Effect of Medical and Surgical Therapy on Aortic Dissection Evaluated by Transesophageal Echocardiography Implications for Prognosis and Therapy

BackgroundAortic dissection still has a poor prognosis despite progress in therapy. Therefore, this prospective follow-up study was designed to determine whether the degree of communication between true and false lumen in relation to the type of dissection, analyzed by transesophageal echocardiography, influences the risk after initiation of medical or surgical therapy. Methods and ResultsIn eight centers, 168 patients (124 men and 44 women) of age range of 23-84 years with proven aortic dissection were examined by transesophageal echocardiography in the acute phase, after start of medical and/or surgical therapy, and during follow-up (0–65 months; mean, 10 months). Analyses were performed prospectively according to a detailed study protocol. Patients were subdivided by transesophageal echocardiography according to a modified DeBakey classification. Type I aortic dissection was found in 35%, typeII aortic dissection in 17%, and typem aortic dissection in 48%. Preoperative mortality was 3%, 7%, and 2%, and survival rates were 52%, 69%, and 70%, respectively. Typem aortic dissection could be subdivided into those with communication and antegrade dissection (ca) (50%), with communication and retrograde dissection limited to the descending aorta (cr desc) (10%), with dissection extended to the aortic arch and ascending aorta (cr asc) (27%), and withnoncommunicating (nc) aortic dissection (13%). An open false lumen with no thrombus formation was present in typesI, II, m ca andmcr asc aortic dissection in 17% 21%, 39%, and 27% respectively, although it was most pronounced in typesm nc andmcr desc (75% and 78%). During follow-up in patients who survived, thrombus was demonstrated in the false lumen in 80% of type I aortic dissection and 81% of typesm ca andm cr asc. Open false lumen was seen in type H aortic dissection in 18%. Spontaneous healing was found in 4% with type H and 4% with typem aortic dissection (mainly in patients with typem nc aortic dissection). Patients with fluid extravasation, pleural effusion, pericardial tamponade, and periaortic effusion as well as mediastinal hematoma had a mortality of 52%. Reoperations were necessary in 12-29%, with thehighest rate in patients with typem ca aortic dissection. Survival for patients with types M nc andm cr desc aortic dissection was higher than those with types I, II, m ca, andm cr asc. ConclusionsPreoperative mortality appears to be reduced by transesophageal echocardiography, allowing rapid initiation of treatment. Intraoperative and postoperative mortality in aortic dissection remains high. Risk factors are fluid extravasation and an open false lumen with high communication. Thrombus formation in the false lumen can be regarded as a good prognostic sign. Surgery appears tobe only a first step in the treatment of aortic dissection. Second surgery or closure of entry sites based on intraoperative echocardiography may be considered to induce thrombus formation and reduce aortic wall stress.