Management of intramural hematoma of the ascending aorta: still room for debate.

See related article on page 918. I n this issue of the Journal, Moizumi and colleagues1 from Sendai City Medical Center and Tohoku University present a thought-provoking analysis of their experience with what would be considered by most Western surgeons an iconoclastic approach to the management of intramural hematoma of the ascending aorta (IMH). Applying an algorithm of expectant (I would not call it conservative) therapy to 33 patients with this condition during a 9-year interval, these authors have acquired what is to my knowledge the largest reported single-center experience with this uncommon entity. Their results are excellent. They challenge us to rethink our approach to this condition. In the authors’ series, only patients with cardiac tamponade, impending rupture (described as hemodynamic instability or persistent pain), rupture, or progression of the IMH underwent surgery. All others were treated medically with aggressive antihypertensive therapy and bed rest. Nine of 33 patients underwent early surgery with what can only be considered a highly acceptable mortality rate of 11%, given that 5 of the 9 patients were in shock on admission and 3 underwent total arch replacement. Early mortality in the medical group was also low at 5% (P not significant). During the follow-up interval, 8 additional patients underwent surgery for progression to frank dissection or for increasing aortic dilatation. Survivals at 1 and 2 years were similar in the two groups. The authors concluded that expectant management with aggressive medical therapy and serial imaging studies, with surgical intervention reserved for those with clinical or radiologic evidence of progression, yields satisfactory results. “It is hard to argue with success,” as one of my mentors is fond of saying, but do these data indicate that medical management is the optimal approach to IMH? Do they indicate equivalent—if not superior—results with medical therapy? Or do they conversely demonstrate remarkably low surgical risk despite the systematic selection of only the sickest patients for surgery? This study is not a comparison of treatment modalities. That would require random assignment to two groups with a head-to-head comparison. To bicker over surgery versus medicine would be to miss the mark. The issue here is much like the debate regarding coronary angioplasty versus coronary artery bypass: it is the validity and safety of a treatment algorithm that attempts triage of individual patients to their most appropriate therapy, sparing unnecessary risk to those for whom less aggressive management will suffice without withholding such therapy from those who require surgery. The central message here is not that medical management is preferable but rather that, in selected cases, it is reasonable. These data serve to open the dialog. Previous studies from Western countries have demonstrated rather consistently that IMHs behave differently depending on location—ascending versus descending aorta. A study of IMH reported in 1993 by Robbins and coworkers2 suggested a particularly poor prognosis of the condition when it involves the ascending aorta, although the experience was quite small. Of only 3 patients in whom the ascending aorta and arch were involved, 1 survived hospitalization but had late progression to aneurysm requiring surgery, a second had rupture in hospital, and the third underwent surgery on an acute basis. These authors suggested that because of the poor prognosis associated with this condition, early surgery should be considered for type A IMH. This recommendation was widely adopted, and just 2 years thereafter O’Gara and From the Mayo Clinic and Foundation, Rochester, Minn.