The Successful Replacement of Aortic Valve and Ascending Aorta in Patients with Type A Aortic Dissection in the Postpartum Period. The Analysis of Literature and Demonstration of Own Observations

Abstract. Aortic dissection is a rupture of the inner layer of the aorta with subsequent penetration of blood into the degeneratively altered middle layer with the formation of false lumen and true lumen. Pregnancy is one of the risk factors for the development of aortic dissection. The incidence of aortic dissection during pregnancy is only 0.0004% of cases.

Aim of the study. To analyze national and foreign literature, as well as share own clinical observations in the diagnosis and treatment of patients with aortic dissection in the postpartum period.

Material and methods. Two patients after successful childbirth, in the late postpartum period, were admitted with a diagnosis of aortic dissection type A according to Stanford.

CT angiography confirmed the presence of Stanford type A aortic dissection. After additional examination, surgical treatment was performed to replace the aortic valve and ascending aorta under artificial circulation, with a satisfactory clinical result.

Conclusion. The diagnosis of aortic dissection should be considered in all pregnant women with chest pain, as this condition often goes undiagnosed.

The pregnancy period is one of the risk factors for the development of aortic dissection with a high mortality rate. The likelihood of developing aortic dissection in women at risk peaks in the third trimester and the first 12 weeks after delivery.

The risk group should include women with confirmed syndromic and non-syndromic genetic diseases, bicuspid aortic valve, coarctation of the aorta, or at least one major criterion indicating the presence of aortopathy (ectopia lentis, aortic aneurysm, habitus, genetic testing).

If Marfan syndrome is present, surgical intervention should be considered if the maximum aortic diameter is more than 4.5 cm before pregnancy. In women with Marfan syndrome and aortic dissection in the family history, as well as in the presence of more aggressive genetic diseases (Loeys-Dietz syndrome, Ehlers-Danlos syndrome), it is possible to consider preventive surgical treatment for an aortic diameter of 4.0 cm or more.

The delivery in high-risk patients is recommended to be performed in a hospital that has a cardiac surgery service and an “aortic” team.

1. Muslimov RS, Popova IE, Khamidova LT, Selyaev VS, Vasilyeva IV, Kokov LS. Computed Tomography Criteria for Differential Evaluation of True and False Lumens in Aortic Dissection. Russian Sklifosovsky Journal Emergency Medical Care. 2022;11(3):394–401. https://doi.org/10.23934/2223-9022-2022-11-3-394-401

2. Isselbacher EM, Preventza O, Hamilton Black J 3rd, Augoustides JG, Beck AW, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/ American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022;146(24):e334–e482. PMID: 36322642 https://doi.org/10.1161/CIR.0000000000001106

3. Sawlani N, Shroff A, Vidovich MI. Aortic dissection and mortality associated with pregnancy in the United States. J Am Coll Cardiol. 2015;65(15):1600–1601. PMID: 25881947 https://doi.org/10.1016/j.jacc.2014.12.066

4. Babich TYu, Sulima AN, Voronaya VV, Kalinina NA. Aortic dissection in childbirth as a cause of maternal mortality. Obstetrics, Gynecology and Reproduction. 2022;16(4):493–500. (In Russ.) https://doi.org/10.17749/2313-7347/ob.gyn.rep.2022.281

5. Yates MT, Soppa G, Smelt J, Fletcher N, van Besouw JP, Thilaganathan BJ, et al. Perioperative management and outcomes of aortic surgery during pregnancy. J Thorac Cardiovasc Surg. 2015;149(2):607–610. PMID: 25524653 https://doi.org/10.1016/j.jtcvs.2014.10.038

6. Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, BlomströmLundqvist C, Cífková R, De Bonis M, et al.; ESC Scientific Document Group. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J. 2018;39(34):3165–3241. PMID: 30165544 https://doi.org/10.1093/eurheartj/ehy340

7. Immer FF, Bansi AG, Immer-Bansi AS, McDougall J, Zehr KJ, Schaff HV, et al. Aortic dissection in pregnancy: analysis of risk factors and outcome. PMID: 12842575 https://doi.org/10.1016/S0003-4975(03)00169-3

8. Tong G, Wu J, Chen Z, Zhuang D, Zhao S, Liu Y, et al. Coronary Malperfusion Secondary to Acute Type A Aortic Dissection: Surgical Management Based on a Modified Neri Classification. J Clin Med. 2022;11(6):1693. PMID: 35330018 https://doi.org/10.3390/jcm11061693

9. Sanghavi M, Rutherford JD. Cardiovascular physiology of pregnancy. Circulation. 2014;130(12):1003–1008. PMID: 25223771 https://doi.org/10.1161/CIRCULATIONAHA.114.009029

10. Wanga S, Silversides C, Dore A, de Waard V, Mulder B. Pregnancy and Thoracic Aortic Disease: Managing the Risks. Can J Cardiol. 2016;32(1):78–85. PMID: 26604124 https://doi.org/10.1016/j.cjca.2015.09.003

11. Goland S, Elkayam U. Pregnancy and Marfan syndrome. Ann Cardiothorac Surg. 2017;6(6):642–653. PMID: 29270376 https://doi.org/10.21037/acs.2017.10.07

12. Zhu JM, Ma WG, Peterss S, Wang LF, Qiao ZY, Ziganshin BA, et al. Aortic Dissection in Pregnancy: Management Strategy and Outcomes. Ann Thorac Surg. 2017;103(4):1199–1206. PMID: 27825688 https://doi.org/10.1016/j.athoracsur.2016.08.089

13. Siromakha S, Kravchenko V, Beregovyi O, Davydova Yu, Zakharova V, Ogorodnik A, et al. Acute Aortic Dissection and Pregnancy. Cardiology in Belarus. 2021;13(3):381–393. https://doi.org/10.34883/PI.2021.13.3.004

14. Pyeritz RE. Maternal and fetal complications of pregnancy in the Marfan syndrome. Am J Med. 1981;71(5):784–790. PMID: 7304650 https://doi.org/10.1016/0002-9343(81)90365-x

15. Lansman SL, Goldberg JB, Kai M, Tang GH, Malekan R, Spielvogel D. Aortic surgery in pregnancy. J Thorac Cardiovasc Surg. 2017;153(2): S44–S48. PMID: 27431443 https://doi.org/10.1016/j.jtcvs.2016.06.015

16. Braverman AC, Mittauer E, Harris KM, Evangelista A, Pyeritz RE, Brinster D, et al. Clinical Features and Outcomes of PregnancyRelated Acute Aortic Dissection. JAMA Cardiol. 2021;6(1):58–66. PMID: 33052376 https://doi.org/10.1001/jamacardio.2020.4876