1. Acute Aortic Dissection AM Report 6/29/09 Brandon M. Williams, MD

2. Classification Two systems: DeBakey Daily (Stanford) = most used

3. DeBakey Type 1: origin in ascending aorta and propagates to at least arch Type 2: origin in ascending and confined within ascending Type 3: origin in descending and extends (distally or proximally)

4. Daily (Stanford) Type A: involves ascending aorta Type B: all others - Nomenclature doesn’t change secondary to site of origin

5. Daily (Stanford)

6. Pathophysiology Tear in aortic intima Need degeneration of media or cystic medial necrosis for nontraumatic dissections Blood crosses into media via tear and separates intima from media/adventitia creating a false lumen ? If rupture of intima or hemorrhage within media causing rupture of intima is initiating event

7. Incidence Acute aortic dissection - 2.6-3.5/100,000 person years

8. Incidence Classic is 60 – 80 yo males (mean 63yo) Women 67 Ascending 2x more likely than descending, with right lateral wall most common site

9. Risk Factors 13% with known aortic aneurysm (19% if < 40yo) Inflammatory disease vasculitis -giant cell arteritis -takayasu arteritis -rheumatoid arthritis -syphilitic aortitis

10. Risk Factors HTN (71%) Atherosclerosis (31%) DM (5.1%) Collagen disorders (Marfan, Ehlers-Danlos) 19% of thoracic with family history Bicuspid aortic valve (9% < 40yo) Aortic coarctation (post intervention) CABG AVR Cardiac catheterization Trauma High-intensity weight lifting and cocaine via transient HTN - cocaine 37% of AA inner city population

11. Signs and Symptoms Abrupt, tearing pain, back (if distal to L subclavian) or anterior (ascending) Associated: syncope, CVA, MI, HF Syncope assoc with worse outcome (almost all type A) Pulse deficit Aortic insufficiency: murmur more at RSB than valve assoc AI (LSB) >20mmHg difference in SBP between UE Vocal cord paralysis (compression of L laryngeal nerve) Hypotension (hemorrhage, tamponade, HF) Spinal cord ischemia “STEMI:” 3/820 EKGs showing STEMI found to have ascending aortic dissection

12. Images

16. Diagnosis Abrupt onset of pain, tearing/ripping Mediastinal/aortic widening on Chest X ray Variation in pulse

17. Imaging Chest Xray TTE TEE CTA chest MRI Coronary angiography

18. Images

21. Treatment Involvement of ascending aorta = surgical emergency Descending aorta: medical management unless progression or hemorrhage into pleural or retroperitoneal space -morphine -SBP 100-120 or lowest tolerated *beta blocker titrate to HR < 60 (labetalol, propranolol, esmolol) *if beta blocker intolerant: verapamil, diltiazem *no nitroprusside until HR < 60 *no hydralazine *no inotropic agents, if hypotensive look for bleeding A-line in radial artery with highest auscultatory pressure

23. References UpToDate Management of Patients with Aortic Dissection. Weigang et al. Dtsch Arztebl Int. 2008 Sep. 105 (38) 639-645 Conditions mimicking acute ST-segment elevation myocardial infarction in patients referred for primary percutaneous coronary intervention. Gu et at. Neth Heart Journal. 2008 Oct: 16 (10) 325-31 Google images