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Anévrysme disséquant de l\\\'aorte (Acute Aortic Dissection)

Perspective: The following are 10 points to remember about acute aortic dissection:

1. Acute aortic dissection is the result of a disruption in the arterial wall of the aorta that can be life-threatening and acute in presentation. The estimated incidence is around 3 cases per 100,000.

2. Important predisposing associated risk factors are hypertension; age; atherosclerosis; previous cardiovascular surgery, especially repair of aortic aneurysm or dissection; and genetic vascular conditions such as Ehlers-Danlos syndrome, Marfan’s syndrome, and Turner’s syndrome, as well as possibly a bicuspid aortic valve.

3. The recent discovery of the role of transforming growth factor-beta (TGF-β) in Marfan’s disease, as well as the Loeys-Dietz syndrome, suggests that dysfunction in the TGF-β system may be related to the development of aortic dissection. The clinical implication of this is yet to be determined. The availability of medications such as angiotensin-receptor blockers and angiotensin-converting enzyme inhibitors, which affect TGF-β metabolism, may have important therapeutic implications in the near future.

4. Aortic dissections are classically most commonly defined as either type A (any dissection involving the proximal or ascending aorta) and type B (the remainder of aortic dissection not involving the ascending aorta). Studies continue to suggest that the natural history of aortic dissection in these two categories differs.

5. Studies have shown that a significant number of patients present with atypical, or nonclassical presentations. As many as 10% have no pain.

6. Because of the protean manifestations of this disorder, and the common complaint of chest pain in the emergency room, a high clinical index of suspicion must be maintained in order to make this diagnosis. Diagnosis is currently dependent on imaging with either computed tomography scanning, transesophageal echocardiogram, or magnetic resonance imaging.

7. Ascending aortic dissection (type A) has a high early mortality and is usually treated with urgent replacement of the proximal aorta with aortic valve replacement if needed.

8. Management of acute aortic dissection not involving the ascending aorta (type B) is in a state of flux and currently somewhat controversial. Because of its lower acute phase mortality, recommendations up until this time have suggested medical management. Recently reported observations suggest that long-term outcomes in type B dissection are not as benign as once appreciated, with death in about one-quarter of subjects over subsequent 3 years. The advent of stent graft therapy has offered a lower morbidity and mortality intervention. The proper role of this and other minimally invasive therapies in the management of type B aortic dissection remains unclear at the present time.

9. Surgical intervention for type B aortic dissection has been reserved for those with evidence of malperfusion. The lower risk of minimally invasive intervention such as stent-grafting raises the possibility of treating patients without malperfusion in the hopes of altering the chronic course of type B aortic dissection. More evidence is necessary to further define management of these patients.

10. In the near future, greater biological understanding of aortic disease and methods to slow aortic destruction, as well as new techniques in molecular and genetic biology, promise to alter the diagnosis and management of aortic syndromes. James B. Froehlich, M.D., F.A.C.C.

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