Acute Type A Intramural Hematoma:
Analysis of Current Management Strategy
Anthony Estrera, MD, Charles Miller, III, PhD, Taek-Yeon Lee, MD,
Paola De Rango, MD, MD, T. Kaneko, MD, Hazim Safi, MD
Department of Cardiothoracic and Vascular Surgery
The University of Texas Medical School at Houston
Memorial Hermann Heart & Vascular Institute
Aortic Surgery Symposium 2010
New York, NY
April, 2010
Background
Acute Type A IMH
Unstable, Tamponade
Stable
Emergent Surgery
(pericardial window)
Initial Medical Optimize
Urgent Surgery
Purpose
 Analyze our experience managing acute
Type A intramural hematoma
 Compare outcomes with Typical Acute
Type A dissection
 Validate our treatment approach
Methods
251 Acute Type A Aortic Dissection
Oct. 1999 – May 2008
Median age: 62 (21-91)
64%
36%
36 IMH (14%)
Methods
36 Patients (IMH)
7 Patients (19%)
1 Patient (3%)
Repaired On Presentation
Medical Management Only
28 Patients (78%)
Managed With Optimal Medical
Management With Eventual Surgical
Treatment
Methods
IMH vs. Typical
Preoperative
Variable
IMH
Typical
P-Value
(n=36)
(n=215)
Age (yr)
63 ± 14
58 ± 15
0.06
Male
66%
71%
0.72
Chest pain
100%
88%
0.04
Abdominal Pain
6%
10%
0.59
Hypotension (<90)
8%
22%
0.07
Tamponade
6%
16%
0.16
Aortic insuff (>mod)
11%
38%
0.002
Asc. Diameter (cm)
5.2 ± 0.8
5.0 ± 0.8
0.17
IMH vs. Typical
Intra-operative
Variable
IMH
Typical
P-Value
(n=36)
(n=215)
Total Arch
14%
6%
0.07
Aortic Root
3%
6%
0.45
Cannulation
(Fem/Asc/Axilla)
32/1/2
206/3/6
0.08
Peripheral bypass
3%
1%
0.73
CABG
9%
5%
0.34
IMH vs. Typical
Post-operative
Variable
IMH
Typical
P-Value
(n=36)
(n=215)
Myocardial Infarct
6%
7%
0.78
Stroke
0%
1%
0.99
Temp Neuro Dysfunct
9%
10%
0.73
Bleeding
0%
7%
0.13
Mortality
8%
13%
0.68
Conversion to Typical
33%
NA
NA
Results by Approach
Variable
Immediate
(n=7)
Medical then Medical only
Repair (n=28)
(n=1)
P-Value
Mortality
14%
7%
0%
0.69
Conversion to
Typical
14%
39%
0%
0.70
Time Sx to OR
(Days)
0.8 ± 0.8
6.5 ± 4.1
NA
0.001
Admit to OR
(Days)
0.6 ± 0.8
5.3 ± 3.6
NA
0.002
Aortic Size
(cm)
5.3 ± 1.1
5.2 ± 0.7
4.8
0.99
Risk of Conversion
Conclusions
 Despite optimal medical management,
conversion of Type A IMH to typical
dissection still remains a concern with
the most significant risk beyond 8 days.
 In our patient population, although
purposeful delay can be safely achieved
in certain patients, timely surgical
repair is recommended.