The Unmet Clinical Needs of Acute Type A Aortic Dissection in Pregnancy

A commentary published in the Journal of Cardiac Surgery advocated that type A aortic dissection (TAAD) in pregnancy can be successfully treated in a subset of patients.

The commentary was authored by investigators at the SRM Institutes for Medical Science in India and the University of York and Velindre University NHS Trust in the United Kingdom. It was a response to a review article about acute TAAD (ATAAD).

ATAAD in pregnancy is a life-threatening event for both mother and fetus and the treatment during the 8-week gestational phase in a primigravid woman remains an unmet clinical need.

The commentary authors agreed that physicians choosing imaging modalities for monitoring the mother need to consider radiation exposure for the fetus. Iodinated- or gadolinium-based contrast media should be avoided.

Almost all patients with ATAAD must be treated via surgical procedure. Operative techniques and cardiopulmonary bypass can place the fetus at significant risk. It is generally advised to avoid performing procedures during the first trimester, however, if the patient is unstable, avoiding a procedure may not be possible.

In addition, there remains substantial debate about the correct surgical approach. Survival rates vary on the basis of surgical strategy as well as the age of the fetus. A study reported outcomes of 11 women who received emergency cardiac procedures at 16 to 21 weeks’ gestation. No maternal mortality occurred, but fetal mortality was 27%. Other published studies reported similar fetal mortality rates (30%-33.1%) but the maternal mortality rates varied (6%-11.2%).

Hypertension drugs and anticoagulants should be monitored carefully as beta-blockers have been shown to have harmful effects on the fetus, such as reduced growth and fetal bradycardia.

“…TAAD in pregnancy adds an extra level of complexity to an already complex process,” the commentary authors noted. “Yet, optimal outcomes can be achieved with planning involving accurate diagnosis, safe imaging, modern surgical techniques, and tight medication control.”

Reference

Idhrees M, Jubouri M, Bashir M, Velayudhan BV. Type A aortic dissection during in pregnancy: confront without aversion or delay. J Card Surg. Published online March 25, 2022. doi:10.1111/jocs.16446