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

OBJECTIVE We seek to evaluate our experience with management of type A aortic dissection (TAAD) in pregnancy or postpartum over 25 years. METHODS From 1998 to 2023, our team managed 60 pregnant women (age 31.4 ± 5.0 years) sustaining TAAD at mean 30.3 ± 8.5 gestational weeks (GWs) (27 in third trimester 45.0%; 13 during postpartum 21.7%). Management strategy was based on gestational weeks (i.e. surgical versus medical treatment, surgery or delivery first). RESULTS Patients were treated medically in 1 (1.7%) and surgically in 59 (98.3%). Management strategies were single-stage delivery and aortic repair at 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 median 9.5 days. Respective maternal and fetal mortalities were 100% (1/1) and 100% (1/1) 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 98.1% complete (53/54) at median 6.7 years (IQR 4.8-10.9). Five maternal and 2 fetal deaths occurred. Eight patients underwent ten reoperations. Maternal and fetal survival were 79.3% and 67.7% at ten years, respectively. CONCLUSIONS For TAAD occurring after 28 gestational weeks, maternal and fetal survival can be adequately achieved with delivery followed by aortic repair, preferably in one stage; before 28 gestational weeks, 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.