Retrograde type a dissection in a 24th gestational week pregnant patient – the importance of interdisciplinary interaction to a successful outcome

Abstract

BackgroundType A Dissection in pregnancy is a devastating medical condition with 2 lives at stake and unclear strategy at early gestational stages. We describe a successful outcome, clearly dependent on the coordination of all involved disciplines.Case presentationThis case history describes a 28 year old female with a 24th week pregnancy gravida 2 para 0 with a DeBakey Type I aortic dissection, diagnosed via ultrasound. Surgery was perfomed on the day of diagnosis. After conferral with the mother, caesarean section was performed and a 690 g fetus could be delivered and was immediately transferred to the neonatal unit. Subsequent aortic repair was performed after hysterectomy, with replacement of the ascending aorta and hemiarch treatment. Intraoperatively no entry in the ascending aorta or transverse arch could be demonstrated, so that a retrograde Type A with entry distal to the left subclavian had to be postulated. We decided to perform subsequent computer tomography, demonstrating multiple entry sites in the descending aorta distal to the left subclavian artery. Successful endovascular treatment could be performed with a Medtronic Valiant Stent via a transfemoral approach. The further hospital stay was uneventful and the patient could be discharged on the 18th postoperative day. The baby demonstrated fighter qualities and could be discharged home after a 3 month hospital stay to be reunited with his mother.ConclusionPrompt diagnosis, precise coordination between all involved subspecialties and ultimately, as in this case, definitive treatment in consensus with operative and interventional departments have led to a successful outcome and encourages us in our daily struggle in this often demanding surgery.

Successful Outcomes following Repair of a Type A Aortic Dissection during Pregnancy

“…3,5 Hypertensive complications of pregnancy, like preeclampsia, also confer a risk. 6 Thus, it is not surprising that pregnancy has been proposed as an independent risk factor for aortic dissection. More recently, however, the association between pregnancy and aortic dissection has been attributed to selective reporting.…”

Aortic Aneurysm and Dissection in Pregnancy: Report of a Rare Case in a Marfan with Bicuspid Aortic Valve

“…In the literature, there are several approaches to treat this disease urgently based on gestational time, such as (1) repairing the ascending aorta with the fetus inside the uterus when the pregnancy is under 28 weeks, (2) performing an urgent C-section after 32 weeks of gestation and immediately after repair/replace the damaged aorta, and (3) performing aortic surgery and C-section simultaneously. 2,13 It remains controversial whether to perform a C-section before or repair the ascending aorta when pregnancy is between 28 and 32 weeks.…”

“…1 Acute aortic dissection occurs more often during the third trimester due to hemodynamic changes characteristic of this period, such as increased cardiac output, vascular Ind J Car Dis Wom:2020;5:331-334 resistance, and water retention. 2,3 A correlation between pregnancy and aortic dissection is mainly reported in patients with family history and connective tissue disorders, such as Marfan's syndrome (MS), Loeys-Dietz's syndrome, and Ehlers-Danlos's syndrome, and patients with bicuspid aortic valve (BAV); exceptional cases are also described in patients without risk factors. 4 In patients with MS, the risk of developing aortic dissection during pregnancy is approximately 1% when the aortic root is <40 mm and approximately 3% when the aortic root is >40 mm, with an increasing risk compared with aortic size.…”

Surgical management of a type A aortic dissection in a pregnant patient

“…18 Staged repair of type A ADs in pregnant patients has been reported in the past, patients with gestational ages ranging from 24 to 36 weeks and the interval between delivery and repair of the aortic defect occurring in the context of patient stability. 19,20 In our patient's case, the clinical team decided to have the patient undergo cesarean section first, in case of any hemodynamic instability that may have developed during the procedure. This was decided in the context of the mother in this case report being relatively stable, the fetus having reached relative gestational maturity, and in keeping with the current literature.…”