What is the management of an ascending aorta dissection?

Management of Ascending Aortic Dissection

Ascending aortic dissection requires immediate surgical repair due to the high risk of life-threatening complications such as rupture. 1

Initial Management

Immediate Stabilization

1. Transfer to intensive care unit for appropriate monitoring 1
2. Establish IV access for medications and fluid administration
3. Monitor heart rate and blood pressure continuously 1
4. Control pain with morphine sulfate 1
5. Reduce blood pressure and heart rate:
   • First priority: Administer IV beta-blockers to reduce heart rate to ≤60 beats per minute 1
     • Options include:
       • Esmolol (loading dose 0.5 mg/kg over 2-5 min, followed by infusion of 0.10-0.20 mg/kg/min) 1, 2
       • Propranolol (0.05-0.15 mg/kg every 4-6 hours) 1
       • Metoprolol or labetalol 1
   • Second priority: If systolic BP remains >120 mmHg after heart rate control, add vasodilators:
     • IV sodium nitroprusside or ACE inhibitors 1, 2
     • Target systolic BP: 100-120 mmHg while maintaining adequate end-organ perfusion 1

CAUTION: Never administer vasodilators before beta-blockers as this can cause reflex tachycardia, increasing aortic wall stress and potentially worsening the dissection 1

Diagnostic Imaging

1. Obtain immediate imaging to confirm diagnosis 1
   • CT angiography, MRI, or transesophageal echocardiography based on availability and patient stability
2. If initial imaging is negative but clinical suspicion remains high, obtain a second imaging study 1

Definitive Management

Type A (Ascending Aorta) Dissection

1. Urgent surgical consultation and emergency surgical repair 1

   • Resect all aneurysmal aorta and proximal extent of dissection
   • Management of aortic root:
     • Partially dissected root: Aortic valve resuspension
     • Extensively dissected root: Root replacement with composite graft or valve-sparing procedure
     • For DeBakey Type II: Replace entire dissected aorta

2. Special considerations for cardiac tamponade:

   • If tamponade is present and patient is unstable before surgery, perform pericardiocentesis with minimal fluid removal (just enough to restore perfusion) 1
   • Consider femoral-femoral bypass before sternotomy to prevent aortic rupture upon tamponade release 3

Management of Complications

1. Hypotension:

   • If due to tamponade: Minimal pericardiocentesis as bridge to surgery 1
   • If due to aortic regurgitation, true lumen obstruction, or MI: Expedite surgical intervention 1
   • If due to rupture into pleural space or mediastinum: Immediate operative management 1

2. Malperfusion syndromes:

   • Address during surgical repair of the ascending aorta

Postoperative and Long-term Management

1. Continue beta-blockers long-term to reduce risk of recurrent dissection 4

   • Never discontinue beta-blocker therapy as this can precipitate recurrent dissection

2. Blood pressure control:

   • Target BP <135/80 mmHg 1
   • Beta-blockers are preferred but combination therapy is usually needed 1

3. Regular imaging surveillance:

   • MRI is preferred for follow-up to avoid radiation exposure 1
   • Monitor for:
     • Aneurysm formation at repair site
     • Progressive enlargement of residual dissection
     • New dissection

4. Reoperation indications:

   • Secondary aneurysm formation (≥5-6 cm diameter) 1
   • Recurrent dissection
   • Graft complications (dehiscence, infection) 1

Emerging Treatments

While endovascular stent grafts are not currently approved for ascending aortic dissection 1, catheter-based treatments may be considered in carefully selected high-risk patients who are poor surgical candidates 5. However, this approach requires further evaluation and specifically designed devices.