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We read with interest the excellent study by Song et al. (1)on “Different Clinical Features of Aortic Intramural Hematoma Versus Dissection Involving the Ascending Aorta.” We write to address a limitation of this study and most other available literature on this topic—namely, the brief follow-up time after presentation.
Our group has previously published data on the presentation and early follow-up of intramural hematomas (2). At the recent American Association of Thoracic Surgery meeting, we presented a report on “Midterm Follow-up of Penetrating Ulcer and Intramural Hematoma of the Aorta.” Our data agree with that of Song et al. on several points, including the advanced age of aortic intramural hematoma (AIH) patients (74 years) and the unusual female preponderance (58%). However, the relatively long follow-up in our report (mean of 41 months, compared to 37 days to 22 months in the available literature) for 19 patients with acute intramural hematoma has led us to different management recommendations. In examining these patients over time, several factors became apparent. First, incidence of rupture on admission is very high in AIH patients, at 26%, compared to 8% and 4%, respectively, for our type A and type B dissections in our total dissection registry (p < 0.01).
Second, in follow-up imaging of our cohort, 46% had healing, 9% had no change, 18% had worsening and 27% had progression to frank dissection. Therefore, 54% had either worsening or no change.
Third, the aorta continues to grow in these patients, at a rate of 0.4 cm/year.
Fourth, of the eight deaths in late follow-up in our series, fully five (63%) were due to documented rupture.
Fifth, nonoperative survival of AIH patients (n = 12) was 50% at four years in our cohort, but with surgical intervention (n = 7) the four-year survival became 86%. Despite the advanced age and acute nature of these patients, operative mortality was a reasonable 14%. Hence, surgical survival exceeded that of equally or less ill medically managed patients.
Thus, our review of this data has led to a distinct change in our policy protocols for treatment of intramural hematoma. Several years ago when our follow-up time was short, as in the study by Song et al. (1)(15 months), we had similar conclusions that nonoperative therapy might suffice initially. Now that we have more solid midtermdata, we consider this virulent lesion to be surgical, if patient comorbidities allow aggressive intervention. This paradigm shift is due to the high rates of rupture on presentation, the frequency of worsening on serial radiographic follow-up, and the continued incidence of death from rupture despite medical management. Though a significant percentage of these lesions heal spontaneously, we believe that operative intervention is justified owing to the high percentage of mortalities attributable to late rupture.
Finally, Song et al. (1)have made a significant contribution with their study, but we express caution regarding their management guidelines because of the short follow-up times. Our own data point to much higher virulence of this condition.
- American College of Cardiology