Ann Thorac Surg 2009;88:1389-1390. doi:10.1016/j.athoracsur.2009.05.071
© 2009 The Society of Thoracic Surgeons
Correspondence
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Kay-Hyun Park, MD, PhD
Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Room 10309, 300 Gumi-dong, Bundang-gu, Seongnam, Gyeonggi-do, 463-707 Republic of Korea
(Email: drkhpark{at}yahoo.co.kr).
To the Editor:
I appreciate the interest and supportive comments by Takagi and colleagues [1] on our article [2]. They proposed the thrombosed type hypothesis with an exemplary computed tomographic image to explain the pathogenesis of an intramural hematoma (IMH). It is concordant with the hypothesis proposed by Vilacosta and colleagues [3] who explained the difference between an IMH and an overt dissection as a result of the size of an intimal tear and presence of re-entry tears. In addition to their observations, I have seen many patients who had thrombosed false lumen in the ascending aorta while the false lumen of the descending aorta was patent. Such cases of so-called retrograde type A dissection could also be regarded as evidence to support the thrombosed type hypothesis. On the basis of such findings, it would be rational to believe there are patients in whom the false lumen rapidly thromboses when the intimal defect is not large and the false lumen is dead ended without a re-entry tear.
Although many reports have been suggesting that an IMH is not necessarily a dissection without an intimal tear, many clinicians are hesitant to call or define the IMH differently. Some clinicians are concerned with confusing referring centers by giving a new definition or nomenclature [4]. However, confusion is already present because some oriental centers reported favorable outcomes after medical or expectant management of type A acute IMHs [5–7]. In my experience, categorizing all patients with thrombosed aortic false lumen as a single group of IMH resulted in the delay of optimal management (ie, delayed early surgery in a considerable number of patients). Therefore, it would be more important to let referring centers or physicians know that an IMH with radiological evidence of intimal defect or large false lumen is not different from overt dissection, whether we still call it an IMH or differently named as a thrombosed type dissection.
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References
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- Takagi H, Manabe H, Kawai N, Goto S, Umemoto T. Thrombosed-type acute aortic dissection (letter) Ann Thorac Surg 2009;88:1389.[Free Full Text]
- Park KH, Lim C, Choi JH, et al. Prevalence of aortic intimal defect in surgically treated acute type A intramural hematoma Ann Thorac Surg 2008;86:1494-1500.[Abstract/Free Full Text]
- Vilacosta I, de Dios RM, Pinto AG. Aortic intramural hematoma during coronary angioplasty: Insights into the pathogenesis of intramedial hemorrhage J Am Soc Echocardiogr 2000;13:403-406.[Medline]
- Reuthenbuch O. Invited commentary Ann Thorac Surg 2000;86:1501.
- Sohn D-W, Jung J-W, Oh B-H, et al. Should ascending aortic intramural hematoma be treated surgically? Am J Cardiol 2001;87:1024-1026.[Medline]
- Song J-K, Kim H-S, Kang D-H, et al. Different clinical features of aortic intramural hematoma versus dissection involving the ascending aorta J Am Coll Cardiol 2001;37:1604-1610.[Abstract/Free Full Text]
- Moizumi Y, Komatsu T, Motoyoshi N, Tabayashi K. Management of patients with intramural hematoma involving the ascending aorta J Thorac Cardiovasc Surg 2002;124:918-924.[Abstract/Free Full Text]
Related Article
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Thrombosed-Type Acute Aortic Dissection
- Hisato Takagi, Hideaki Manabe, Norikazu Kawai, Shin-nosuke Goto, and Takuya Umemoto
Ann. Thorac. Surg. 2009 88: 1389.
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