBakey Figure 1. The most common classification systems of thoracic aortic dissection: Stanford and DeBakey. Reproduced with permission from Reference 54, Copyright 2003, American Heart Association. All rights reserved. Tsai T T et al. Circulation 2005;112:3802-3813 Copyright © American Heart Association

Schematic of aortic dissection (left), penetrating ulcer (middle), and IMH (right). Figure 2. Schematic of aortic dissection (left), penetrating ulcer (middle), and IMH (right). Reprinted from Reference 22, Copyright 1997, with permission from Elsevier. Tsai T T et al. Circulation 2005;112:3802-3813 Copyright © American Heart Association

Michael Ellis Debakey 1908-2008

Golledge et al. Lancet 2008.

Mechanism of aortic regurgitation

Examples of AD by TTE Evangelista, et al. Eur J Echocardiogr 2010.

Diagram shows events leading to intramural hematoma, from rupture of vasa vasorum feeding aortic media to creation of intramedial hematoma with intact intimal layer. —Diagram shows events leading to intramural hematoma, from rupture of vasa vasorum feeding aortic media to creation of intramedial hematoma with intact intimal layer. Macura K J et al. AJR 2003;181:309-316 ©2003 by American Roentgen Ray Society

In-hospital mortality for IMH according to site of origin. Figure 4. In-hospital mortality for IMH according to site of origin. IMH was defined after the first imaging test failed to demonstrate IMH or dissection but the second test confirmed IMH or the first study showed IMH but no evidence of dissection. Reproduced with permission from Reference 58, Copyright 2005, American Heart Association. All rights reserved. Tsai T T et al. Circulation 2005;112:3802-3813 Copyright © American Heart Association

Examples of IMH Pics from Evangelista, et al. Eur J Echocardiogr 2010, Flachskampf, FA. Seminars in Cardiothoracic and Vascular Anesthesia 2006, and Meredith EL and Masani ND. Eur J Echocardiogr 2009

Examples of IMH Pics from google images

Axial double-inversion-recovery MR images (TR/TE, 1690/29; inversion time, 150 msec) of 76-year-old man with progression of intramural hematoma to overt dissection in ascending aorta within 6 days. —Axial double-inversion-recovery MR images (TR/TE, 1690/29; inversion time, 150 msec) of 76-year-old man with progression of intramural hematoma to overt dissection in ascending aorta within 6 days. Image shows high-signal-intensity crescentic intramural collection in ascending aorta (arrow), consistent with early subacute type A intramural hematoma. Macura K J et al. AJR 2003;181:309-316 ©2003 by American Roentgen Ray Society

Axial double-inversion-recovery MR images (TR/TE, 1690/29; inversion time, 150 msec) of 76-year-old man with progression of intramural hematoma to overt dissection in ascending aorta within 6 days. —Axial double-inversion-recovery MR images (TR/TE, 1690/29; inversion time, 150 msec) of 76-year-old man with progression of intramural hematoma to overt dissection in ascending aorta within 6 days. Image obtained 6 days after A shows that intramural hematoma progressed to type A aortic dissection within 6 days. Note signal intensity difference between true and false lumens. Signal void within true lumen reflects high-velocity blood flow, whereas higher signal within false lumen is related to slower, turbulent flow. Also note defect in intimomedial flap (arrow) representing intimal tear. Macura K J et al. AJR 2003;181:309-316 ©2003 by American Roentgen Ray Society

Diagram shows events leading to penetrating aortic ulcer from formation of extensive aortic atheroma confined to intimal layer, through lesion progression to deep ulceration of plaque with penetration into media, to entrance of blood from aortic lumen into media and splitting of media with intramural hematoma. —Diagram shows events leading to penetrating aortic ulcer from formation of extensive aortic atheroma confined to intimal layer, through lesion progression to deep ulceration of plaque with penetration into media, to entrance of blood from aortic lumen into media and splitting of media with intramural hematoma. Hematoma formation may extend along media, resulting in long-segment intramural hematoma. Macura K J et al. AJR 2003;181:309-316 ©2003 by American Roentgen Ray Society

Examples of PAU Pics from Meredith EL and Masani ND. Eur J Echocardiogr 2009 and Evangelista, et al. Eur J Echocardiogr 2010.

58-year-old woman presenting with severe back pain and penetrating atherosclerotic ulcer of aorta —58-year-old woman presenting with severe back pain and penetrating atherosclerotic ulcer of aorta. Multiplanar reformatted CT scan in sagittal view shows ulcer crater (open arrow) and long-segment intramural hematoma (solid arrows) in descending aorta. Macura K J et al. AJR 2003;181:309-316 ©2003 by American Roentgen Ray Society

58-year-old woman presenting with severe back pain and penetrating atherosclerotic ulcer of aorta —58-year-old woman presenting with severe back pain and penetrating atherosclerotic ulcer of aorta. Lateral angiogram of distal thoracic aorta shows anterior ulcerlike aortic lesion (arrow) filling with contrast material above level of celiac axis. Macura K J et al. AJR 2003;181:309-316 ©2003 by American Roentgen Ray Society

58-year-old woman presenting with severe back pain and penetrating atherosclerotic ulcer of aorta —58-year-old woman presenting with severe back pain and penetrating atherosclerotic ulcer of aorta. Contrast-enhanced CT scan obtained at level corresponding to A shows ulcer (arrow) filling with contrast material. Note that intramural hematoma presents as eccentric low-attenuation thickening of aortic wall. Macura K J et al. AJR 2003;181:309-316 ©2003 by American Roentgen Ray Society

83-year-old man with chronic obstructive pulmonary disease and hypertension —83-year-old man with chronic obstructive pulmonary disease and hypertension. Contrast-enhanced CT scan shows calcified atheromatous plaque with focal ulceration (arrow) but without contrast extravasation beyond plaque. Macura K J et al. AJR 2003;181:309-316 ©2003 by American Roentgen Ray Society

Diagram illustrates events leading to aortic dissection from formation of entrance tear and exit tear of intima to splitting of aortic media and formation of intimomedial flap —Diagram illustrates events leading to aortic dissection from formation of entrance tear and exit tear of intima to splitting of aortic media and formation of intimomedial flap. Blood under pressure dissects media longitudinally, and double-channel aorta is formed with blood filling both true and false lumens. Macura K J et al. AJR 2003;181:309-316 ©2003 by American Roentgen Ray Society

Examples of AD by TEE Meredith EL and Masani ND. Eur J Echocardiogr 2009.

61-year-old man with symptoms of right hemispheric stroke who was found to have marked blood pressure discrepancy between arms and hypertension —61-year-old man with symptoms of right hemispheric stroke who was found to have marked blood pressure discrepancy between arms and hypertension. Urgent CT scan (not shown) revealed type A aortic dissection. Patient went into asystole and died 15 hr after imaging. Axial CT scan shows dissection continuing along right wall of abdominal aorta (arrow). No enhancement of right kidney parenchyma was present. Macura K J et al. AJR 2003;181:309-316 ©2003 by American Roentgen Ray Society

61-year-old man with symptoms of right hemispheric stroke who was found to have marked blood pressure discrepancy between arms and hypertension —61-year-old man with symptoms of right hemispheric stroke who was found to have marked blood pressure discrepancy between arms and hypertension. Urgent CT scan (not shown) revealed type A aortic dissection. Patient went into asystole and died 15 hr after imaging. Axial CT scan shows irregular dissection flap within lumen of ascending and descending aorta (arrows). Macura K J et al. AJR 2003;181:309-316 ©2003 by American Roentgen Ray Society

68-year-old man with aberrant right subclavian artery and horseshoe kidney —68-year-old man with aberrant right subclavian artery and horseshoe kidney. Anteroposterior volume-rendered CT image of origin of aberrant subclavian artery depicts aberrant vessel course (arrow) better than axial scans A and B. Macura K J et al. AJR 2003;181:309-316 ©2003 by American Roentgen Ray Society

46-year-old man with concurrent intramural hematoma involving ascending aorta and communicating dissection involving descending aorta —46-year-old man with concurrent intramural hematoma involving ascending aorta and communicating dissection involving descending aorta. Axial contrast-enhanced CT scan obtained at same level as A shows wall thickening in ascending and descending aorta, but high-attenuation intramural hematoma is less obvious. Classic intimomedial flap (arrow) dividing true and false lumens in descending aorta is more conspicuous after contrast administration. Note irregular margin of flap on false lumen side. Intramural hematoma (arrowhead) is seen along lateral wall of false lumen. Macura K J et al. AJR 2003;181:309-316 ©2003 by American Roentgen Ray Society

46-year-old man with concurrent intramural hematoma involving ascending aorta and communicating dissection involving descending aorta —46-year-old man with concurrent intramural hematoma involving ascending aorta and communicating dissection involving descending aorta. Axial unenhanced CT scan shows hyperdense crescentic hematoma in wall of ascending aorta (white arrow) with eccentric narrowing of lumen, type A intramural hematoma. Small intramural hematoma (arrowhead) is also noted at left lateral aspect of proximal descending aorta. High-attenuation dissection flap (black arrow) is seen in descending aorta. Macura K J et al. AJR 2003;181:309-316 ©2003 by American Roentgen Ray Society

Initial management of patients with suspected aortic dissection Recommendation Class ECG: documentation of ischemia I Heart rate and blood pressure monitoring Pain relief (morphine sulfate) Reduction of systolic blood pressure with ß-blockers (intravenous metoprolol, esmolol, or labetelol) In patients with severe hypertension despite ß-blockers, additional vasodilator (intravenous sodium nitroprusside to titrate blood pressure to 100–120 mm Hg) In patients with obstructive pulmonary disease, blood pressure lowering with calcium channel blockers II Imaging in patients with ECG signs of ischemia before thrombolysis if aortic pathology is suspected Chest x-ray III All recommendations are level of evidence аdapted from Reference 43, by permission of Oxford University Press.

Surgical therapy of acute Type A (Type I and II) aortic dissection Recommendation Class Emergency surgery to avoid tamponade/aortic rupture I Valve-preserving surgery—tubular graft if normal-sized aortic root and no pathological changes in valve cusps Replacement of aorta and aortic valve (composite graft) if ectatic proximal aorta and/or pathological changes of valve/aortic wall Valve-sparing operations with aortic root remodeling for abnormal valves IIa Valve preservation and aortic root remodeling in Marfan patients All recommendations are level of evidence аdapted from Reference 43, by permission of Oxford University Press.

Fourteen-day mortality in 645 patients from the IRAD registry stratified by medical and surgical treatment in both type A and B aortic dissection. Figure 3. Fourteen-day mortality in 645 patients from the IRAD registry stratified by medical and surgical treatment in both type A and B aortic dissection. Adapted with permission from Reference 12, Copyright 2000, American Medical Association. All rights reserved. Tsai T T et al. Circulation 2005;112:3802-3813 Copyright © American Heart Association

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