A streak of good fortune after type A aortic dissection
From left, Dawn Hui, MD, a professor in the Department of Cardiothoracic and Vascular Surgery at McGovern Medical School at UTHealth Houston and patient, Kay Matheny. (Photo by UTHealth Houston)
Around midnight on July 6, Kay Matheny’s son Connor walked upstairs and discovered his 59-year-old mother lying unconscious on her bedroom floor, their dog Bailey sitting next to her. He called 911. A police officer arrived and asked him to wait outside the room for the paramedics, who transported her to the closest hospital. When she showed no neurologic response, emergency physicians ordered a CT scan, intubated her, and administered medication to reduce her blood pressure and preserve blood flow to her organs.
The CT imaging showed a type A aortic dissection, a life-threatening condition that requires immediate surgical intervention to repair or replace the affected section of the heart’s aorta. Both carotid arteries supplying blood to the brain were occluded due to the dissection, significantly increasing her risk for stroke. Emergency staff prepared her for transfer by air ambulance to Memorial Hermann Memorial City Medical Center, where cardiothoracic surgeon Dawn Hui, MD, a professor in the Department of Cardiothoracic and Vascular Surgery at McGovern Medical School at UTHealth Houston, was called to the case.
“Ms. Matheny was described by the referring ER physician as having no neurologic response on presentation.?Propofol was started for transport to slow the activity of the brain and nervous system, but?when we turned off the propofol, she was?in fact?alert and able to nod or shake her head in response to questions,” Hui said. “She seemed to understand us,?although?it’s difficult to?fully?assess an intubated patient’s neurologic condition because they’re unable to speak. She could move her right side but not her left, and her left foot was cold and without a pulse, indicating?extremity?malperfusion?as well. Our biggest immediate concern was the blocked carotids, which, combined with her inability to move her left side, suggested that she’d had a stroke. We took her emergently to the OR for a type A aortic dissection repair.”
For type A aortic dissections, the American Heart Association recommendation is to pursue surgery over medical therapy in patients who present with nonhemorrhagic stroke complicating the dissection. The recommendation hinges on original work?done by Anthony Estrera, MD, professor and chair of the Department of Cardiothoracic and Vascular Surgery and Hazim J. Safi Distinguished Chair in Cardiothoracic and Vascular Surgery at McGovern Medical School.
In the operating room, Hui?performed?a type A aortic dissection repair with a hemiarch replacement of the tissue on the underside of the aortic arch. “With a dissection, we move very quickly and don’t always know what damage the patient has suffered until the chest is open,” she said. “There wasn’t a strong indication for a total arch replacement—such as an aneurysm or arch tear—and I was concerned that a total replacement would subject her to additional stroke risk.”
?Matheny tolerated the surgery well and was discharged following an 11-day hospital stay. After using a walker for two days, she regained the use of her left foot and hand. She has little memory of the experience.
“It was probably quite jarring—even surreal—for her to wake up and be told that she’d had a radical emergency operation,” Hui said. “Her recovery in the hospital was good, and I was shocked—very pleasantly—that she ended up with no serious residual neurologic deficits.?The CT scan demonstrating bilateral carotid occlusion was just a snapshot in time, and likely the initial medical treatment of blood pressure management helped re-establish carotid flow until she could have the definitive repair.”
Aortic dissection is rare, with an annual global incidence rate of 3 out of 100,000, but it remains a challenging clinical problem. “Not every hospital is staffed with a cardiac surgeon with the skill to handle dissections, or the hospital may have other resource limitations. The 2022 guidelines recommend that patients who need aortic dissection repair and are stable be transferred to a high-volume center,” said Hui, who served on the guideline writing committee.
“I’m incredibly lucky from what I understand,” Matheny said. “I have only minor problems. I wasn’t living the best heart-healthy life, and I don’t know why I had such good luck. I don’t remember much of what happened, but I liked Dr. Hui very much, and I’m happy to be home.”
Hui will present research on cerebral malperfusion in acute type A aortic dissection at the 63rd Annual Meeting of the Society of Thoracic Surgeons, to be held Jan. 28-31, 2027, in San Diego.?Her abstract coauthors include?Estrera; Akiko Tanaka, MD, PhD, assistant professor at UTHealth Houston Heart & Vascular; Yuki Ikeno, MD, instructor at McGovern Medical School; and Uzoma Okere, MD, a fourth-year general surgery resident at the medical school.
