Long term follow-up in a patient with acute type A aortic dissection complicated with cardiac tamponade without surgery.

To the Editor,

Acute type A aortic dissection complicated by cardiac tamponade is a rare disease but frequently associated with poor outcomes. Urgent open surgical repair is required for this patient group. Here, we discussed long term follow-up in a patient who developed acute type A aortic dissection complicated by cardiac tamponade and did not undergo surgery.

A 77-year-old male patient was admitted to the hospital with chest pain and shortness of breath. His physical examination revealed only tachypnea and hypotension with blood pressure of 85/65 mm Hg. Urgent echocardiography demonstrated a large pericardial effusion with suspicious aortic dissection flap in ascending aorta. A computed tomography (CT) was immediately performed to assess the aorta. CT imaging documented aortic dissection flap in ascending aorta. Emergency surgery was planned but patient and his relatives persistently refused it. Therefore, the patient was admitted intensive care unit for close follow-up. After a while, patient's hemodynamic status and consciousness progressively deteriorated, which required immediate pericardiocentesis. After pericardiocentesis, blood pressure increased to 110/60 mm Hg and patient's consciousness was improved. No complication related to the dissection was noted during the hospitalization and patient was discharged with beta-blocker treatment at seventh day of hospitalization. During the next two years follow-up, there was no clinical complication related with aortic dissection. However, second CT image demonstrated that ascending aortic diameter has expanded from 57.1 mm to 61.3 mm without extension of dissection.

Patients with acute type A aortic dissection who do not receive treatment die at a rate of 1-2% per hour during the first day and almost half of them die within one week (1). Pericardial tamponade may be observed in less than 20% of patients with acute Type A aortic dissection and its presence is associated with a doubling of the mortality. Urgent aortic surgery with intraoperative pericardial drainage is the recommend treatment approach in this patient group (2). Percutaneous pericardiocentesis is contraindicated in acute aortic dissection complicated by cardiac tamponade because it can be associated with propagation of the aortic dissection and precipitating hemodynamic collapse (3). However, Cruz et al. (4) reported that controlled pericardiocentesis before the surgery could be a life-saving approach in patients with critical cardiac tamponade such as pulseless electrical activity, when cardiac surgery is not immediately available. There is scarce information about clinical follow up in patients with type A aortic dissection without surgical treatment in medical literature. Scholl et al. (5) have reported clinical results of patients who could not undergo surgical treatment Type A aortic dissection because of initial misdiagnosis or severe comorbidity. However, there is no data about long-term follow-up of patients with Type A aortic dissection complicated by cardiac tamponade, which was treated by pericardiocentesis without surgical intervention in literature.

In conclusion, to the best of our knowledge, this case is the first report that a patient with type A aortic dissection complicated by cardiac tamponade could survive only by pericardiocentesis without surgery.