Acute aortic type A dissection is a life-threatening disease that requires immediate surgical intervention. When dissection occurs during pregnancy, it is of high risk for both the mother and the fetus. In this study, we reported two cases of acute aortic dissection in late pregnancy at 28 weeks and 32 weeks of gestation respectively. After the two patients underwent a cesarean section and delivered a baby, we performed composite graft replacement of the aortic valve, aortic root and ascending aorta, with re-implantation of the coronary arteries into the graft (Bentall procedure) instead of repairing the arch with deep hypothermia and circulation arrest. Both mothers and children survived and recovered well

Changfa Guo

Chunsheng Wang

CJ Zeebregts

Demin Xu

FF Immer

JP Rossiter

KJ Lipscomb

LJ Meijboom

M Groenink

P Manallo-Estrella

S Nistri

T Krüger

English

PubMed

Abstract
          Acute aortic type A dissection is a life-threatening disease that requires immediate surgical intervention. When dissection occurs during pregnancy, it is of high risk for both the mother and the fetus. In this study, we reported two cases of acute aortic dissection in late pregnancy at 28 weeks and 32 weeks of gestation respectively. After the two patients underwent a cesarean section and delivered a baby, we performed composite graft replacement of the aortic valve, aortic root and ascending aorta, with re-implantation of the coronary arteries into the graft (Bentall procedure) instead of repairing the arch with deep hypothermia and circulation arrest. Both mothers and children survived and recovered well.</jats:p

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Journal of Cardiothoracic Surgery

Successful treatment for acute aortic dissection in pregnancy-bentall procedure concomitant with cesarean section

Abstract Acute aortic type A dissection is a life-threatening disease that requires immediate surgical intervention. When dissection occurs during pregnancy, it is of high risk for both the mother and the fetus. In this study, we reported two cases of acute aortic dissection in late pregnancy at 28 weeks and 32 weeks of gestation respectively. After the two patients underwent a cesarean section and delivered a baby, we performed composite graft replacement of the aortic valve, aortic root and ascending aorta, with re-implantation of the coronary arteries into the graft (Bentall procedure) instead of repairing the arch with deep hypothermia and circulation arrest. Both mothers and children survived and recovered well.</p

Xu Demin

Guo Changfa

Wang Chunsheng

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Successful treatment for acute aortic dissection in pregnancy---bentall procedure concomitant with cesarean section

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CASE REPORT Open Access
Successful treatment for acute aortic dissection in
pregnancy—bentall procedure concomitant with
cesarean section
Changfa Guo, Demin Xu and Chunsheng Wang*
Abstract
Acute aortic type A dissection is a life-threatening disease that requires immediate surgical intervention. When
dissection occurs during pregnancy, it is of high risk for both the mother and the fetus. In this study, we reported
two cases of acute aortic dissection in late pregnancy at 28 weeks and 32 weeks of gestation respectively. After
the two patients underwent a cesarean section and delivered a baby, we performed composite graft replacement
of the aortic valve, aortic root and ascending aorta, with re-implantation of the coronary arteries into the graft
(Bentall procedure) instead of repairing the arch with deep hypothermia and circulation arrest. Both mothers and
children survived and recovered well.
Background
Acute aortic type A dissection in pregnancy is rare,
however, of high risk for both the mother and the fetus.
Concomitant diseases of Marfan and bicuspid aortic
valve disease (BAVD) are of special interest. From Jan
2001 to April 2008, we had two cases of acute aortic
dissection in pregnancy (one BAVD patient, and the
other Marfan patient), 1.38% (2/145) in all acute aortic
type A dissection cases.
Case report
Case I. A 33-year-old Marfan woman, who had had a
normal previous pregnancy, was referred because of the
acute chest pain with back irradiation. She was at the 28
weeks’ pregnancy this time. Echocardiography revealed
moderate-severe aortic regurgitation, a dilated aortic
root measuring 5.2 cm in diameter, and an acute aortic
dissection involving the ascending aorta and the aortic
arch, which was also verified by a computed tomography
arteriogram (Figure 1-A, B).
Case II. A 30-year-old woman at 32 weeks of gestation
was admitted because of the acute onset of severe chest
pain and dyspnea. Her chest x-ray revealed an enlarged
heart shadow and widening of the mediastinum.
Echocardiography revealed BAVD (Figure 2-A) with
moderate aortic stenosis and regurgitation, a dilated aor-
tic root measuring 4.6 cm in diameter, and an acute
aortic dissection involving the ascending aorta, which
was also verified by a computed tomography arterio-
gram (Figure 2-B).
These two patients had a negative history of vascular
events, high blood pressure, and previous vascular sur-
gery. Under general anesthesia, the cardiopulmonary
bypass was built by draining from right atrium and per-
fusion into the femoral artery or axillary artery. Cesar-
ean section was performed immediately followed by
Bentall procedure. After 24 hours of a regular intensive
care unit (ICU) postoperative period, the patients were
transferred to the ward and then discharged on the 7th
postoperative day.
Discussion
Aortic dissection is rare in young woman, but when it
does occur, it is often associated with pregnancy of
highest incidence in the third trimester. This is the per-
iod of maximal hyper-hemodynamic stress during preg-
nancy. During this period, there are maximal increases
in heart rate, stroke volume, cardiac output, and in left
ventricular wall mass and end-diastolic dimension. In
addition, estrogen reportedly inhibits collagen and elas-
tin deposition in the aorta, while progestogen accelerates
deposition of noncollagen proteins in the aortas. These
* Correspondence: cswang@medmail.com.cn
Department of Cardiac Surgery, Zhongshan Hospital, Fudan University,
Shanghai, China
Guo et al. Journal of Cardiothoracic Surgery 2011, 6:139
http://www.cardiothoracicsurgery.org/content/6/1/139
© 2011 Guo et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
hormonal effects led to a fragmentation of the reticulin
fibers, diminished the amount of acid mucopolysacchar-
ides, and favored loss of the normal corrugation of the
elastic fibers [1]. Since these modifications occur in
every pregnancy, it is assumed that aortic dissection
may have some etiologic factors, such as an inherent
defect in the arterial wall. From the literature, Marfan
syndrome is responsible for up to 50% of the reports of
aortic dissection with pregnancy [2]. Patients with Mar-
fan syndrome have a mutation within the fibrillin gene,
and the connective tissue disorder often affects cardio-
vascular system, and may favor aortic root dilatation
and aortic dissection. Abnormal biophysical properties
of the aorta in patients with Marfan syndrome were
found in normal-sized aortas in patients with magnetic
resonance flow mapping [3]. BAVD is another important
predisposing factor for aortic dissection. Abnormal elas-
tic properties, similar to the findings in patients with
Marfan syndrome, have been demonstrated [4].
Now, the aortic root diameter above which pregnancy
is associated with a considerable risk for the occurrence
of aortic dissection is still a matter of debate. In a pro-
spective study of 21 Marfan patients, two out of four
women with aortic root diameter of between 40 and 43
mm at pregnancy developed an aortic complication [5].
In a retrospective study in 36 patients, four Marfan
women with aortic root diameters of between 40 and 45
mm developed aortic dissection [6]. More recently, in
2003, Immer et al. showed that the aortic root enlarge-
ment (> 4 cm) during pregnancy in patients with BAVD
and Marfan syndrome was associated with a consider-
able disk for the occurrence of Type A dissection. Not
only was the absolute diameter of the aortic root impor-
tant, but also the rapidity of aortic dilatation was impor-
tant, and should be taken into account [7]. On the other
hand, a recent prospective study of 127 Marfan patients
reported by Meijboom and his colleagues demonstrated
that pregnancy in women with Marfan syndrome
seemed to be relatively safe up to an aortic root dia-
meter of 45 mm [8]. In our cases, the aortic root dia-
meters of the two patients are 46 mm and 52 mm. It
seems consistent with Meijboom’s study. However, since
pregnant women did have aortic dissection with a dia-
meter less than 45 mm, as suggested by previous studies
[5-7], we recommend monitor all pregnant women with
Marfan syndrome or BAVD very carefully and closely.
Pregnancy and aortic dissection is of no standardized
therapeutic concept. In the third trimester of the gesta-
tion, especially after 30-weeks of gestation, immediate
Figure 1 Aortic dissection in case I with Marfan syndrome. (A)
CT scan: Ascending aortic dissection (grey arrow), (B) CT scan: Aortic
arch dissection (grey arrow).
Figure 2 Aortic dissection in case II with bicuspid aortic valve.
(A) Echocardiography: Bicuspid aortic valve (grey arrow). (B) CT scan:
Ascending aortic dissection (grey arrow).
Guo et al. Journal of Cardiothoracic Surgery 2011, 6:139
http://www.cardiothoracicsurgery.org/content/6/1/139
Page 2 of 3
cesarean section followed directly by cardiac surgery
seems to be the most promising option to save the live
of the mother and her child. No serious complications
have been reported in the literature by adapting this
modality of treatment. In our opinion, minimizing surgi-
cal repair of acute type A dissection in pregnant patients
using Bentall procedure instead of repairing the arch
with deep hypothermia and circulation arrest will lead
to favorable results at a lower risk. In a recent analysis
of 1558 patients with Acute Aortic Type A Dissection,
hypothermic circulatory arrest alone resulted in a 30-
day mortality rate of 19.4% and a mortality-corrected
permanent neurological dysfunction rate of 11.5% [9].
Hence, avoiding the use of this technique and minimiz-
ing surgical repair might be important to save the life in
our two cases. In case I, though the acute aortic dissec-
tion involved the aortic arch, the primary intimal tear
was in the ascending aorta, and there was no aneurysm
formation in the aortic arch or the distal aorta, and no
occlusion of the brachiocephalic artery. So we only did
the Bentall procedure without performing the aortic
replacement. This patient recovered well at hospital and
suffered no complications during 1-year follow-up. In
case II, since the acute aortic dissection involved only
the ascending aorta, we did the Bentall procedure and
cesarean section as well. Both mother and the baby sur-
vived and recovered well.
Consent
Written informed consent was obtained from the next
of the kin of the patient involved for publication of this
case report and any accompanying images. A copy of
the written consent is available for review by the Editor-
in-Chief of this journal
Authors’ contributions
CSW did the operations, conceived of the study, and helped in revising the
manuscript critically. CFG, and DMX participated in its design and
coordination, and drafted the manuscript. All authors read and approved the
final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 6 August 2011 Accepted: 15 October 2011
Published: 15 October 2011
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doi:10.1186/1749-8090-6-139
Cite this article as: Guo et al.: Successful treatment for acute aortic
dissection in pregnancy—bentall procedure concomitant with cesarean
section. Journal of Cardiothoracic Surgery 2011 6:139.
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Guo et al. Journal of Cardiothoracic Surgery 2011, 6:139
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Page 3 of 3


AE: Histopathologic findings in human aortic media associated with pregnancy. Arch Path

al: Biophysical properties of the normal-sized aorta in patients with Marfan syndrome: evaluation with MR flow mapping. Radiology

Bicuspid aortic valve: abnormal elastic properties. J Heart Valve Dis

BJ: Pregnancy and aortic root growth in the Marfan syndrome: a prospective study. Eur Heart J

Carrel TP: Aortic dissection in pregnancy: analysis of risk factors and outcome. Ann Thorac Surg

Cerebral protection during surgery for acute aortic dissection type A: results of the German Registry for Acute Aortic Dissection Type A (GERAADA). Circulation

de la Riviere AB: Acute aortic dissection complicating pregnancy. Ann Thorac Surg

Outcome of pregnancy in women with Marfan’s syndrome.

Pyeritz RE: A prospective longitudinal evaluation of pregnancy in the Marfan syndrome.

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Successful treatment for acute aortic dissection in pregnancy---bentall procedure concomitant with cesarean section

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