Type A aortic dissection during pregnancy and postpartum: Experience in 60 patients over 25 years

We seek to evaluate our experience with the management of type A aortic dissection (TAAD) during pregnancy or in the postpartum period over 25 years.

From 1998 to 2023, our team managed 60 pregnant women (mean age, 31.4 ± 5.0 years) who sustained TAAD at mean of 30.3 ± 8.5 gestational weeks (GWs), including 27 in the third trimester (45.0%) and 13 during the postpartum period (21.7%). Marfan syndrome (MFS) was seen in 39 patients (65.0%) with 13 (21.7%) having a positive family history. Before operation, aortic root diameter averaged 53.6 ± 17.1 mm, which was significantly larger in MFS patients than non-MFS patients (57.0 ± 17.0 mm vs 47.0 ± 15.0 mm, P = .019). Management strategy was based on GWs (ie, surgical versus medical treatment, surgery first, or delivery first).

One patient was treated medically (1.7%), and 59 were treated surgically (98.3%). Management strategies were single-stage delivery and aortic repair at a mean of 32.4 ± 4.5 GWs in 29 (48.3%); delivery first at 35 ± 8 GWs in 18 (30%), followed by aortic repair after a median of 6.2 days, and aortic repair first at 18.6 ± 6.3 GWs in 12 (20%), followed by delivery after a median of 9.5 days. Maternal and fetal mortality rates were 100% (1/1) and 100% (1/1), respectively, with medical therapy, 11.1% (2/18) and 11.1% (2/18) with delivery first, 3.4% (1/29) and 22.6% (7/31) with single-stage delivery and aortic repair, and 16.7% (2/12) and 66.7% (8/12) with aortic repair-first strategies. Follow-up was complete in 98.1% (53/54) at a median duration of 6.7 years (interquartile range, 4.8-10.9 years). Five maternal deaths and 2 fetal deaths occurred. Eight patients underwent a total of 10 reoperations. Ten-year maternal and fetal survival rates were 79.3% and 67.7%, respectively. Eight patients (7 with MFS, 87.5%) underwent 10 reoperations at a median of 4.7 years (IQR, 2.1-9.1 years).

For TAAD occurring after 28 GWs, adequate maternal and fetal survival can be achieved with delivery followed by aortic repair, preferably in one stage. Before 28 GWs, maternal survival should be prioritized, given the high uncertainty of fetal survival. Prophylactic aortic repair may be reasonable for women with Marfan syndrome contemplating pregnancy when the root diameter is 45 mm or even smaller.