Aortic Dissection Postpartum Without Common Risk Factors Except Pregnancy
Year: 2024
Type: article
Study design: Case Report
Abstract: Introduction Aortic dissection (AD) is rare but often life-threatening. About half of the female patients with aortic dissection are pregnancy-related.1 Due to its rapid onset, missed diagnoses are prone to occur, often resulting in sudden death.2 Therefore, early identification and multidisciplinary treatment are important for the prognosis of patients. We report a 27-year-old woman without known common risk factors such as connective tissue disease, hypertension, or heart disease who suffered from aortic dissection after cesarean section. She was diagnosed and cured at Chengdu Women and Children’s Central Hospital and West China Hospital of Sichuan University. Case presentation A 27-year-old woman with a previously healthy medical history underwent a normal pregnancy, including a 33-week ultrasound cardiogram. On admission day, preoperative examination results were unremarkable. A cesarean section was performed under intraspinal anesthesia on the second day after admission. The baby weighed 3860 grams with an Apgar score of 10-10-10, indicating excellent health. The operation was successful. At approximately 8:00 p.m. on the first postoperative day, after eating, the patient experienced precordial discomfort that evolved into pain accompanied by gradually increasing dyspnea and tearing pain. This lasted for approximately 20 minutes and then spontaneously resolved. At that time, electrocardiogram (ECG) monitoring showed a heart rate (HR) of 82 beats per minute (bpm), blood pressure (BP) of 102/65 mmHg, and oxygen saturation (SpO2) of 97% (without oxygen inhalation). Brain natriuretic peptide (BNP) levels were 247.36 pg/mL, and no significant abnormalities were found in myocardial injury markers or myocardial enzyme spectra. On the second postoperative day, transthoracic echocardiography (TTE) revealed aortic insufficiency with moderate to severe regurgitation, left ventricular enlargement, and mild mitral regurgitation. A re-examination of BNP levels showed an increase to 508.52 pg/mL. Cardiology consultation and physical examination revealed a BP of 120/76 mmHg, HR of 106 bpm, and SpO2 of 98% (with oxygen administration). Bilateral lung breath sounds were clear, with no dry or wet rales. The cardiac border was suspiciously enlarged, and there was an apical systolic murmur, aortic valve sound, and a slight diastolic sigh murmur. Oral furosemide 10-20 mg once daily (qd) for 2-3 days was recommended. On the fourth postoperative day, a TTE re-examination showed aortic dissection (AD) (Fig. 1A).Figure 1.: Preoperative and postoperative imaging findings for the patient. A Transthoracic echocardiography results. The red arrow indicates the presence of aortic dissection. B-C Computed tomography angiography results. The yellow and green arrows point to a dissection involving the ascending aorta, which extends to the anterior part of the aortic arch. D Postoperative artificial images showing the aortic valve region, ascending aorta, aortic arch, and arm trunk after surgery.Treatment process and follow-up Considering the patient’s critical and urgent condition, we promptly activated the green channel for transfer to the Department of Cardiac Surgery at West China Hospital of Sichuan University. A computed tomography angiography (CTA) confirmed aortic dissection, with the following findings: aortic sinus dilatation (4.3 cm in diameter), ascending aorta dissection involving the ascending aorta and anterior aortic arch, right coronary artery and head/arm vessels originating from the pseudolumen/mixed lumen, and left common carotid and left subclavian arteries originating from the true lumen (Fig. 1B-C). Surgical intervention and postoperative care After completing preoperative preparations, we successfully performed Bentall’s procedure combined with a half-arch replacement under cardiopulmonary bypass and general anesthesia. During the surgery, the ascending aorta was resected, and the aortic valve was excised. The aortic annulus was then sutured with 18 interrupted stitches using calf pericardium. A St. Jude 21 mm artificial mechanical valve integrated with a 26 mm four-branch artificial blood vessel was implanted. Holes were drilled in the artificial blood vessel, corresponding to the left and right coronary artery ostia, with a diameter of approximately 0.8 cm. The coronary arteries were anastomosed into the artificial vessels, and the anastomosis was completed using a 4-0 sliding suture at the distal end of the four-branch artificial vessel and the proximal end of the aortic arch (Fig. 1D). Postoperative care included monitoring vital signs, diuretic therapy, potassium supplementation, and anti-infective treatment. The patient was discharged successfully eight days after the operation and prescribed lifelong anticoagulation therapy with 1.25 mg of warfarin daily. Follow-up at six months post-surgery showed that the patient was generally in good condition with no discomfort. Literature review on pregnancy-related aortic dissection Our review of English literature on pregnancy-related aortic dissection from 2000 to 2023 identified 18 sporadic postpartum cases with no other known risk factors besides pregnancy. The mean age was 33.41 ± 2.16. Among these, 5 cases (27.78%) were fatal, including 2 diagnosed post-mortem. All cases were confirmed by CTA, presenting with sudden chest and back pain. Most cases (88.89%) were classified as Stanford A. Clinical characteristics and outcomes are summarized in Supplemental Table 1, https://links.lww.com/MFM/A60. Discussion Schnitker et al. first reported the case of aortic dissection during pregnancy in 1994.3 No large sample of cases has been reported, and there are no exact incidence statistics in China, while the incidence reported in the United States is 0.0004%.4–5 Although pregnancy-related aortic dissection is rare, the mortality rate is very high, 21-53%.6 Pregnancy-related aortic dissection can occur during pregnancy, childbirth, and the postpartum period. At present, the well-known risk factors for aortic dissection include congenital connective tissue diseases, such as Marfan syndrome, Turner syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome, mitral aortic malformation, and hereditary thoracic and abdominal aortic aneurysms, among which Marfan accounts for 65%.7 Chronic hypertension, gestational hypertension, and preeclampsia are also risk factors for aortic dissection.8–9 In patients without any of these conditions, as in our case, pregnancy is an independent risk factor for aortic dissection.10 This may be due to changes in arterial elasticity and fragility caused by the synergistic effect of estrogen and progesterone during pregnancy, increased postpartum circulating blood volume, and increased impact of blood flow on the tube wall, leading to aortic dissection.11 The main clinical manifestations of aortic dissection include thoracic and back tearing pain, with some patients experiencing chest tightness, shortness of breath, pallor, fatigue, and sweating, which must be differentiated from myocardial infarction, acute pancreatitis, pulmonary embolism, and heart failure.12 Diagnostic methods primarily involve echocardiography (transthoracic or transesophageal), CTA, CT, MRI, and other imaging examinations, with CTA demonstrating 100% sensitivity and specificity.4 In this case, initial TTE indicated moderate to severe aortic regurgitation, while a reexamination two days later highly suspected aortic dissection, which was later confirmed by CTA. Therefore, due to technological and experiential limitations, TTE may yield false negatives, necessitating repeated examinations or direct CTA, especially in specialized hospitals with limited experience and vigilance, where misdiagnosis and sudden death are more likely. Additionally, patients with sudden chest pain and short-term D-dimer levels > 0.5 mg/L have a 100% sensitivity and 67% specificity for aortic dissection diagnosis.13 Blood routine, biochemistry, coagulation function tests, myocardial injury markers, myocardial enzyme spectrum, and BNP have auxiliary diagnostic value, but with lower sensitivity and specificity. The Standford type A aortic dissection mainly relies on surgical treatment. Among the cases reviewed in this study, only one died during the operation, one died after refusing surgery, and the remaining patients were cured. The Standford type B aortic dissection mainly relies on conservative treatment with drugs, and good outcomes are often achieved after early diagnosis and surgical treatment.14 Two of the deaths were due to a lack of early diagnosis and the disease was confirmed at autopsy. Conclusion For pregnant women without known common risk factors for sudden chest or back pain, this fatal disease of aortic dissection may still occur, non-general hospital obstetricians and gynecologists, should be timely identify and diagnose, as soon as possible to refer to the general hospital cardiothoracic surgery for treatment, to achieve a good outcome. Funding None. Conflicts of Interest None. Data Availability Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
Source: Maternal-Fetal Medicine
Authors: Xin Yuan, Dongmei Tang, Xiaohui Wu, Dan Luo
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4404902836