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Cardiovascular Disease |

Neurologic Catastrophe in the Setting of Acute Ascending Aortic Syndromes: A Case for Delayed Surgical Intervention

Nishtha Sodhi*, MD; Joseph Bavaria, MD; Nimesh Desai, MD
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The Cleveland Clinic Foundation, Cleveland, OH


Chest. 2012;142(4_MeetingAbstracts):129A. doi:10.1378/chest.1388396
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Abstract

SESSION TYPE: Cardiovascular Student/Resident Case Report Posters II

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Acute syndromes involving the ascending aorta are typically emergently surgically repaired [1]. We describe a case presenting with spinal ischemia where aortic intervention was delayed in order to perform spinal cord rescue.

CASE PRESENTATION: 64 year old female with past medical history of hypertension presented with acute onset of total lower extremity flaccid paralysis, chest and back pain. CT revealed acute type A intramural hematoma (IMH) extending from the aortic root to the iliac bifurcation. TEE showed maximal ascending aortic diameter at 4.8cm with 1.2cm IMH thickness, and no aortic insufficiency or pericardial effusion. A lumbar drain was emergently inserted and spinal cord perfusion was optimized by maintaining high hematocrit and elevated systemic perfusion pressures. In the following days, she regained 4/5 strength of her bilateral lower extremities and lumbar drain was removed on hospital day 5. On day 13, CTA showed her ascending aorta had increased to 5.4cm and echo showed new aortic insufficiency and pericardial effusion. She underwent planned aortic valve resuspension, ascending and extended hemiarch replacement with pre-operative lumbar drain insertion. Intraoperative findings were significant for a ruptured plaque in the proximal to mid aortic arch, which was excised. Postoperatively she initially had 3/5 bilateral lower extremity strength but by 1 year, she was ambulatory with cane. CT at 1 year showed small amount of residual arch hematoma.

DISCUSSION: Spinal involvement in acute ascending aortic syndromes is likely secondary to the sheering effects of the intramural hematoma on the intercostals. In this setting, emergent proximal repair will not likely revascularize the spinal cord, but it may be rescued by optimization of spinal perfusion and delayed aortic repair as we demonstrate.

CONCLUSIONS: Purposeful surgical delay [1, 2] with medical optimization of comorbidities, including neurologic complications [3], may be utilized in the management of acute type A IMH.

1) Song JK, Yim JH, Ahn JM, Kim DH, Kang JW, Lee TY, Song JM, Choo SJ, Kang DH, Chung CH, Lee JW, Lim TH. Outcomes of patients with acute type A aortic intramural hematoma. Circulation. 2009; 120: 2046-2052.

2) Estrera A, Miller C 3rd, Lee TY, De Rango P, Abdullah S, Walkes JC, Milewicz D, Safi H. Acute type A intramural hematoma: analysis of current management strategy. Circulation. 2009 Sep 15;120(11 Suppl):S287-91.

3) Augoustides JG, Szeto WY, Desai ND, Pochettino A, Cheung AT, Savino JS,Bavaria JE. Classification of acute type A dissection: focus on clinical presentation and extent. Eur J Cardiothorac Surg. 2011 Apr;39(4):519-22.

DISCLOSURE: The following authors have nothing to disclose: Nishtha Sodhi, Joseph Bavaria, Nimesh Desai

No Product/Research Disclosure Information

The Cleveland Clinic Foundation, Cleveland, OH

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