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Little information is available regarding the incidence of aortic dissection after previous aortic valve replacement (AVR), and factors associated with its development. Therefore, a meta-analysis of the literature was performed, and a patient population was studied retrospectively. Data from published studies showed that 87% of 31 patients were men (mean age 60 years), and 68% were known to have systemic hypertension. A dilated ascending aorta was observed at the time of AVR in 88% of patients. AVR was performed because of pure aortic regurgitation in 55% of patients, and combined aortic stenosis and regurgitation in 23%. More than 50% of patients did not survive dissection. The present series consisted of 7 patients. Four patients were known to the department before dissection occurred, and the other 3 were referred by other hospitals. Eighteen of 330 patients with previous AVR whose data were stored in an echocardiographic data base had an ascending aortic diameter >50 mm. Of these 18 patients, aortic dissection occurred in 4. Three of the remaining 14 patients underwent elective ascending aortic replacement. Characteristics including sex, age, severity of dilatation, presence of progression in diameter, left ventricular function and time interval after AVR were not helpful in determining a cumulative risk for developing dissection. Because dissection occurred in 4 of 18 patients (22%) with an ascending aorta diameter >50 mm, it is suggested to consider replacement of the ascending aorta during AVR when a value of 50 mm is exceeded. (Am J Cardiol 1993;72:1043-1047)

Coronary dissection is a major cause of abrupt arterial closure after coronary angioplasty but may also be associated with no discernible event. Deciding which dissections should receive further treatment is often a dilemma if the artery remains patent. This case-control study examined predictors of major ischemic complications after coronary dissections. Fifty-eight patients with coronary dissections, but a patent artery at the completion of the angloplasty procedure, subsequently had in-hospital abrupt arterial closure, acute myocardial infarction, emergency coronary bypass surgey, or died; they were matched to 58 control subjects with dissection but no event. Analysis of each angiogram was performed with the examiner unaware of patient's history. Baseline angiographic and clinical characteristics of cases and controls were similar except for an excess of current smokers among the cases (33. vs 16%; p: 0.048). Residual luminal diameter at the dissection site was 1.2 [+ or -] 0.6 mm (cases) versus 1.6 [+ or -] 0.6 mm (controls; p=0.001) with relative stenosis of 59 [+ or -] 23.% vs 43 [+ or -] 21%, respectively (p: 0.0001). Dissections among cases were longer than among controls (11 [+ or -] 7 mm vs 7 [+ or -] 4 mm; p=0.001). No significant difference was found in dissection morphology using 2 classification schemes or in final Thrombolysis in Myocardial Infarction study flow grade. Transient occlusion during the procedure, however, occurred in 47% of cases versus 5% of controls (p=0.0001). Transient occlusion, residual percent stenosis [is greater than or equal to] 70%, and dissections [is greater than or equal to] 6 mm were independently predictive of major ischemic events. (Am J Cardiol 1993;71:1402-1407)

Patients who arrive at the ER with indications of aortic dissection or an aneurysm about to burst need not undergo lengthy, risky procedures to confirm or exclude diagnosis. Nonenhanced true [...]

ORLANDO, FLA. -- New data from the largest-ever prospective study of acute aortic dissection are punching a plethora of holes in traditional thinking about this highly lethal disorder. Physicians have [...]

Repeat percutaneous transluminal coronary angioplasty (PTCA) for subacute intimal dissections that produce symptoms after a period of 1 month or more is reluctantly performed for fear of extension and abrupt closure. Patients were identified with demonstrated intimal dissections intimal contrast staining or frank intimal flap) at the time of initial PTCA who returned a mean of 17.5 weeks (range 9 to 50) later with recurrent chest pain. Repeat angiography revealed luminal compromise due to dissection rather than restenosis in 22 patients. Of these, 17 underwent repeat PTCA. Elective bypass surgery without attempted PTCA was chosen in the other 5 patients because at extensive intimal dissections [is greater than] 2 balloon lengths) or involvement of critical branches. In the group of 17 patients who had repeat PTCA, 10 (group 1) had a frank intimal flap without persistent contrast staining after the initial PTCA, while 7 (group 2) had both persistent staining and a flap. Successful PTCA was performed in 13 of these 17 patients (76%). There were 2 abrupt closures and 2 unsatisfactory luminal openings. One of these patients required urgent coronary bypass surgery. AN 10 group 1 patients had successful repeat procedures versus only 3 of 7 group 2 patients (p = 0.01). The 3 patients with the greatest degree of luminal compromise immediately after the initial PTCA had failed repeat PTCA attempts. These results suggest that repeat PTCA for subacute intimal dissections presenting as restenosis can be successfully performed in selected patients, and that the presence of contrast staining and the degree of luminal compromise by the dissection may be predictive of outcome. (Am J Cardiol 1989;64-.980-984), The wall of a typical artery has three layers, the intima, the media, and the adventitia, with the intima the innermost. A condition called intimal dissection occurs when the intima works itself loose or even partly tears off, leaving a flap of tissue that can interfere with or even stop the blood flow. Percutaneous transluminal coronary angioplasty (PTCA) is a procedure whereby a small balloon is threaded into a coronary artery, which delivers blood to the heart itself, and then inflated to enlarge the vessel. Patients who have undergone this procedure sometimes develop intimal dissections days or weeks after the procedure, with attendant symptoms of chest pain. A repeat PTCA is generally considered risky since it could induce complete blockage of the artery, necessitating emergency surgery. However, dissection that is not too extensive may have a more optimistic prognosis. Twenty-two patients who had undergone successful PTCA at least 4 weeks previously but who continued to have chest pain received repeat angiography, an X-ray examination of the coronary arteries. The angiographs were examined for narrowing of the arteries (stenosis), presence of an intimal 'flap' (a piece of intima partially torn off), or signs that the dye used in the angiography had 'leaked' into the space between the intima and media, an indication of a less extreme dissection than a flap. Based on comparison with the initial angiogram taken for the first PTCA, the size and characteristics of any dissection or stenosis were noted. Five patients underwent successful bypass surgery because their disease was extensive. Of the remaining 17, 10 (Group 1) had an apparent intimal flap without staining of the region between the two layers of the artery. The remaining seven (Group 2) had both a flap and staining. When PTCA was attempted, the arteries of 76 percent of all patients were successfully dilated, but all failures occurred in Group 2 patients. All patients without staining between the layers of the arterial wall had a good response to repeat PTCA, indicating that healed dissections that produce symptoms can be treated if patients are screened and evaluated carefully. (Consumer Summary produced by Reliance Medical Information, Inc.)

Dissection, or rupture, of the coronary arteries, the major blood vessels supplying the heart, may occur during or after childbirth and can lead to sudden collapse and death or severe ischemia, an insufficient blood supply to the heart. Survival after coronary artery dissection is rare, and diagnosis of this abnormality is often made at autopsy. In most cases, the left coronary artery is involved. A case is described of a 33-year-old woman who had a coronary artery dissection four days after giving birth. She experienced severe pain above the stomach area, which spread towards the back and was associated with excessive sweating. Abnormalities in the electrical activity of the heart, dilation and swelling of the left ventricle, and decreased movement of the heart muscle were detected. Due to progressive heart failure, the patient required a heart transplantation three months after delivery. She has remained free of symptoms for 36 months after the transplantation, and is maintained on a drug regimen of cyclosporine, azathioprine, and prednisone to prevent rejection of the transplant. Examination of the diseased heart showed dissection of the left coronary artery leading to a myocardial infarction (heart attack). Changes in blood flow during labor, the straining during delivery, and degenerative changes in the blood vessels may contribute to rupture of the coronary arteries in pregnancy or after childbirth. This is the first reported case of coronary artery dissection occurring after childbirth which was successfully treated by heart transplantation. (Consumer Summary produced by Reliance Medical Information, Inc.)