What is the treatment for a type A aortic dissection?

Treatment for Type A Aortic Dissection

Immediate surgical intervention is the treatment of choice for all patients with Type A aortic dissection, as surgery reduces 1-month mortality from 90% to 30% compared to medical management. 1

Initial Management

1. Medical stabilization while preparing for surgery:

   • Control pain and hemodynamic state 1
   • Titrate IV beta-blockers to target heart rate ≤60 bpm 2
   • After heart rate control, add vasodilators if SBP remains >120 mmHg 2
   • Never initiate vasodilators before heart rate control (risk of reflex tachycardia) 2

2. Immediate surgical consultation and transfer to a high-volume aortic center if transfer won't significantly delay surgery 2

Surgical Management

Indications for Surgery

• All Type A aortic dissections require emergency surgical repair due to:
  • 50% mortality within first 48 hours if not operated 1
  • High risk of aortic rupture, pericardial tamponade, and aortic regurgitation 1
  • Even patients with unfavorable presentations (coma, shock, malperfusion, stroke) benefit from surgery over medical management 1

Surgical Approach

1. Aortic Root Management:

   • For normal valve and root: Supracommissural graft implantation 1
   • For detached commissures: Valve resuspension 1
   • For extensive root destruction/aneurysm: Root replacement with valved conduit 2
   • Valve-sparing root repair when performed by experienced surgeons 2

2. Distal Repair Strategy:

   • Open distal anastomosis under hypothermic circulatory arrest 2
   • Hemi-arch repair when no intimal tear involves the arch 2
   • Consider extended repair with proximal descending thoracic aorta stenting for secondary tears in arch or proximal descending aorta 2

Prognostic Factors and Outcomes

• Perioperative mortality: 15-25% despite improvements in surgical techniques 1, 3

• Risk factors for poor outcomes:

  • Age >60 years 4
  • Hemodynamic compromise/shock 4, 5
  • Cardiac tamponade 5
  • Malperfusion syndrome 3
  • Rupture 3
  • More extensive surgical resection 4

• Long-term survival: 5-year survival of 71% and 10-year survival of 54% after successful surgery 4

Special Considerations

• Elderly patients: Age alone should not exclude surgical treatment, though mortality is higher 1
• Patients with shock: Administer IV fluids to improve blood pressure and cardiac output before surgery 5
• Patients with cardiac arrest: Consider extracorporeal cardiopulmonary resuscitation as a bridge to surgery 5

Follow-up After Surgery

• Imaging within 6 months, then at 12 months and yearly thereafter 2
• If stable for 5 years, imaging can be reduced to every 2 years 2

Common Pitfalls to Avoid

1. Delaying surgical intervention for Type A dissection
2. Initiating vasodilators before adequate heart rate control
3. Using beta-blockers without caution in patients with acute aortic regurgitation
4. Failing to consider transfer to high-volume aortic centers when appropriate
5. Inadequate imaging follow-up after surgical repair

Type A aortic dissection is a surgical emergency with high mortality if left untreated. Prompt diagnosis, medical stabilization, and immediate surgical intervention offer the best chance for survival.