Successful repair of acute type A aortic dissection during pregnancy at 16^th gestational week with maternal and fetal survival: A case report and review of the literature

Abstract

BACKGROUNDAortic dissection during pregnancy is a rare but life-threatening event for mothers and fetuses. It often occurs in the third trimester of pregnancy and the postpartum period. Most patients have connective tissue diseases such as Marfan syndrome. Thus, the successful repair of a sporadic aortic dissection with maternal and fetal survival in the early second trimester is extremely rare.CASE SUMMARYA 28-year-old woman without Marfan syndrome presented with chest pain at the 16th gestational week. Aortic computed tomographic angiography confirmed an acute type A aortic dissection (TAAD) with aortic arch and descending aorta involvement. Preoperative fetal ultrasound confirmed that the fetus was stable in the uterus. The patient underwent total arch replacement with a frozen elephant trunk using moderate hypothermic circulatory arrest with the fetus in situ. The patient recovered uneventfully and continued to be pregnant after discharge. At the 38th gestational week, she delivered a healthy female infant by cesarean section. After 2.5 years of follow-up, the patient is uneventful and the child’s development is normal.CONCLUSIONA fetus in the second trimester may have a high possibility of survival and healthy growth after aortic arch surgery.

Acute Type A Aortic Dissection during Pregnancy: Trials and Tribulations

“…The precise timing of when to deliver varies around the age of the fetus, with some authors such as Zeebregts suggesting between 28 -32 weeks the option for concomitant delivery should fetal maturity have occurred 8,9,41 . Others, such as the European Society of Cardiology, recommend delivery from 26 weeks gestation, when fetal maturity is likely to have been reached 8 . In a systematic review by de Martinoet al , analysis of seven studies and 63 patients represented a maternal and fetal mortality of 23 and 27% respectively 42 .…”

“…If delivery of the fetus is not possible-in general, this is at less than 28 weeks-there are limited studies and evidence regarding CPB and pregnancy, bar the consensus that it is a high-risk, with high fetal and maternal mortality 43 . Fetal mortality is a significant risk during CPB, with estimates of around 3 -20%, with highest risk in early gestational age 8,40 . If the decision to perform aortic surgery with the foetus in-utero is made, it is necessary to take steps to maximise chances of foetal survival.…”

“…Analysis of case studies has shown a link between hypothermia during CPB and increased foetal mortality 4,8 . One hypothesis for this increase in mortality is due to induced foetal bradycardia.…”

“…Therefore, many authors recommend avoiding temperatures below 35 degrees. However there have been case reports of successful deep hypothermic circulatory arrest performed with foetus in-utero, and some bigger retrospective studies 8,28,41,52,53 . Normothermic perfusion was recommended by Becker in 1983, or antegrade cerebral perfusion with moderate hypothermia, used by Bachet and Guilmet; no single technique has been proven to greater efficacy than the other 28 .…”

“…The highest incidence of TAAD is in the third trimester (50%) and the early postpartum period (33%) 6 . This suggests a link between the integrity of the aortic wall and the cardiocirculatory changes in late pregnancy 7,8 . Oestrogen and progesterone cause structural changes in the intima and media 9 .…”