Acute aortic dissection: All about this critical life-threatening disorder of the heart

Acute aortic dissection is a time critical life-threatening disorder affecting the aorta. Untreated type A dissection is almost always fatal. It is crucial to make early diagnosis and surgical treatment for survival of patients.

Aortic Dissection Awareness Day is an annual event held on September 19th to raise awareness about aortic dissection, a life-threatening condition that affects thousands of people every year. Aortic dissection is caused by a partial tear in the wall of the aorta converting it into 2 lumens, a true and false lumen. This tear then spreads along the length of the aorta causing problems with the blood supply to vital organs such as brain, bowels, kidneys, gut and limbs. If the tear occurs in the first part of the aorta, in the front of the chest, it is called a type A dissection. It can extend towards the heart causing leak in the aortic valve and bleeding in the chest cavity which can be life threatening. If it occurs in the aorta in the back of the chest it is a type B dissection.

Aortic dissection can affect adults of any age. Risk Factors for acute aortic dissection is Hypertension, Atherosclerosis, Smoking and Pregnancy. Certain conditions of the heart such as bicuspid aortic valve , family history of aortic dissection, presence of Marfan’s syndrome , presence of pre-existing aortic aneurysm makes the individuals susceptible for aortic dissection.

Symptoms of acute aortic dissection can be

⦁Acute onset , severe sharp stabbing chest pain , which can also involve neck, back pain mimicking a heart attack

⦁ Neurological symptoms due to malperfusion Syncope attacks , stroke (hemiparesis/ hemiplegia ) Altered mental status

⦁Abdominal pain (with gut ischemia )

⦁Acute limb ischemia

⦁ In severe cases patient can present with features of cardiac tamponade following aortic rupture or sudden death

Diagnosis This condition can be diagnosed by echocardiography to see the presence of tears in the aorta . CT scan of the aorta shows the exact nature of the tear and the extent of the pathology and the organs involved. When aortic dissection is suspected these 2 investigations are necessary to plan the treatment of the patients.

Treatment for type A dissection requires emergency open-heart surgery. The diseased aorta is removed and replaced with a prosthetic graft) artificial blood vessel) If the valve at the opening of the aorta is involved it needs to be replaced. The aortic arch may have to be replaced partially or completely depending on the nature of the diseased segment. These are extremely complex aortic surgeries and require specialised care and technical expertise. Although the number of operations for type A dissection are increasing, still only very few patients who could be saved undergo an operation. This is commonly due to missed or delayed diagnosis, lack of awareness of the disease and infrastructure.

Patient story 1
Mr. Nitin, 38 year old farm worker from a small town in northern Maharashtra presented with a chest pain to the local cardiologist. On initial treatment he had abnormal findings on echo and was referred to a nearby facility for CT scan. CT scan showed acute aortic dissection . As the surgical expertise to operate on such a condition was not available the patient was transferred to Jaslok hospital Mumbai in a critical stage. He underwent a supramajor complex surgery to replace the diseased aorta , the aortic valve and the aortic root . He had excellent surgical results and is living a normal life now. Suspecting acute aortic dissection and timely surgical care by an expert team could give him the gift of life .

Patient story 2
37 year8 months ago, Sandhya pregnant lady suffered from chest pain and shortness of breath in Mumbai suburbs. She was diagnosed to have Type A acute aortic dissection. She had pregnancy induced extremely high blood pressure which caused the catastrophic problem. Knowing the gravity of the situation with life of mother and baby at stake , Aortic surgery team at Jaslok operated her for emergency heart surgery replacing the aortic valve aortic root and ascending aorta . The baby was subsequently delivered . Prompt referral, alert and caring specialized aortic surgery team could save lives in such a situation .

Patient story 3
A 48 year old man had undergone emergency surgery for acute aortic dissection 2 years back , he had 2 younger brothers . One of them suffered from chest pain and had sudden cardiac death while traveling in train, possibly from aortic dissection. The Younger brother suffered from chest pain at the age of 37 and was rushed to Jaslok hospital where he was diagnosed with acute aortic dissection . He underwent successful aortic surgery and survived . Knowledge of aortic dissection can run in families and picking up the aortic pathology early helped to save the life of younger siblings in this case.

Untreated Type A acute aortic dissection has high mortality with more than 80 % dying within 24 hours of developing symptoms .Hence Type A aortic dissection should be suspected in patients with chest pain, diagnosed early and promptly referred for surgical treatment .Overall in hospital surgical mortality is 4-11%for stable patients with Type A dissections and 15-18 % in patients who are unstable at initial presentation. Survival is better in high volume aortic surgery centres with technical expertise of aortic surgical team

(Author: Dr Upendra Bhalerao, Consultant Cardiovascular & Thoracic Surgery & Heart Transplantation, Jaslok Hospital & Research Centre)