Acute Aortic Dissection: Symptoms, Diagnosis, and Emergency Surgery

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• What is Acute Aortic Syndrome?
• Main Causes and Risk Factors
• Symptoms and Presentation
• Diagnosis and CT Scan
• Mortality Risk and Urgency
• Emergency Surgery Treatment
• Importance of Specialized Care

What is Acute Aortic Syndrome?

Acute aortic syndrome is an umbrella term for three critical medical emergencies that affect the body's main artery. Dr. Tsuyoshi Kaneko, MD, a cardiac surgeon, clarifies that this syndrome comprises aortic dissection, intramural hematoma, and penetrating aortic ulcer. These conditions are grouped together because they all manifest suddenly and require immediate medical attention.

For the purpose of this discussion, the focus is on aortic dissection, as it represents the vast majority, over 90%, of acute aortic syndrome cases. Understanding this specific condition is paramount for recognizing its gravity.

Main Causes and Risk Factors

The primary causes of an acute aortic dissection are chronic high blood pressure, underlying connective tissue disorders, and a pre-existing history of aortic aneurysms. Dr. Tsuyoshi Kaneko, MD, emphasizes that hypertension is a major predisposing risk factor, though it does not guarantee someone will develop the condition.

Other factors can contribute, but these three are the most significant. Controlling blood pressure is a key preventative measure for individuals at risk.

Symptoms and Presentation

The hallmark symptom of an acute aortic dissection is a sudden, severe, and often tearing pain in the chest or back. Dr. Kaneko describes this as a type of pain unlike anything a person has experienced before. This distinct quality of pain is a critical red flag.

This symptom demands immediate action and should never be ignored or dismissed as simple muscle strain or indigestion.

Diagnosis and CT Scan

Diagnosing an acute aortic dissection typically requires a computed tomography (CT) scan. While an echocardiogram can sometimes detect the problem, the CT scan is the gold standard for a definitive diagnosis. Dr. Tsuyoshi Kaneko, MD, stresses the importance of this specific imaging.

He and Dr. Anton Titov, MD, discuss how a diagnosis can be missed if only an electrocardiogram (EKG) is performed, as it may appear normal. Patients must seek a center equipped to perform these advanced scans quickly.

Mortality Risk and Urgency

The mortality risk associated with an untreated aortic dissection is extremely high and time-sensitive. Dr. Kaneko provides a stark statistic: the risk of death increases by approximately 1% for every hour that passes without treatment.

This means that within the first 48 hours, the mortality rate can reach nearly 50%. This underscores the critical need for rapid response and explains why this condition is a true medical emergency.

Emergency Surgery Treatment

The only effective treatment for an acute aortic dissection affecting the ascending aorta is emergency open-heart surgery. Dr. Tsuyoshi Kaneko, MD, confirms that medication alone cannot repair the torn layers of the aorta. The surgical procedure is complex and aims to replace the damaged section of the artery with a synthetic graft.

This intervention is lifesaving and must be performed by a highly specialized cardiac surgical team without delay to stop the progression of the dissection and prevent fatal complications like rupture.

Importance of Specialized Care

Seeking care at the right facility is crucial for survival. Dr. Kaneko advises that anyone experiencing these symptoms must go directly to an emergency room at a hospital that has the capability to perform open cardiac surgery. Not all hospitals are equipped for this specific, complex operation.

Dr. Anton Titov, MD, and Dr. Kaneko reference tragic cases, such as the playwright Jonathan Larson, to highlight the consequences of misdiagnosis. A high index of suspicion from both patients and physicians is essential for a positive outcome.

Full Transcript

Dr. Anton Titov, MD: Aortic dissection. You are a cardiac surgeon with particular interest in surgery of the aorta, aortic heart valve, and mitral heart valve. Let's start with aortic valve disease. What is acute aortic syndrome?

Dr. Anton Titov, MD: What causes acute aortic syndrome? How to diagnose and treat patients with acute aortic syndrome?

Dr. Tsuyoshi Kaneko, MD: Acute aortic syndrome is an acute aortic disease that happens. It consists of three medical problems. One problem is called aortic dissection. The second problem is called intramural hematoma. The third problem in acute aortic syndrome is penetrating aortic ulcer.

Dr. Tsuyoshi Kaneko, MD: Acute aortic syndrome is a combination of these three diseases because they occur in an acute fashion. For the sake of time, I will only focus on aortic dissection, as this represents over 90% of acute aortic syndrome.

Dr. Tsuyoshi Kaneko, MD: The cause of acute aortic dissection is hypertension, high blood pressure, and connective tissue disorders. Patients also have a history of aortic aneurysms. There are some other risk factors that can predispose to aortic dissections, but these are the main three.

This doesn't mean you must have high blood pressure to have an acute aortic dissection. But if you have hypertension, you do have a risk factor and are predisposed to this acute aortic syndrome.

The typical presentation of acute aortic dissection is chest pain or back pain. This is a type of pain that you have never experienced before—it will be a severe chest pain or back pain.

Dr. Anton Titov, MD: Usually, aortic dissection is diagnosed with a CT scan. You can diagnose it with an echocardiogram, but usually, the diagnosis of acute aortic syndrome is done by CT scan.

Dr. Tsuyoshi Kaneko, MD: It is crucial to go to an emergency room as soon as possible when you experience acute chest pain or acute severe back pain. Aortic dissection is a very high-risk disease. In the first 48 hours, the risk of dying from aortic dissection is 1% every hour.

If you do not treat aortic dissection for 48 hours, there's about a 50% chance of dying.

Dr. Anton Titov, MD: The only method to treat aortic dissection is through an emergency operation, especially if it occurs in the front of the aorta, which is called the ascending aorta.

Dr. Tsuyoshi Kaneko, MD: It is crucial for you to go to the emergency room if you have aortic dissection. You have to go to a center where they perform open cardiac surgery to fix this type of aortic disease. Aortic dissection requires urgent cardiac surgery.

It's also important to have a high index of suspicion for aortic dissection. There was a producer of a famous musical on Broadway, Jonathan Larson, 35 years old, of "Rent." He had acute chest pain. He was in New York and was initially misdiagnosed. He died from a misdiagnosed aortic dissection.

Dr. Tsuyoshi Kaneko, MD: Yes. Recently, there was a case in Japan where one of the performers actually doing a musical died on the stage. He just collapsed and died. They later found it was acute aortic dissection.

Acute aortic dissection can be very abrupt. But if you can go to the emergency room in a timely fashion, there is a chance to survive acute aortic syndrome.

Dr. Anton Titov, MD: You have to go to the operating room very fast for heart surgery. And you also must ask doctors for the CT scan, not just an electrocardiogram—that is, if you can talk.

That's correct, absolutely!