1. Острый аортальный синдром
магистр второго года обучения по специальности «Кардиология»

2. Острый аортальный синдром - общее понятие для описания состояний, вызванных острым прогрессирующим нарушением целостности стенки аорты.

3. Pathophysiology
Medial degeneration
Intimal tear

4. Epidemiology
Knowledge regarding the incidence of aortic dissection in the general population is limited.
Studies suggest an incidence of 2.6 to 3.5 cases per person-years.
In a review of 464 patients from the International Registry of Acute Aortic Dissection (IRAD), two thirds were male, with a mean age for all patients of 63 years.
Although less frequently affected by acute aortic dissection, women were significantly older than men, with a mean age of 67 years.

5. Risk Conditions for Aortic Dissection
3. Vascular inflammation
Giant cell arteritis
Takayasu arteritis
Behcet’s disease
Syphilis
Ormond’s disease
4. Deceleration trauma
Car accident
Fall from height
5. Iatrogenic factors
Catheter/instrument intervention
Valvular/aortic surgery
Side or cross-clamping/aortotomy
Graft anastomosis
Patch aortoplasty
Aortic wall fragility
1. Long-standing arterial hypertension
Smoking, dyslipidemia, cocaine/crack
2. Connective tissue disorders
Hereditary vascular disease
Marfan syndrome
Vascular Ehlers-Danlos syndrome (type 4)
Bicuspid aortic valve
Coarctation of the aorta
Hereditary thoracic aortic aneurysm/dissection

6. Demographics and history of patients with acute aortic dissection (N=464)
Variable
n* (%)
Type A, n (%) (N=289)
Type B, n (%) (N=175)
P, Type A vs B
Demographics
Age, mean (SD), y
63.1 (14.0)
61.2 (14.1)
66.3 (13.2)
<0.001
Male
303 (65.3)
182 (63.0)
121 (69.1)
0.18
Patient history
Marfan syndrome
22/449 (4.9)
19 (6.7)
3 (1.8)
0.02
Hypertension
326/452 (72.1)
194 (69.3)
132 (76.7)
0.08
Atherosclerosis
140/452 (31.0)
69 (24.4)
71 (42)
Prior aortic dissection
29/453 (6.4)
11 (3.9)
18 (10.6)
0.005
Prior aortic aneurysm
73/453 (16.1)
35 (12.4)
4 (2.3)
0.006
Diabetes
23/451 (5.1)
12 (4.3)
11 (6.6)
0.29
Prior cardiac surgery
83 (17.9)
46 (15.9)
37 (21.1)
0.16
Adapted with permission from Reference 12, Copyright 2000, American Medical Association.

7. Independent predictors of in-hospital death
Overall Model Variable
Overall Type A, %
Among Survivors, %
Among Deaths, %
Parameter Coefficient P
OR for Death (95% CI)
Age >70 y
35.2
30.0
46.1
0.53
0.03
1.70 (1.05–2.77)
Female
34.5
30.7
42.7
0.32
0.20
1.38 (0.85–2.27)
Abrupt onset pain
84.5
82.3
89.0
0.96
0.01
2.60 (1.22–5.54)
Abnormal ECG
69.6
65.2
79.5
0.57
1.77 (1.06–2.95)
Any pulse deficit
30.1
24.7
41.1
0.71
0.004
2.03 (1.25–3.29)
Kidney failure
5.6
2.9
11.9
1.56
0.002
4.77 (1.80–12.6)
Hypotension/shock/tamponade
29.0
20.1
47.1
1.09
<0.0001
2.97 (1.83–4.81)

8. Острый аортальный синдром
Острое расслоение аорты
Острый аортальный синдром
Интрамуральная гематома
Пенетрирующая язва

9. The most common classification systems of thoracic aortic dissection: Stanford and DeBakey
Figure 1. The most common classification systems of thoracic aortic dissection: Stanford and DeBakey. Reproduced with permission from Reference 54, Copyright 2003, American Heart Association. All rights reserved.
Tsai T T et al. Circulation 2005;112:
Copyright © American Heart Association

10. Schematic of aortic dissection (left), penetrating ulcer (middle), and IMH (right).
Figure 2. Schematic of aortic dissection (left), penetrating ulcer (middle), and IMH (right). Reprinted from Reference 22, Copyright 1997, with permission from Elsevier.
Tsai T T et al. Circulation 2005;112:
Copyright © American Heart Association

11. Michael Ellis Debakey 1908-2008

12. Golledge et al. Lancet 2008.

13. Mechanism of aortic regurgitation

16. Examples of AD by TTE
Evangelista, et al. Eur J Echocardiogr 2010.

17. Diagram shows events leading to intramural hematoma, from rupture of vasa vasorum feeding aortic media to creation of intramedial hematoma with intact intimal layer.
—Diagram shows events leading to intramural hematoma, from rupture of vasa vasorum feeding aortic media to creation of intramedial hematoma with intact intimal layer.
Macura K J et al. AJR 2003;181:
©2003 by American Roentgen Ray Society

18. In-hospital mortality for IMH according to site of origin.
Figure 4. In-hospital mortality for IMH according to site of origin. IMH was defined after the first imaging test failed to demonstrate IMH or dissection but the second test confirmed IMH or the first study showed IMH but no evidence of dissection. Reproduced with permission from Reference 58, Copyright 2005, American Heart Association. All rights reserved.
Tsai T T et al. Circulation 2005;112:
Copyright © American Heart Association

19. Examples of IMH
Pics from Evangelista, et al. Eur J Echocardiogr 2010, Flachskampf, FA. Seminars in Cardiothoracic and Vascular Anesthesia 2006, and Meredith EL and Masani ND. Eur J Echocardiogr 2009

20. Examples of IMH
Pics from google images

21. Axial double-inversion-recovery MR images (TR/TE, 1690/29; inversion time, 150 msec) of 76-year-old man with progression of intramural hematoma to overt dissection in ascending aorta within 6 days.
—Axial double-inversion-recovery MR images (TR/TE, 1690/29; inversion time, 150 msec) of 76-year-old man with progression of intramural hematoma to overt dissection in ascending aorta within 6 days. Image shows high-signal-intensity crescentic intramural collection in ascending aorta (arrow), consistent with early subacute type A intramural hematoma.
Macura K J et al. AJR 2003;181:
©2003 by American Roentgen Ray Society

22. Axial double-inversion-recovery MR images (TR/TE, 1690/29; inversion time, 150 msec) of 76-year-old man with progression of intramural hematoma to overt dissection in ascending aorta within 6 days.
—Axial double-inversion-recovery MR images (TR/TE, 1690/29; inversion time, 150 msec) of 76-year-old man with progression of intramural hematoma to overt dissection in ascending aorta within 6 days. Image obtained 6 days after A shows that intramural hematoma progressed to type A aortic dissection within 6 days. Note signal intensity difference between true and false lumens. Signal void within true lumen reflects high-velocity blood flow, whereas higher signal within false lumen is related to slower, turbulent flow. Also note defect in intimomedial flap (arrow) representing intimal tear.
Macura K J et al. AJR 2003;181:
©2003 by American Roentgen Ray Society

23. Diagram shows events leading to penetrating aortic ulcer from formation of extensive aortic atheroma confined to intimal layer, through lesion progression to deep ulceration of plaque with penetration into media, to entrance of blood from aortic lumen into media and splitting of media with intramural hematoma.
—Diagram shows events leading to penetrating aortic ulcer from formation of extensive aortic atheroma confined to intimal layer, through lesion progression to deep ulceration of plaque with penetration into media, to entrance of blood from aortic lumen into media and splitting of media with intramural hematoma. Hematoma formation may extend along media, resulting in long-segment intramural hematoma.
Macura K J et al. AJR 2003;181:
©2003 by American Roentgen Ray Society

24. Examples of PAU
Pics from Meredith EL and Masani ND. Eur J Echocardiogr 2009 and Evangelista, et al. Eur J Echocardiogr 2010.

25. 58-year-old woman presenting with severe back pain and penetrating atherosclerotic ulcer of aorta
—58-year-old woman presenting with severe back pain and penetrating atherosclerotic ulcer of aorta. Multiplanar reformatted CT scan in sagittal view shows ulcer crater (open arrow) and long-segment intramural hematoma (solid arrows) in descending aorta.
Macura K J et al. AJR 2003;181:
©2003 by American Roentgen Ray Society

26. 58-year-old woman presenting with severe back pain and penetrating atherosclerotic ulcer of aorta
—58-year-old woman presenting with severe back pain and penetrating atherosclerotic ulcer of aorta. Lateral angiogram of distal thoracic aorta shows anterior ulcerlike aortic lesion (arrow) filling with contrast material above level of celiac axis.
Macura K J et al. AJR 2003;181:
©2003 by American Roentgen Ray Society

27. 58-year-old woman presenting with severe back pain and penetrating atherosclerotic ulcer of aorta
—58-year-old woman presenting with severe back pain and penetrating atherosclerotic ulcer of aorta. Contrast-enhanced CT scan obtained at level corresponding to A shows ulcer (arrow) filling with contrast material. Note that intramural hematoma presents as eccentric low-attenuation thickening of aortic wall.
Macura K J et al. AJR 2003;181:
©2003 by American Roentgen Ray Society

28. 83-year-old man with chronic obstructive pulmonary disease and hypertension
—83-year-old man with chronic obstructive pulmonary disease and hypertension. Contrast-enhanced CT scan shows calcified atheromatous plaque with focal ulceration (arrow) but without contrast extravasation beyond plaque.
Macura K J et al. AJR 2003;181:
©2003 by American Roentgen Ray Society

29. Diagram illustrates events leading to aortic dissection from formation of entrance tear and exit tear of intima to splitting of aortic media and formation of intimomedial flap
—Diagram illustrates events leading to aortic dissection from formation of entrance tear and exit tear of intima to splitting of aortic media and formation of intimomedial flap. Blood under pressure dissects media longitudinally, and double-channel aorta is formed with blood filling both true and false lumens.
Macura K J et al. AJR 2003;181:
©2003 by American Roentgen Ray Society

30. Examples of AD by TEE
Meredith EL and Masani ND. Eur J Echocardiogr 2009.

31. 61-year-old man with symptoms of right hemispheric stroke who was found to have marked blood pressure discrepancy between arms and hypertension
—61-year-old man with symptoms of right hemispheric stroke who was found to have marked blood pressure discrepancy between arms and hypertension. Urgent CT scan (not shown) revealed type A aortic dissection. Patient went into asystole and died 15 hr after imaging. Axial CT scan shows dissection continuing along right wall of abdominal aorta (arrow). No enhancement of right kidney parenchyma was present.
Macura K J et al. AJR 2003;181:
©2003 by American Roentgen Ray Society

32. 61-year-old man with symptoms of right hemispheric stroke who was found to have marked blood pressure discrepancy between arms and hypertension
—61-year-old man with symptoms of right hemispheric stroke who was found to have marked blood pressure discrepancy between arms and hypertension. Urgent CT scan (not shown) revealed type A aortic dissection. Patient went into asystole and died 15 hr after imaging. Axial CT scan shows irregular dissection flap within lumen of ascending and descending aorta (arrows).
Macura K J et al. AJR 2003;181:
©2003 by American Roentgen Ray Society

33. 68-year-old man with aberrant right subclavian artery and horseshoe kidney
—68-year-old man with aberrant right subclavian artery and horseshoe kidney. Anteroposterior volume-rendered CT image of origin of aberrant subclavian artery depicts aberrant vessel course (arrow) better than axial scans A and B.
Macura K J et al. AJR 2003;181:
©2003 by American Roentgen Ray Society

34. 46-year-old man with concurrent intramural hematoma involving ascending aorta and communicating dissection involving descending aorta
—46-year-old man with concurrent intramural hematoma involving ascending aorta and communicating dissection involving descending aorta. Axial contrast-enhanced CT scan obtained at same level as A shows wall thickening in ascending and descending aorta, but high-attenuation intramural hematoma is less obvious. Classic intimomedial flap (arrow) dividing true and false lumens in descending aorta is more conspicuous after contrast administration. Note irregular margin of flap on false lumen side. Intramural hematoma (arrowhead) is seen along lateral wall of false lumen.
Macura K J et al. AJR 2003;181:
©2003 by American Roentgen Ray Society

35. 46-year-old man with concurrent intramural hematoma involving ascending aorta and communicating dissection involving descending aorta
—46-year-old man with concurrent intramural hematoma involving ascending aorta and communicating dissection involving descending aorta. Axial unenhanced CT scan shows hyperdense crescentic hematoma in wall of ascending aorta (white arrow) with eccentric narrowing of lumen, type A intramural hematoma. Small intramural hematoma (arrowhead) is also noted at left lateral aspect of proximal descending aorta. High-attenuation dissection flap (black arrow) is seen in descending aorta.
Macura K J et al. AJR 2003;181:
©2003 by American Roentgen Ray Society

36. Initial management of patients with suspected aortic dissection
Recommendation
Class
ECG: documentation of ischemia I
Heart rate and blood pressure monitoring
Pain relief (morphine sulfate)
Reduction of systolic blood pressure with ß-blockers (intravenous metoprolol, esmolol, or labetelol)
In patients with severe hypertension despite ß-blockers, additional vasodilator (intravenous sodium nitroprusside to titrate blood pressure to 100–120 mm Hg)
In patients with obstructive pulmonary disease, blood pressure lowering with calcium channel blockers II
Imaging in patients with ECG signs of ischemia before thrombolysis if aortic pathology is suspected
Chest x-ray
III
All recommendations are level of evidence аdapted from Reference 43, by permission of Oxford University Press.

37. Surgical therapy of acute Type A (Type I and II) aortic dissection
Recommendation
Class
Emergency surgery to avoid tamponade/aortic rupture I
Valve-preserving surgery—tubular graft if normal-sized aortic root and no pathological changes in valve cusps
Replacement of aorta and aortic valve (composite graft) if ectatic proximal aorta and/or pathological changes of valve/aortic wall
Valve-sparing operations with aortic root remodeling for abnormal valves
IIa
Valve preservation and aortic root remodeling in Marfan patients
All recommendations are level of evidence аdapted from Reference 43, by permission of Oxford University Press.

38. Fourteen-day mortality in 645 patients from the IRAD registry stratified by medical and surgical treatment in both type A and B aortic dissection.
Figure 3. Fourteen-day mortality in 645 patients from the IRAD registry stratified by medical and surgical treatment in both type A and B aortic dissection. Adapted with permission from Reference 12, Copyright 2000, American Medical Association. All rights reserved.
Tsai T T et al. Circulation 2005;112:
Copyright © American Heart Association

39. Thank you for your attention!