From the Guidelines
The treatment for Type A aortic dissection is emergency surgery, which should be performed as soon as possible after diagnosis to prevent fatal complications. This approach is supported by the most recent and highest quality study, which emphasizes the importance of prompt surgical intervention to reduce morbidity, mortality, and improve quality of life 1.
Pre-Surgical Management
Before surgery, patients require immediate medical stabilization with:
- Intravenous beta-blockers (such as esmolol 50-300 μg/kg/min or labetalol 2-4 mg/min) to reduce heart rate to 60-80 beats per minute and systolic blood pressure to 100-120 mmHg.
- Vasodilators like nicardipine (5-15 mg/hour) or sodium nitroprusside (0.3-10 μg/kg/min) may be added if beta-blockers alone are insufficient for blood pressure control, but never used alone as they can increase the force of cardiac contraction.
- Pain management with intravenous opioids is essential.
Surgical Procedure
The surgical procedure typically involves:
- Replacing the damaged portion of the ascending aorta with a synthetic graft.
- Repairing or replacing the aortic valve if necessary.
- Reestablishing blood flow to vital organs.
Post-Surgical Management
After surgery, patients require:
- Lifelong blood pressure control, typically with beta-blockers and other antihypertensives.
- Regular imaging surveillance (CT or MRI) at 1,3,6, and 12 months post-surgery and then annually.
- Lifestyle modifications including smoking cessation and limited physical exertion.
This aggressive approach is necessary because Type A dissections have a high mortality rate if left untreated, with nearly 50% of patients dying within 48 hours without intervention 1. The importance of prompt surgical intervention is further emphasized by the fact that surgery reduces 1-month mortality from 90% to 30% 1.
Key considerations in the surgical management of Type A aortic dissection include:
- The extent of aortic repair, with options ranging from ascending aortic replacement to more extensive repairs such as the "frozen elephant trunk" technique.
- The management of the aortic valve, with options including valve-sparing repair, valve replacement, or composite grafting.
- The importance of intraoperative aortoscopy and immediate post-operative imaging to confirm the effectiveness of therapy 1.
Overall, the treatment of Type A aortic dissection requires a multidisciplinary approach, with prompt surgical intervention and careful pre- and post-operative management to optimize outcomes and reduce morbidity and mortality.
From the Research
Treatment for Type A Aortic Dissection
The treatment for Type A aortic dissection typically involves immediate surgical intervention. The goal of surgery is to repair or replace the damaged aorta and prevent further complications.
- Surgical options may include:
- Replacement of the ascending aorta (Asc Ao) with or without valve replacement
- Replacement of the Asc Ao with or without arch or hemiarch replacement
- Frozen elephant trunk and endovascular repair for managing the rest of the aortic dissection that involves the thoracic aorta 2
- The management of Type A aortic dissection is tailored by individual surgeons and unit experience to save lives 2
- In some cases, patients with Type A aortic dissection with malperfusion syndrome may undergo percutaneous reperfusion prior to open surgical repair 3
Initial Management
The initial management of acute aortic dissection involves:
- Immediate imaging with chest computed tomography scan followed by transthoracic echocardiography (TTE) to confirm diagnosis 4
- Medical management aimed at controlling the heart rate, systolic blood pressure, and pain 4
- Referral to cardiothoracic surgeons for emergency aortic surgery for patients with Type A acute aortic dissection 4
Outcomes
The outcomes of surgical treatment for acute Type A aortic dissection can be predicted according to the preoperative condition of the patient 5