What is the appropriate aftercare for a patient following aortic dissection repair?

From the Guidelines

Aftercare following aortic dissection repair requires careful monitoring and management to ensure proper healing and prevent complications, with follow-up appointments typically at 1,3,6, and 12 months, and then yearly, as recommended by the 2024 ESC guidelines 1.

Key Considerations

• Imaging surveillance should focus on persistence or obliteration of the false lumen, anastomotic dehiscence, progressive dilatation of residual native aorta, or graft infection, with CCT being the most used modality, but CMR can be considered to reduce radiation in patients requiring frequent examinations 1.
• Blood pressure control is critical and should be maintained below 120/80 mmHg using medications such as beta-blockers as first-line therapy, with additional medications including ACE inhibitors or calcium channel blockers as needed.
• Patients should monitor for warning signs requiring immediate medical attention, including new chest/back pain, shortness of breath, syncope, or neurological symptoms.

Follow-up Schedule

• Follow-up appointments should be scheduled at 1,3,6, and 12 months, and then yearly, with imaging surveillance at each visit to monitor for complications and progression of disease.
• The first year is critical, with a higher risk of complications, and more frequent follow-up may be necessary in some cases.

Lifestyle Modifications

• Patients must permanently avoid heavy lifting and high-intensity activities to reduce the risk of recurrence or complications.
• Cardiac rehabilitation should begin 4-6 weeks post-surgery to improve overall cardiovascular health and reduce the risk of future complications.
• A heart-healthy diet with sodium restriction (<2000mg daily) is essential to reduce blood pressure and prevent further aortic damage.

Medications

• Beta-blockers, such as metoprolol or labetalol, should be used as first-line therapy to control blood pressure and reduce the risk of recurrence.
• Additional medications, such as ACE inhibitors or calcium channel blockers, may be necessary to achieve optimal blood pressure control.

Pain Management

• Pain management typically involves acetaminophen and limited opioids during early recovery, with a focus on minimizing the use of opioids to reduce the risk of dependence and addiction.

Warning Signs

• Patients should be educated on the warning signs of complications, including new chest/back pain, shortness of breath, syncope, or neurological symptoms, and should seek immediate medical attention if any of these symptoms occur.

From the Research

Aortic Dissection Repair Aftercare

• The management of aortic dissection involves controlling blood pressure and reducing myocardial contractility 2
• Beta blockers are commonly used in the treatment of aortic dissection, with studies showing their effectiveness in reducing mortality and improving outcomes 3, 4
• The use of oral beta blockers has been associated with significant protection against in-hospital mortality and stroke following repair of type B thoracic aortic dissection 4
• Intravenous beta blockers, such as metoprolol, have also been shown to reduce mortality in patients with nontraumatic type B aortic dissection 4
• Esmolol, an ultrashort-acting beta blocker, has been used to control heart rate in patients with acute aortic dissection, with studies showing its efficacy and safety in this setting 2, 5
• Combination therapies, such as labetalol and esmolol, have also been evaluated for their hemodynamic safety in patients with type B aortic dissections, with results suggesting that they may be associated with a lower incidence of hemodynamic instability 6

Medications Used in Aortic Dissection Repair Aftercare

• Beta blockers:
  • Oral beta blockers, such as metoprolol, have been shown to reduce mortality and improve outcomes in patients with type B thoracic aortic dissection 4
  • Intravenous beta blockers, such as metoprolol, have been shown to reduce mortality in patients with nontraumatic type B aortic dissection 4
• Esmolol:
  • Has been used to control heart rate in patients with acute aortic dissection, with studies showing its efficacy and safety in this setting 2, 5
• Labetalol:
  • Has been evaluated in combination with esmolol for its hemodynamic safety in patients with type B aortic dissections, with results suggesting that it may be associated with a lower incidence of hemodynamic instability 6
• Statins:
  • Have been associated with higher long-term survival in medically managed patients with aortic dissection 3

Outcomes of Aortic Dissection Repair Aftercare

• Mortality:
  • Has been shown to be reduced with the use of oral beta blockers in patients with type B thoracic aortic dissection 4
  • Has been shown to be reduced with the use of intravenous beta blockers, such as metoprolol, in patients with nontraumatic type B aortic dissection 4
• Stroke:
  • Has been shown to be reduced with the use of oral beta blockers in patients with type B thoracic aortic dissection 4
• Hemodynamic instability:
  • Has been evaluated in patients receiving combination therapies, such as labetalol and esmolol, with results suggesting that they may be associated with a lower incidence of hemodynamic instability 6