Discussion
Gilon et al. reported that 126 of the 674 patients (18.7%) enrolled in
the International Registry of Acute Aortic Dissection were combined with
cardiac tamponade, which resulted in 54% in-hospital mortality. The
mortality was more than double compared to that of AAD
alone.1 In the present case, the patient was in a
shock state on arrival with the possibility of a fatal course.
Therefore, PD was performed as one of the effective methods for
releasing cardiac tamponade, despite it is not always recommended for
cardiac tamponade associated with AAD.
According to the US guidelines,2 performing PD should
be minimized, and should only be done when circulation cannot be
maintained before surgery. This is believed to be because PD may
increase fluid flowing into the pericardial space. Hayashi et
al.3 reported using a pigtail catheter to control the
drainage volume and prevent blood pressure from rising. PD was performed
in 18 patients whose blood pressure dropped due to cardiac tamponade
associated with AAD during the preoperative period. Circulatory dynamics
were improved in 10 patients with drainage of 30 ml, and they were able
to be operated. Fujii et al.4 also reported the
importance of controlling the drainage volume while not raising blood
pressures excessively. Honda et al.5 proposed the PD
volume in the elderly of average age over 80 years. In their study, to
avoid a drop in pericardial intracavitary pressure and a rise in blood
pressure, the volume of drainage was set to 10 ml and blood pressure was
controlled under 100mmHg. They also reported that good results were
obtained without surgery by repeating PD appropriately. As in our case,
although a single drainage volume was 30 ml, a little volume of drainage
was intermittently obtained under strict blood pressure control and had
a good result. This provides an alternative treatment for AAD combined
with cardiac tamponade in the elderly.
Aoyama et al.6 reported a comparative study on
surgical and conservative treatment for AAD patients over 80 years old
in Japan. As a result, all in-hospital mortality rates were
significantly decreased in patients who underwent surgery, but there was
no significant difference in the event-free survival rate considering
the presence or absence of complications. As in our case, complications
such as dementia, chronic nephropathy, and the age of 94 made it
difficult to decide on a treatment method. Finally, conservative
treatment was decided with the consent of the patient and family
members. As a result, the patient had a good clinical course, despite
she was in a shock state due to cardiac tamponade, and the treatment
policy must be decided in a short time including emergency treatment and
family burden under an emergency situation. In Japan, where the number
of patients with complications is expected to increase due to further
aging of the population, it is necessary to make appropriate treatment
decisions for emergent diseases based on the patient’s background and
continue to find appropriate policies. It seems imperative to accumulate
such cases as much as possible.