Type B Aotic Dissection Identified Following Cardiac Ablation

Type B Aotic Dissection Identified Following Cardiac Ablation Procedure. Aref Obagi MD [1], Michael P Carson MD [1], M. Usman Nasir Khan MD [2] Jersey Shore University Medical Center, Neptune NJ. [1] Department of Medicine [2] Department of Surgery LEARNING OBJECTVES • Diagnose and treat Type B Aortic dissection after cardiac ablation procedures. • Review data supporting early endovascular treatment of Type B dissections to improve survival CASE PRESENTATION • A woman in her late 50’s with non-ischemic cardiomyopathy (CM) was admitted for electrophysiologic procedure to ablate the source of premature ventricular contractions (PVC) that were felt to be the cause of her CM. • PMH includes hypertension, hyperlipidemia , mitral valve prolapse, EF 45% 35 pack/yr tobacco history • She underwent a successful mapping and ablation of the PVC focus. • The next day she developed severe chest and abdominal discomfort. • A CT scan (figure 1) of the chest/ abdomen/ pelvis with contrast showed dissection of the thoracic aorta ~3 cm distal to the left subclavian artery extending into both common iliac arteries DISEASE COURSE • Patient was treated medically with Labetalol. • Two months later, she presented with worsening chest/abdominal pain • CTA showed extension of the dissection with compression of true lumens. • With this clinical change, she underwent successful deployment of a percutaneous stent graft in the abdominal aorta at the bifurcation site DISCUSSION • Aortic dissection is classified into two types: 1) Stanford Type A in which the dissection originates from the ascending aorta 2) Type B where the tear originates from the descending aorta. • The International Registry of Aortic Dissection (IRAD) published retrospective survival rates for aortic dissection based on the onset of symptoms: 1)hyperacute (<24 hours) 2)acute (1 -7 days), 3)subacute (8 -30 days) 4)chronic (>30 days). • For those with a chronic dissection, 60 -day-survival was highest with endovascular and medical treatment (91%), vs. medical alone (87%), or open surgical (73%). Figure 2 A: Pre intervention with narrowing of common iliac arteries (arrows). Figure 2 B: post intervention and stent deployment with widening of true lumens. • CT scan 6 months later showed decreased dissection, decreased false lumen size, and patent stent graft without leak. • Secondary analysis of a randomized trial for stable Type B dissections demonstrated that Thoracic Endovascular Aortic Repair (TEVAR), in addition to optimal medical treatment, was associated with improved 5 -year aortaspecific survival and delayed disease progression when compared to medical treatment alone. SUMMARY • Recent data, and this case, support the utility of early endovascular interventions to improve survival for patients with Stanford Type B aortic dissections. REFERENCES • Christoph A. Nienaber, MD, Ph. D, Stephan Kische, MD, Hervé Rousseau, MD, Ph. D, Holger Eggebrecht, MD, Tim C. Rehders, MD, Guenther Kundt, MD, Ph. D, Aenne Glass, MA, Dierk Scheinert, MD, Ph. D, Martin Czerny, MD, Ph. D, Tilo Kleinfeldt, MD, Burkhart Zipfel, MD, Louis Labrousse, MD, Rossella Fattori, MD, Ph. D and Hüseyin Ince, MD, Ph. D for the INSTEAD-XL trial. Circulation: Cardiovascular Interventions. 2013; 6: 407 -416 Figure 1: CT scan of the abdomen showing extension of the aortic dissection to both common ilia arteries, True lumens (white arrows), False lumens (yellow arrows). Figure 3 A: Aortic Dissection before intervention with large false lumen (white arrow) and small true lumen (Black arrow) Figure 3 B: 6 months post-stent deployment with widening of true lumen (black arrow) and resolved dissection (disappearance of false lumen). • Anna M. Booher, MDcorrespondenceemail, Eric M. Isselbacher, MD, Christoph A. Nienaber, MD, Santi Trimarchi, MD, Arturo Evangelista, MD, Daniel G. Montgomery, BS, James B. Froehlich, MD, MPH, Marek P. Ehrlich, MD, Jae K. Oh, MD, James L. Januzzi, MD, Patrick O'Gara, MD, Thoralf M. Sundt, MD, Kevin M. Harris, MD, Eduardo Bossone, MD, Ph. D, Reed E. Pyeritz, MD, Ph. D, Kim A. Eagle, MD, IRAD Investigators. August 2013 Volume 126, Issue 8, Pages 730. e 19– 730. e 24