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Original Articles: Adult Cardiac

Invited Commentary

Clinic for Cardiovascular Surgery, University Hospital Zurich, Raemistrasse 100, Zurich, CH-8091 Switzerland

(Email: oliver.reuthebuch{at}triemli.stzh.ch).

There is still an ongoing debate on how to define, diagnose, and consequently how to treat intramural hematoma (IMH). Beside acute dissection and ulcer, intramural hematoma is a third entity of aortic disorder. Park and colleagues [1] have compared preoperative computed tomographic scans with intraoperative findings, showing that there seems to be a substantial proportion of patients (27 of 37 [73%]) suffering from intramural hematoma associated with intimal tear. In only 10 of 37 (27%), intimal tear is absent.

The questions asked seem to be more philosophical than medical in importance. What is an IMH with intimal tear? Is it a fourth entity? Is it a subgroup? Does it have any clinical impact?

The common definition of IMH is a split of aortic wall layers without the presence of an intimal tear, caused by disrupted vasa vasora. In these cases there should be no enhancement by contrast agent with computed tomography.

However, a total of 18 of 37 patients included in this retrospective study showed signs of intimal defects in the preoperative computed tomographic scan, such as "ulcer-like defect" and "contrast enhancement". Regarding the well-defined criteria, should they not better be stated as (limited) dissections rather than intramural hematoma and thus be excluded?

The clinical impact of subdividing IMH seems to be low. According to the authors' suggestions, treatment of IMH (with or without intimal tear) should result in surgery. Apparently, there is no difference compared with the treatment of ulcer or dissection.

Subdividing IMH may also cause irritation, because patients with IMH and intimal tear can be easily categorized as patients with (limited) dissection. Referring centers should not get too confused due to an ongoing formation of new definitions.

This article nicely shows the dynamic process underlying aortic dissection (ie, IMH, limited dissection, and extension of dissection). However, there is still work to be done to better predict the exact time course and development of aortic disease.

Dissection and aortic ulcer are well-defined entities, and so is IMH. Regarding these definitions, IMH with intimal tear should be considered a (limited, beginning) dissection.

I would deny the need for an extension of the existing definition of IMH. We should try to keep things simple and stick to these definitions.

	References

Top References

 

1. Park K-H, Lim C, Choi JH, et al. Prevalence of aortic intimal defect in surgically treated acute type A intramural hematoma Ann Thorac Surg 2008;86:1494-1501.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Reuthebuch, O. Search for Related Content PubMed PubMed Citation Articles by Reuthebuch, O. Related Collections Great vessels Related Article