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\begin{document}

\title{Type A Aortic Dissection during in pregnancy: Can We Succeed? Fend-Off
\& Don't Avert}



\author[1]{Mohammed Idhrees}%
\author[2]{Matti Jubouri}%
\author[3]{Mohamad Bashir}%
\author[1]{Bashi Velayudhan}%
\affil[1]{SRM Institutes for Medical Science Vadapalani}%
\affil[2]{Hull York Medical School}%
\affil[3]{Velindre University NHS Trust}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\begin{abstract}
Type A aortic dissection (TAAD) is a life-threatening clinical emergency
requiring timely surgical intervention. Concomitant with pregnancy at
any stage, it adds an additional level of complexity which mandates
careful planning for the management strategy that will yield the optimal
outcomes. It is life-threatening pathology to both the mother and
foetus, with mortality rates of up to 30\% and 50\% reported,
respectively. Safe imaging modalities that do no expose the foetus to
radiation and contrast are recommended to reach an accurate diagnosis.
In addition, meticulous multi-disciplinary team planning is pivotal to
ensure optimal outcomes are achieved through careful choice of surgical
technique as well as strict control of medications. Although TAAD in
pregnancy is associated with high mortality and morbidity to both the
mother and her foetus, success in the treatment of this small subset of
patients can certainly be achieved.%
\end{abstract}%



\sloppy


\textbf{Type A Aortic Dissection during in pregnancy: Can We Succeed?
Fend-Off \& Don't Avert}

\textbf{Idhrees Mohammed MS MCh FAIS \textsuperscript{1}, Matti
Jubouri\textsuperscript{2}, Mohamad Bashir MD PhD MRCS
\textsuperscript{1,3}, Bashi Velayudhan MBBS MS MCh \textsuperscript{1}}

\begin{enumerate}
\tightlist
\item
  Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for
  Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India.
\item
  Hull York Medical School, University of York, York, UK
\item
  Vascular \& Endovascular Surgery, Velindre University NHS Trust,
  Health Education \& Improvement Wales (HEIW), Cardiff, UK
\end{enumerate}

\textbf{Correspondence:}

Idhrees Mohammed MS MCh FAIS

Institute of Cardiac and Aortic Disorders (ICAD)

SRM Institutes for Medical Science (SIMS Hospital)

Chennai

Tamil Nadu

India

Keywords: aortic dissection, Type A aortic dissection, pregnancy,
surgery

COI: None

\textbf{Abstract}

Type A aortic dissection (TAAD) is a life-threatening clinical emergency
requiring timely surgical intervention. Concomitant with pregnancy at
any stage, it adds an additional level of complexity which mandates
careful planning for the management strategy

that will yield the optimal outcomes. It is life-threatening pathology
to both the mother and

foetus, with mortality rates of up to 30\% and 50\% reported,
respectively. Safe imaging

modalities that do no expose the foetus to radiation and contrast are
recommended to

reach an accurate diagnosis. In addition, meticulous multi-disciplinary
team planning is pivotal to ensure optimal outcomes are achieved through
careful choice of surgical technique as well as strict control of
medications. Although TAAD in pregnancy is associated with high
mortality and morbidity to both the mother and her foetus, success in
the treatment of this small subset of patients can certainly be
achieved.

\textbf{Commentary}

We read with great interest Ayati et al. {[}1{]} recent review article
abating on a rare occurrence of type A aortic dissection (TAAD) during 8
week gestational phase in a primigravid. Its unequivocal that there is
an unmet clinical need in aortic practice on this entity. TAAD during
pregnancy is a life-threatening event for both the mother and the unborn
baby. Furthermore, pregnancy has been recognized as an independent risk
factor for TAAD, postulated to be due to physiological changes that
cause hyperdynamic circulation. The authors are to be commended on their
comprehensive literature search and methodology as well as their
detailed approach to describing the relationship between aortic
dissection and pregnancy and to summarising its predisposing factors,
imaging modalities, surgical treatment and techniques, medication
challenges and future directions.

The challenges faced when dealing with TAAD in pregnancy are
multifaceted and require an individualised and tailored approach.
Despite this, challenges in implementing management strategies in the
form of operative techniques and cardiopulmonary bypass (CPB) use place
the foetus at a significant and must be approached with great caution.
The general consensus is not to operate or avoid surgery in the first
trimester. But if the patient is unstable, the risk has to explained and
them mother to undergo central aortic repair. Few authors even advise
termination of pregnancy and central aortic repair {[}2{]}.

In agreement with Ayani et al. {[}1{]}, the choice of imaging modality
is one to be taken with care and consideration of the foetus's health.
However, imaging-posed additional radiation exposure and teratogenicity
of the contrast material, such as iodinated- or Gadolinium-based
contrast media, must be avoided {[}3{]}{[}4{]}. Thus, we recommend an
existential ultrasonography and MRI and in line with what is recommended
radiological methods in the literature for any pregnant woman {[}4{]}.

The choice of treatment for TAAD depends on the extent of the disease,
this is almost always surgical {[}5{]}. Despite the evolution of
surgical techniques as well as pre- and post-operative care, the
surgical mortality rate for TAAD still remains highly variable depending
on the technique used. There is a substantial debate as to limit
surgical extent to saving the patient with limited aortic approach
versus the more aggressive extended approach. If only the ascending is
pathological, the surgeon can perform a hemiarch replacement, however,
if the aortic arch is contemplated in the pathology, the surgical
approach changes to whether or not to adopt the frozen elephant trunk
(FET) technique. Both of the above procedures involve the use of
cardiopulmonary bypass (CPB) and both can be combined with a Bentall or
David procedure to replace or repair the aortic valve
{[}6{]}{[}7{]}{[}11{]}. In the case that the aortic valve needs to be
replaced, the choice of prosthetic valve, whether mechanical or
biological, needs to be taken with care on a case-by-case basis {[}1{]}.

The other dilemma that compounds the scenario is the question of when to
deliver the foetus as essentially this varies around the age of the
foetus, with some authors such as Zeebregts et al. {[}8{]} suggesting
the option of concomitant delivery between 28 and 32 gestational weeks
should foetal maturity have occurred. The European Society of Cardiology
recommend delivery from 26 gestational weeks when foetal maturity is
likely to have been reached {[}9{]}. On the other hand, Yates et al
{[}10{]} reported their series of 11 pregnant patients (19 gestational
weeks, range 16-21 weeks) who underwent emergency cardiac surgery. The
authors succeeded with no maternal mortality but reported a foetal
mortality rate of 27\% (3/11) within 1 week of surgery with the
remaining 8 babies born at full-term.

Initiating CPB requires alterations in the coagulation factors,
complement cascade activation and hypothermia, which can have
detrimental effects on the placenta and, in turn, the foetus {[}1{]}. A
2018 meta-analysis combined data from 10 studies on maternal and foetal
outcome after open heart surgery during pregnancy. The pooled results
showed 11.2\% and 33.1\% rates of maternal and pregnancy loss,
respectively {[}12{]}. The 33.1\% foetal mortality rate is in line with
that found in Weiss et al. (30\%) {[}13{]}, however, here the authors
reported a lower maternal mortality rate of 6\%. In addition, Weiss et
al. {[}13{]} showed that aortic dissection is associated with the
highest mortality amongst the causes for cardiac surgery during
pregnancy. Although Ayani et al. {[}1{]} summarised intraoperative
measures, particularly concerning CPB, this does not indicate that any
surgical approach can be diligently considered as safe or risk-averse,
as life-threatening risks do exist on both the mother and her foetus.
Ayani et al. {[}1{]} rightly stressed on the importance of carefully
coordinating medications, namely hypertension drugs and anticoagulants,
as this can have a serious impact on outcomes for both patients (mother
and foetus). However, this is not without limitations, especially in the
peri-operative period. Alas, beta-blockers have been shown in several
studies to have untoward effects in pregnancy, such as intrauterine
growth restriction and foetal bradycardia {[}9{]}. A study on
celiprolol, however, had a decrease of arterial events (20\%) in a
randomized control trial compared with control (50\%), but this has not
been demonstrated in patients with aortic disease {[}14{]}.

In conclusion, TAAD in pregnancy adds an extra level of complexity to an
already complex process. Yet, optimal outcomes can be achieved with
planning involving accurate diagnosis, safe imaging, modern surgical
techniques, and tight medication control. There is no easy answer to
such scenarios, but we remain dutiful in promoting patient-centred and
tailored care to achieve optimal results.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Ayati A, Sarraf S, Fallah SA, et al. Aortic dissection in the first
  trimester; is it a dead end? A narrative review of recent articles. J
  Card Surg. 2022.
\item
  Rajasekaran P, Gandhi P, Idhrees M, Velayudhan BV. Aortic
  complications in pregnancy: the less remembered chapter---a narrative
  review. Explor Med. 2021;2:423-34.
  https://doi.org/10.37349/emed.2021.00060
\item
  Segal A, Ellis J, Baumgartner B, et al. ACR Committee on Drugs and
  Contrast Media: Manual on contrast media. In: Version; 2008.
\item
  Lowe S. Diagnostic imaging in pregnancy: Making informed decisions.
  Obstet Med. 2019;12(3):116-122.
\item
  Jubouri M, Tan SZCP, Bashir M. Monocyte to high-density lipoprotein
  ratio as a predictive biomarker for in-hospital mortality following
  surgery for type A aortic dissection: Reality or myth? J Card Surg.
  2022;10.1111/jocs.16317.
\item
  Harky A, Singh VP, Khan D, Sajid MM, Kermali M, Othman A. Factors
  Affecting Outcomes in Acute Type A Aortic Dissection: A Systematic
  Review. Heart Lung Circ. 2020;29(11):1668-1681.
  doi:10.1016/j.hlc.2020.05.113
\item
  Conzelmann LO, Weigang E, Mehlhorn U, Abugameh A, Hoffmann I, Blettner
  M et al. Mortality in patients with acute aortic dissection type A:
  analysis of pre-and intraoperative risk factors from the German
  Registry for Acute Aortic Dissection Type A (GERAADA). Eur J
  Cardiothorac Surg 2016;49:e44--e52.
\item
  Zeebregts CJ, Schepens MA, Hameeteman TM, Morshuis WJ, de la Rivi\selectlanguage{ngerman}ère
  AB. Acute aortic dissection complicating pregnancy. Ann Thorac Surg.
  1997;64(5):1345-1348.
\item
  Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, et al. 2018 ESC
  Guidelines for the management of cardiovascular diseases during
  pregnancy. Eur Heart J. 2018;39(34):3165-3241.
\item
  Yates MT, Soppa G, Smelt J, Fletcher N, van Besouw J-P, Thilaganathan
  B, et al. Perioperative Management and outcomes of aortic surgery
  during pregnancy. The Journal of Thoracic and Cardiovascular Surgery.
  2015;149(2):607--10.
\item
  Jubouri M, Abdelhaliem A. BioGlue and E-Vita Open NEO graft oozing:
  Long-term solution or band aid?. J Card Surg. 2022;37(3):561-562.
\item
  Jha N, Jha AK, Chauhan RC, Chauhan NS. Maternal and fetal outcome
  after cardiac operations during pregnancy: a meta-analysis. The Annals
  of thoracic surgery. 2018;106(2):618-626.
\item
  Weiss BM, von Segesser LK, Alon E, Seifert B, Turina MI. Outcome of
  cardiovascular surgery and pregnancy: a systematic review of the
  period 1984-1996. American journal of obstetrics and gynecology.
  1998;179(6):1643-1653.
\item
  Baderkhan H, Wanhainen A, Stenborg A, Stattin E-L, Björck M.
  Celiprolol treatment in patients with Vascular Ehlers-Danlos syndrome.
  European Journal of Vascular and Endovascular Surgery.
  2021;61(2):326--31.
\end{enumerate}

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