UNDERSTANDING PREGNANCY-RELATED AORTIC DISSECTION
Still a long way to go?
Andrea De Martino, MD1, Stefania Blasi,
MD2, Uberto Bortolotti, MD1
1Section of Cardiac Surgery, University Hospital,
Pisa, and
2Division of Cardiac Surgery, Fondazione
Poliambulanza, Brescia, Italy
Address correspondence to: Andrea De Martino, MD, Sezione Autonoma di
Cardiochirurgia Universitaria, Dipartimento Cardiotoracico e Vascolare,
Via Paradisa 2, 54126 Pisa, Italy
Tel: +39 050 995276
e-mail: andrea.demartino@unipi.it
Word count: 619
Acute aortic dissection (AAD) is a rare event during gestation but
nevertheless pregnancy has been recognized as a predisposing factor for
AAD. Our interest in this subject is outlined by recent
publications1-3. From our review of the Literature, it
appears evident that pregnancy-related AAD is an infrequent but at times
fatal disease, especially in women with Marfan or Loeys–Dietz
syndromes, while a bicuspid aortic valve has not emerged as a clear risk
factor2. Since AAD can occur throughout all the phases
of gestation and even during puerperium, a continuous follow-up with
special attention to aortic size monitoring appears indicated in women
at particular risk for developing this dramatic complication.
We have been, therefore, very interested in the paper by Liu et al. in
the Journal of Cardiac Surgery , for providing further data on the
complex problem of AAD and pregnancy4. The authors
have focused their attention specifically on the repair of AAD combined
with cesarean section, reviewing the reported cases in the last decade.
This issue was non covered in our previous review and meta-analysis on
AAD during pregnancy, since this was aimed to assess the incidence,
clinical presentation and pathological substrates of this disease in
this peculiar physiological setting1. For such reason
the paper by Liu et al. brings new valuable information on a specific
and extremely important aspect of this issue. They reviewed all
published case reports of type A AAD occurring in the last trimester of
pregnancy and described the fetal and maternal outcomes after cesarean
section and aortic intervention. In particular, their findings, that
simultaneous repair of AAD and cesarean section provides excellent
results in terms of maternal and fetal outcomes, indicate feasibility
and effectiveness of combining these procedures4.
Surgery for AAD is generally a complex procedure which becomes
particularly challenging when required during the first two trimesters
of pregnancy, when adequate conduction of anesthesia and cardiopulmonary
bypass, coupled with a fast and effective repair, must provide adequate
fetal oxygenation by minimizing hemodilution and avoiding
hypothermia5.
The paper of Liu et al.4, together with the currently
available evidence, helps to increase the awareness of the specific risk
factors for AAD associated to pregnancy, particularly Marfan and
Loeys-Dietz syndromes and a preexisting aortic dilatation; this
indicates that ultrastructural changes in the aortic wall may occur,
probably related to hemodynamic and hormonal derangements specific of
pregnancy and may play a key role in understanding how this catastrophic
occurrence may be prevented.