What is an Aortic Dissection?

Acute aortic dissection type A is one of the most urgent emergences in heart surgery. Mostly without warning signs, the inner layer of the wall of the aorta (the body’s main artery) splits directly at the heart. This can shut off the blood supply to other organs, including the brain. Frequently, blood collects in the pericardium, the tissue sac containing the heart. This compresses the heart and can cause fatal cardiovascular failure.

Fifty years ago aortic dissection was mainly fatal; today most of the patients survive by having an immediate operation. This is mainly because the most dangerous forms are operated on immediately. Rapid diagnosis is therefore decisively important.

Dissection of the aorta in its ascending segment, close to the heart, is known by an international classification as “type A” dissection. This is the most dangerous form of the disease.

Causes and Incidence

It is not entirely clear why some people suffer from weakness of the inner aortic wall leading to splitting. Current studies show an incidence of up to 12 cases per 100,000 of the population. Men are affected up to three times more often than women. Aortic dissection is most common at the age of 50 to 70 years. For unknown reasons aortic dissection is more frequent in the winter months. It is also not known why most dissections occur in the morning between 6 am and noon.

A team from the Department of Cardiothoracic and Vascular Surgery at the German Heart Center Berlin (Director: Prof. Volkmar Falk) headed by Stephan Kurz analyzed the files and emergency doctor records of over 1600 patients who were treated at the German Heart Center for acute type-A dissection.

Further, 14,000 autopsy reports were checked to establish how many patients in Berlin and Brandenburg died from an aortic dissection that could not be operated upon in time. The results were published in the renowned “International Journal of Cardiology” (link) and showed the need for urgent action. The study found that

  • the average time between the occurrence of the first symptoms and the beginning of the operation was over 8 hour
  • aortic dissection is much more common than previously thought. The Federal Statistics Office has recorded 4.6 cases per 100,000 of the population whereas the data collected for the study suggests that the number is more than twice as high (11.9 cases).

Symptoms and Diagnosis

Typical for aortic dissection is a sudden start of stabbing or roaring pain. The pain is most often experience in the chest, but frequently also in the back, radiating to the abdomen.
In the case of such symptoms always phone an emergency doctor immediately and describe the symptoms.
Depending on which blood vessels leading off from the aorta are being blocked by the dissection, the blood supply to organs may be reduced. If the flow of blood to the intestine or kidneys is disrupted the patient experiences severe abdominal pain. In some cases there may also be symptoms of a stroke.
The symptoms of aortic dissection may be misinterpreted by emergency doctors as symptoms of myocardial infarction (a “heart attack”), which is far more common. In the worst case this can lead to the wrong initial treatment. Definite diagnosis is usually only possible with computed tomography.

Treatment

With every hour that an aortic dissection remains untreated, statistically two percent of the patients die. The only treatment for acute aortic dissection is immediate surgery on the open heart, carried out by a special team from the disciplines of surgery, cardiac perfusion, anesthesia and surgical nursing.

The surgeon opens the patient’s chest. Next the patient is attached to the heart-lung machine and the heart is stopped. The surgical treatment depends on the site and extent of the dissection. Usually the part of the aorta affected is replaced by a vessel prosthesis; sometimes an artificial aortic valve must also be implanted. After the operation the patient is transferred to the intensive care unit.

The German Heart Center Berlin is one of the few hospitals that can operate for acute aortic dissection at any time, as specialized teams are available 24 hours a day. Performing over 100 such operations each year, we are one of the main centers in Germany for this procedure.

The Aortic Emergency Hotline at the German Heart Center Berlin

This film shows how the aortic emergency hotline works

In 2015 the German Heart Center Berlin developed the concept of an “Aortic Emergency Hotline”, the first of its kind in Europe. This is a medical hotline available to all doctors in Berlin and Brandenburg 24 hours a day on which an aortic specialist offers advice and coordinates treatment. The aim is to greatly reduce the pain cut time (PCT), which is the time from the first symptoms to surgical treatment, and to ensure that this time is efficiently used.
The Aortic Emergency Hotline has the number 030 4593-2007 and an anesthetist or heart surgeon is available 24 hours a day to
aid the regional emergency departments. He or she provides medical and organizational support for the colleagues on the spot and also coordinates preparations for the operation at the German Heart Center Berlin.
For this purpose doctors at our institution have developed standard procedures for diagnostic imaging and medication and have agreed them with the emergency services, emergency doctors and emergency departments of the hospitals in Berlin and Brandenburg.

The procedures for admission, anesthesia, surgery and further treatment on the intensive care unit at the German Heart Institute have also been standardized and further optimized.

The concept has already led to a significant improvement in the diagnosis and initial treatment. The number of patients operated on at the German Heart Center Berlin for an acute type-A dissection rose from an average of 80 per year to 138 in 2016, an increase of over 70 percent.
The time from the first symptoms to the beginning of the operation has already been reduced by an average of 20 percent.
The aim of the program is to halve the time it takes for the patient to receive surgery in Berlin and Brandenburg. Here you can watch a video report on the aortic hotline in “Medizinermagazin: Notfall”.