ABC | Volume 112, Nº3, March 2019

Case Report Taglialegna & Lucena Chronic aortic dissection and pregnancy Arq Bras Cardiol. 2019; 112(3):321-323 1. Kamel H, Roman MJ, Pitcher A, Devereux RB. et al. Pregnancy and the risk of aortic dissection or rupture: a Cohort-Crossover Analysis. Circulation. 2016; 134(7):527-33. 2. Sawlani N, Shroff A, Vidovich MI. Aortic dissection and mortality associated withpregnancy intheUnitedStates. JAmCollCardiol.2015;65(15):1600-1. 3. Zhu JM,MaWG,PetersS,WangLF,ChiaoZY,ZiganashinBA,etal.Dissection in pregnancy: management strategy and outcomes. Ann Thorac Surg. 2017;103(4):1199-206. 4. Kamalakannan D, Rosman HS, Eagle KA. Acute aortic dissection. Crit Care Clin. 2007;23(4):779-800. 5. Braverman AC, Harris K, Pyeritz R. Aortic dissection during pregnancy: results from the International Registry of Acute Aortic Dissection (IRAD). J Am Coll Cardiol. 2012; 59:E1903. 6. Thrumurthy Sri G, KarthikesalingamAlan, Patterson BenjaminO, Holt Peter J E, Thompson Matt M. The diagnosis and management of aortic dissection BMJ. 2012 Jan 11;344:D8290. 7. Meszaros I, Morocz J, Szlavi J, Schmidt J, Tornoci L, Nagy L, et al. Epidemiology and clinicopathology of aortic dissection. Chest. 2000;117(5):1271-8. 8. Patel PA, Fernando RJ, Augoustides JG, Yoon J, Gutsche JT, Feinman JW, et al. Acute type-B aortic dissection in pregnancy: therapeutic challenges in a multidisciplinary setting. J Cardiothorac Vasc Anesth. 2017;31(6):2268-76. 9. Kaji S. Update on the therapeutic strategy of Type B aortic dissection. J Artherioscler Tromb. 2017;25(3):203-12. References This is an open-access article distributed under the terms of the Creative Commons Attribution License The CT allowed the diagnostic confirmation, as well as a better detailing of the dissection extent and involvement of the aortic vascular branches, fundamental data for the dissection classification and therapeutic planning. 3 The decision about clinical management only or the need for surgical intervention before or after the pregnancy interruption should consider the risk of rupture, type of dissection and fetal viability. 3,8 Delamination in the descending aorta characterized the dissection as type B and clinical treatment was chosen during the pregnancy, followed by the implantation of a thoracic endoprosthesis in the immediate postpartum. 3,8,9 The maternal hemodynamic stability and the strict monitoring of the aortic pathology and fetal vitality allowed this conduct in our service. Beta-blockers are the first-line drug therapy, as they reduce both HR and BP and, consequently, the shear forces in the aorta, thus limiting the extent of the dissection and reducing the risk of rupture or damage to target-organs. 9 They can be used with relative safety during pregnancy (Propranolol is a Class C drug by the Food and Drug Administration - FDA). 3,8,9 The pregnancy interruption prior to the dissection repair offered a greater chance of survival to this conceptus, since the reported rates of morbidity and mortality may reach 30% and 9%, respectively, during the repair procedures. 3,8 The type of delivery in patients with heart disease is controversial. A normal delivery results in less bleeding, faster recovery, and decreases the risk of postoperative complications. In the absence of acute dissection, normal delivery can be performed with an aortic diameter < 40 mm in cases of Marfan Syndrome, with a cesarean section being indicated above this reference value. 3,8 The carrying out of the delivery should include interventions to reduce aortic wall stress, strict blood pressure control, adequate analgesia, and instrumental delivery when indicated. 3,8 The patient’s aorta had a maximum diameter of approximately five centimeters, which supported the choice of delivery route by the team. Bilateral tubal ligation was appropriately indicated as a definitive contraceptive method and was based on the high risk of maternal death in the event of a new pregnancy. 8 The great diversity of cases and the small number of cases reported in the literature do not allow establishing guidelines for the management of aortic dissection during pregnancy. Multidisciplinary management and individualized treatment aim to provide survival opportunities for the mother and fetus, considering maternal hemodynamic stability, fetal viability and the best opportunity for surgical intervention, when indicated. Author contributions Conception and design of the research: Taglialegna GM, Katz L, Albuquerque LMA, Freitas MM, Lucena AJG; Acquisition of data: Taglialegna GM, Albuquerque LMA, Freitas MM, Lucena AJG; Analysis and interpretation of the data: Taglialegna GM, Albuquerque LMA, Freitas MM; Writing of the manuscript: Taglialegna GM, Albuquerque LMA, Freitas MM; Critical revision of the manuscript for intellectual content: Katz L, Lucena AJG, Amorim MMR. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This article is part of the course conclusion of Giulia de Miranda Taglialegna, Milena Máximo de Freitas and Larissa Mayara Aristóteles de Albuquerque from Instituto de Medicina Integral Professor Fernando Figueira. 323