1. Aortic Surgery Symposium 2010 New York, NY April, 2010 Department of Cardiothoracic and Vascular Surgery The University of Texas Medical School at Houston Memorial Hermann Heart & Vascular Institute Anthony Estrera, MD, Charles Miller, III, PhD, Taek-Yeon Lee, MD, Paola De Rango, MD, MD, T. Kaneko, MD, Hazim Safi, MD Acute Type A Intramural Hematoma: Analysis of Current Management Strategy

2. Unstable, Tamponade Acute Type A IMH Emergent Surgery (pericardial window) Stable Initial Medical Optimize Urgent Surgery Background

3. Purpose  Analyze our experience managing acute Type A intramural hematoma  Compare outcomes with Typical Acute Type A dissection  Validate our treatment approach

4. Methods 251 Acute Type A Aortic Dissection Oct. 1999 – May 2008 Median age: 62 (21-91) 64% 36% 36 IMH (14%)

5. Methods 28 Patients (78%) Managed With Optimal Medical Management With Eventual Surgical Treatment 1 Patient (3%) Medical Management Only 7 Patients (19%) Repaired On Presentation 36 Patients (IMH)

6. Methods

7. IMH vs. Typical Variable IMH (n=36) Typical (n=215) P-Value Age (yr) 63 ± 1458 ± 15 0.06 Male66%71%0.72 Chest pain100%88%0.04 Abdominal Pain6%10%0.59 Hypotension (<90)8%22%0.07 Tamponade6%16%0.16 Aortic insuff (>mod)11%38%0.002 Asc. Diameter (cm)5.2 ± 0.85.0 ± 0.80.17 Preoperative

8. IMH vs. Typical Variable IMH (n=36) Typical (n=215) P-Value Total Arch14%6%0.07 Aortic Root3%6%0.45 Cannulation (Fem/Asc/Axilla) 32/1/2206/3/60.08 Peripheral bypass3%1%0.73 CABG9%5%0.34 Intra-operative

9. IMH vs. Typical Variable IMH (n=36) Typical (n=215) P-Value Myocardial Infarct6%7%0.78 Stroke0%1%0.99 Temp Neuro Dysfunct9%10%0.73 Bleeding0%7%0.13 Mortality8%13%0.68 Conversion to Typical33%NA Post-operative

10. Results by Approach Variable Immediate (n=7) Medical then Repair (n=28) Medical only (n=1) P-Value Mortality14%7%0%0.69 Conversion to Typical 14%39%0%0.70 Time Sx to OR (Days) 0.8 ± 0.86.5 ± 4.1 NA0.001 Admit to OR (Days) 0.6 ± 0.85.3 ± 3.6 NA0.002 Aortic Size (cm) 5.3 ± 1.15.2 ± 0.74.80.99

11. Risk of Conversion

12. 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, although purposeful delay can be safely achieved in certain patients, timely surgical repair is recommended.