title: Outcomes and management of type A intramural hematoma.
abstract: BACKGROUND
  Initial optimal management of acute type A aortic dissection (ATAAD) with intramural hematoma (ATAIMH) remains controversial, especially between centers in the Eastern vs. Western worlds. We examined the literature and our experience to report outcomes after repair of ATAIMH.
  
  
  METHODS
  We reviewed the hospital, follow-up clinic records and online mortality databases for all patients who presented to our center for open repair of ATAAD between 1999 and 2014. Preoperative characteristics, early and long-term outcomes were compared between classic ATAAD vs. ATAIMH. Survival was analyzed using Kaplan-Meier and log-rank statistics.
  
  
  RESULTS
  Of the 523 repaired ATAAD, 101 patients (19%) presented with IMH and 422 (81%) had classic dissection. ATAIMH were significantly older (64.8±12.9 vs. 56.8±14.6 years; P<0.001), more commonly females (39% vs. 26%; P=0.010), had poor baseline renal function (i.e., glomerular filtration rate) (P<0.017), more retrograde dissections (27% vs. 8.3%; P<0.001), and less distal malperfusion (5% vs. 15%; P<0.001). Age greater than 60 years, female sex, retrograde dissection, and Marfan syndrome were strongly correlated with ATAIMH. Time to repair for ATAIMH was longer (median, 55.3 vs. 9.8 hours; P<0.001) with one death in ATAIMH within three days of presentation (0.9% vs. 6%; P=0.040). In all, 30-day mortality in ATAIMH was not different from classic ATAAD (12% vs.16%; P=0.289). A significantly lower incidence of postoperative dialysis in ATAIMH was noted (10% vs. 19%; P=0.034). When adjusted for age and renal function, late survival was improved with IMH (P<0.039).
  
  
  CONCLUSIONS
  ATAIMH continues to be associated with significant morbidity and mortality, comparable to classic aortic dissection. A multidisciplinary management approach involving aggressive medical management and risk stratification for timely surgical intervention, along with genetic profiling, is recommended for optimal care. Long-term monitoring is mandatory to assess compliance to medical therapy and recognition of evolving complications.
authors: Department of Cardiothoracic and Vascular Surgery, Clinical Science Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.
authors: Harleen K
authors: HK
authors: Sandhu
authors: Department of Cardiothoracic and Vascular Surgery, Clinical Science Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.
authors: Akiko
authors: A
authors: Tanaka
authors: Department of Cardiothoracic and Vascular Surgery, Clinical Science Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.
authors: Kristofer M
authors: KM
authors: Charlton-Ouw
authors: Department of Cardiothoracic and Vascular Surgery, Clinical Science Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.
authors: Rana O
authors: RO
authors: Afifi
authors: Department of Cardiothoracic and Vascular Surgery, Clinical Science Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.
authors: Charles C
authors: CC
authors: Miller
authors: Department of Cardiothoracic and Vascular Surgery, Clinical Science Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.
authors: Hazim J
authors: HJ
authors: Safi
authors: Department of Cardiothoracic and Vascular Surgery, Clinical Science Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.
authors: Anthony L
authors: AL
authors: Estrera
keywords: Acute type A dissection; intramural hematoma; management