Long-term follow-up of aortic intramural hematoma: predictors of outcome.

BACKGROUND: Aortic intramural hematoma (IMH) evolves very dynamically in the short-term to regression, dissection, or aortic rupture. The aim of the present study was to assess the long-term clinical and morphological evolution of medically treated IMH. METHODS AND RESULTS: Fifty of 68 consecutive patients with aortic IMH monitored clinically and by imaging techniques at 3, 6, and 12 months and annually thereafter were prospectively studied. Mean follow-up was 45+/-31 months. In the first 6 months, total IMH regression was observed in 14 and progression to aortic dissection in 18 patients; in 14 of these, the dissection was localized, and 12 later developed pseudoaneurysm. At the end of follow-up, the IMH had regressed completely without dilatation in 17 patients (34%), progressed to classical dissection in 6 (12%), evolved to fusiform aneurysm in 11 (22%), evolved to saccular aneurysm in 4 (8%), and evolved to pseudoaneurysm in 12 (24%). Evolution to dissection was related to echolucency (P<0.02) and to longitudinal extension of IMH (P<0.01). Multivariate analysis showed an independent association between regression and smaller maximum aortic diameter and between aneurysm formation and atherosclerotic ulcerated plaque and absence of echolucent areas in IMH. CONCLUSIONS: The most frequent long-term evolution of IMH is to aortic aneurysm or pseudoaneurysm. Complete regression without changes in aorta size is observed in one third of cases, and progression to classical dissection is less common. A normal aortic diameter in the acute phase is the best predictor of IMH regression without complications, and absence of echolucent areas and atherosclerotic ulcerated plaque are associated with evolution to aortic aneurysm.

[Non-bacterial thrombotic endocarditis of the aortic valve in a young woman]. / Endocarditis trombótica no bacteriana sobre válvula aórtica en mujer joven.

A 40-year-old woman without heart disease suffered two embolic episodes in both legs due to a thrombus of the aortic valve. Transesophageal echocardiography performed after the first episode was considered normal, but a second study performed after the second embolism demonstrated a thrombus in the non-coronary leaflet that failed to resolve with the intravenous administration of heparin for two weeks. Surgical excision of the mass revealed a thrombus on an otherwise healthy aortic valve. The case is interesting because it is an exceptional cause of systemic embolism and the patient did not present a prothrombotic status in coagulation studies. The 3 years of follow-up was uneventful.

[Predictive factors of abnormal dynamic intraventricular gradient after valve replacement in severe aortic stenosis]. / Aparición de gradiente dinámico intraventricular después de la sustitución valvular aórtica en pacientes con estenosis aórtica severa.

INTRODUCTION: Dynamic intraventricular gradients (DIG) after valve replacement in severe aortic stenosis have been reported, although the incidence of DIG and clinical signs are still poorly understood.Aim. To evaluate the incidence of DIG)and determine risk factors and associated morbimortality. PATIENTS AND METHOD: One hundred nine consecutive patients with severe aortic valve stenosis undergoing valve replacement were studied prospectively by echocardiography to detect the postoperative appearance of DIG, defined as a maximum flow velocity >/= 2.5 m/s. RESULTS: Sixteen patients (14.9%) developed postoperative DIG. Significant differences between the patients with or without DIG were found for ventricular diameter (left end-diastolic ventricular diameter (LEDVD) 43.2 vs. 47.7 mm, respectively, p < 0.001; left end-systolic ventricular diameter (LESVD) 21 vs. 29 mm, p < 0.001); left ventricular mass index (165 vs. 193 g/m(2), p < 0.05); mean aortic valve gradient (68 vs. 59 mmHg, p < 0.01),; ejection fraction (73 vs. 61%, p < 0.001). No significant differences were found with respect to ventricular wall thicknesses (septal 16.3 vs. 15.7; posterior 14.37 vs. 14.62), the presence of aortic insufficiency, or other postoperative factors (anemia, inotropic agents, etc.). CONCLUSIONS: DIG after aortic valve replacement to treat severe stenosis is not unusual (15%). DIG is usually found at a midventricular location, close to the septum. In patients with postoperative DIG the most common associated factors were small LEDVD, high ejection fractions and ratios of intraventricular septal to posterior wall ratios, high valve gradients and small left ventricular masses. Preoperative echocardiography can identify patients with a higher risk of developing DIG after aortic valve replacement.

Transesophageal echocardiography in the diagnosis of acute aortic syndrome.

In recent years, technological advances in echocardiography have led to improvements in the diagnosis of acute aortic disease. With transesophageal echocardiography (TEE) and, particularly, bi- and multiplane probes, the physiopathologic understanding of these diseases has widened. Thus, new entities such as penetrating ulcer and intramural hematoma have been described and differentiated from classical aortic dissection.

Prognostic value of clinical and morphologic findings in short-term evolution of aortic intramural haematoma. Therapeutic implications.

AIMS: Intramural haematoma (IMH) forms part of the acute aortic syndrome presenting physiopathologic and evolutive patterns different from those of aortic dissection. The aim of this study was to determine the mortality and predictive factors of IMH in the first 3 months of evolution. METHODS AND RESULTS: Sixty-eight consecutive patients diagnosed of IMH (12 type A, 56 type B) were prospectively studied. Ten patients (eight type A, two type B) were surgically treated for clinical or haemodynamic evolution. Mortality rate was 19% (six type A and seven type B): five surgically treated (three type A, two type B) and eight medically treated (three type A, five type B). No relationship was observed between clinical variables and evolution. Maximum aortic diameter was greater in the group of patients who died (65.5+/-14.4 mm vs 46.0+/-7.6 mm; P<0.0001). Mortality rate in patients with aortic diameter >50 mm was 50% (P<0.0001). Significant periaortic bleeding was mortality-related (47%; P<0.005). Multivariate analysis showed only a significant relationship between mortality and maximum aortic diameter >50 mm (OR=11.33; P<0.005) and ascending aorta involvement (OR=11.18; P<0.05). CONCLUSION: Intramural haematoma mortality in the first 3 months of evolution is high (19%). Maximum aortic diameter >50 mm and ascending aorta involvement are predictive of early mortality.