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.