Optimal treatment strategy for type A acute aortic dissection with intramural hematoma

Objective: The management strategy for type A acute aortic dissection (AAD) with intramural hematoma (IMH) remains controversial. The aim of this study was to compare the outcomes of emergency surgery and medical treatment for patients with acute type A IMH. Methods: One hundred seventy-one patients with acute type A IMH, whose average age was 69.4 years (range, 39-90 years) were divided into 3 groups: groups I and II consisted of 74 and 33 patients undergoing emergency surgery for complicated and uncomplicated type A IMH, respectively, and group III comprised 66 patients who were treated conservatively. We compared the 3 groups in terms of mortality and morbidity. Results: In group I, postoperative hospital mortality was 5.4% (4 patients). In group II, all patients survived without any complications after surgery. On the other hand, in group III, 5 patients underwent emergency surgery within 7 days after onset owing to newly developed cardiac tamponade and 17 (25.8%) patients died in the hospital, which was a significantly higher rate than those in groups I and II. Furthermore, although the group III patients survived, 5 patients required mechanical ventilation owing to heart failure or pneumonia, and 4 patients had a stroke during the hospital stay. There was no difference in actuarial survivals at 10 years, which were 64.2% in group I, 64.9% in group II, and 68.7% in group III. Conclusions: Emergency surgery for patients with type A IMH showed favorable mortality rates because most of the patients were in hemodynamically stable condition preoperatively. On the other hand, several patients died suddenly during medical care. Emergency surgical treatment may provide a better outcome than medical treatment at the time of onset, even for patients with type A IMH.