My story of `CHRONIC DESCENDING AORTIC DISSECTION `

Dr. Vilas A. Bidaye,Baroda,India

I was a fairly healthy individual till I reached 66 Yrs of age. I have a good athletic figure as I was involved in various sports activities and in regular swimming and lately morning walks. I have earned many medals in these activities since my childhood. I have very regular habits and am a non-smoker, though I rarely take a drink or two, once or twice in a year. I am a non-diabetic and have no high blood pressure any time.

I am a practicing Eye Surgeon and in this profession for last 45 yrs. I am a pioneer Implant Surgeon in this part of the country. I have traveled all over the world for various international conferences. There was no health problem any time during these activities.

On 21st Sept. 2003 I got up as usual and was getting ready to go for my regular swimming exercise. I was sipping my morning cup of tea and midway suddenly experienced a chocking sensation in my chest. I felt all my energy has drained out. I was sitting on the chair but had no energy to get up. Within few minutes every thing settled down and I could finish my tea. I felt my pulse and found it O.K., but both my hands felt so weak that I thought I may not be able to swim though I could now get up on my legs and walk around. The strength in the hands came back within 30 minutes and I felt alright. That day being a Sunday I could rest for the whole day. As I was feeling alright I avoided disturbing my Physician colleague on a Sunday.

After a full day’s rest I had a good sleep and got up nest day as fresh as ever. However I was rightly not allowed by my family to go swimming that day. Instead I went for a walk as it was my routine to take a walk on a swimming holiday. That day I met a young professional colleague and I walked briskly in his company. I was feeling normal and went home, had my breakfast and was ready to my hospital. My wife reminded me to visit my Physician friend and to make sure I do so, asked my doctor son to accompany me. As usual I did not wait for the lift and climbed the stairs. I felt nothing and was sure to get a green signal from my Physician.

He took the history, examined me and took an ECG. Finding some early changes in the ECG he did not allowed me to get up and straight way we headed for a Heart Institute where things were ready to receive me. I straight way went to I.C.U. and had to undergo a battery of tests. They diagnosed a 100% block in one main artery leading to my heart and advised for a angioplasty. It was immediately carried out with a medicated stent which was new then. Every thing happened so suddenly that there was no time to inform anybody at home though my son was with me. I saw my physician friend at 10.00 A.M. and my angioplasty was over by 12.30 noon. I then had a rapid recovery and was back to my routine in short time. This story I am narrating purposely to make you aware of the background.

I regularly followed my medications and check-ups and could even undertake a strenuous journey, organized by Govt. of India to Kailash Mansarovar, involving 200 KM of trekking in Himalayan range of mountains at high altitude. I could get through the initial thorough Medical Fitness tests carried out for one full day, at Delhi Heart and Lung institute. I could withstand this hectic journey without much difficulty. This was in August 2006.

Next two years were fine for me and I was enjoying my routine physical exercise and my professional work.

On 10th Aug. 2007, while in the swimming pool, doing my routine 50 meter underwater swimming, as a part of my regular exercise, and nearing to complete it, I experience a sudden, severe pain in the epigastrium, (where chest ends and abdomen starts) and I could barely reach the pool wall. I felt as if all my strength has drained out and I stood motionless in the shallow waters with the support of the side wall. After this underwater event I usually swim the whole length (50 Mt.) before coming out of the pool. That day, I got out from the shallow side and slowly walked out to change. The severe stabbing pain lasted for few minutes only and then there was dull pain. I could drive back home with that dull pain and could take my light breakfast before going to my clinic. At the clinic I examined few patients but the pain then started increasing and I thought it to be pain of cardiac origin. I immediately rang my Cardiac Interventionist who

made all the arrangements to receive me at the Heart Institute. I was straight away admitted in ICU and ran through battery of tests. By 12 noon he declared that this is not a cardiac problem. But my pain did not come down. I was restless and was changing from lying down to sitting up and even walking around, but the pain would not go. He rechecked everything once again and then referred me to a Gastro-enterologist.

The Gastroenterologist got me admitted in his hospital and gave me pain killers and then only I could go to sleep after few hours. He then did Gastroscopy and Ultra Sonography of Abdomen. He found tiny ulcers in my stomach and tiny stones in the Gall bladder and started treatment for the same. I was sent home with a diagnosis of acute cholecystitis (Inflammation of Gall Bladder) and the only treatment was surgery, to remove the Gall Bladder, which was deferred for 6 weeks because of inflammation. My pain was now intermittent but regular and could be relieved only by injection of pain killer. This pain lasted for a week and then I was alright. I once again started attending my clinic and shortly started my surgical work as well.

I had no fever any time and that created doubt in the mind of my clinician and he delayed the surgery. To get rid of any chance of this episode to repeat, I showed my eagerness for the surgery. He advised me for MRI study of the Gall Bladder. On the MRI, my Radiologist found this Aortic Dissection condition. He was a young doctor and was in dilemma how to tell me about this serious condition. He gave me the report and advised me to consult for this more serious condition and to forget about Gall Bladder which was normal. I was completely astonished now as I had never seen any patient of Aortic Dissection, so seeing the grave faces of my clinicians, I was confused. I was wondering why these people are so much worried when I feel absolutely hale and hearty. Then I combed the internet to find more about this condition. On the internet I could find the impression of general people about this dreadful disease. This disease has many varieties. Aortic Dissection may be Acute or chronic, affecting different parts of Aorta such as Ascending Aorta, Aortic arch and descending Aorta. Most of the varieties are very, very serious and have little survival chances. But all varieties are not equally grave. I am writing this story to let people know that all varieties of Aortic Dissection are not grave.

I could collect a lot of information from internet and our medical books and after that I could co-related all the above events that happened with me and now my version is as follows :

The common causes of Aortic Dissection are as follows :

Causes

Aortic dissection is associated with hypertension (high blood pressure) and many connective tissue disorders. Vasculitis (inflammation of an artery) is rarely associated with aortic dissection. It can also be the result of chest trauma. 72 to 80% of individuals who present with an aortic dissection have a previous history of hypertension.

The highest incidence of aortic dissection is in individuals who are 50 to 70 years old. The incidence is twice as high in males as in females (male-to-female ratio is 2:1). Half of dissections in females before age 40 occur during pregnancy (typically in the 3rd trimester or early postpartum period).

A bicuspid aortic valve (a type of congenital heart disease involving the aortic valve) is found in 7-14% of individuals who have an aortic dissection. These individuals are prone to dissection in the ascending aorta. The risk of dissection in individuals with bicuspid aortic valve is not associated with the degree of stenosis of the valve.

Marfan syndrome is noted in 5-9% of individuals who suffer from aortic dissection. In this subset, there is an increased incidence in young individuals. Individuals with Marfan syndrome tend to have aneurysms of the aorta and are more prone to proximal dissections of the aorta.

Turner syndrome also increases the risk of aortic dissection, by aortic root dilatation.

Chest trauma leading to aortic dissection can be divided into two groups based on etiology: blunt chest trauma (commonly seen in car accidents) and iatrogenic. Iatrogenic causes include trauma during cardiac catheterization or due to an intra-aortic balloon pump.

Aortic dissection may be a late sequela of cardiac surgery. 18% of individuals who present with an acute aortic dissection have a history of open heart surgery. Individuals who have undergone aortic valve replacement for aortic insufficiency are at particularly high risk. This is because aortic insufficiency causes increased blood flow in the ascending aorta. This can cause dilatation and weakening of the walls of the ascending aorta.

Of note, although this is extremely rare in this day and age, Syphilis can cause aortic dissection. In the tertiary stage of this disease, the aorta gets Luetic lesions which lead to dissection

In my case there was no hypertension, no connective tissue disease, no Vasculitis, no Marfan syndrome, no Turner syndrome, nor any cardiac surgery or external trauma but I had undergone cardiac catheterization in 2003.

This cardiac catheterization might have caused a trivial damage to some part of the aorta during the process and it has gone unnoticed. Usually the catheter end is blunt and can never cause any injury. But it could be a slightly defective piece and it was my luck that it was used for me. My cardiologist was extremely careful and he had taken utmost care in my case and I am ever grateful to him for I had very rapid recovery after the episode and I could undertake the strenuous trekking in Himalayas in 2006.

If anything is to be blamed for my Aortic dissection it was my underwater swimming exercise, as I read it to day.

Being a medial practitioner I was aware that even in a normal person the Blood Pressure temporarily shoots up to 300 mm of Hg. during underwater swimming, under Sona-bath etc. and it becomes normal within moments. I used to call this a stress Test for all my co-swimmers who used to join me for underwater swimming. We have been doing this exercise for over five years now and no one had any trouble any time.

The little damage to my aorta in past must have given way when it was exposed to momentarily high Blood Pressure during the underwater swimming. This is how I co-relate the starting point of my dissection.

The MRI study revealed that the dissection has started just above Superior Mescenteric artery and then first extended into that blood vessel (Superior Mescenteric artery) that feeds the digestive tract in the abdomen. The blood flow in this feeder vessel was blocked almost to 80% and the upper gastro-intestinal tract suffered from ischemia (poor blood supply) just like a heart attack when blood supply to heart suffers. All my symptoms of Gall Bladder were mimicked due to this ischemia. Had I not gone for MRI, I might have undergone Gall Bladder surgery. In those eight days of sufferings the Aortic dissection slowly extended to the end of the aorta, that is up to Iliac arteries. Very fortunately it did not enter into any other major vessel and I was spared from any kidney damage or paralysis of both legs and remained completely asymptomatic till to-day. My Superior Mescenteric artery is still blocked but within 8 days of the sufferings the co-laterals developed and once again the blood supply to upper G.I tract was re-established. This way I proved to be lucky to escape major damage.

In Dec. 2007 there was an International meeting of Vascular surgeons in Baroda and I got a chance to take opinion of few reputed vascular Surgeons from different countries and they all asked me to adopt policy of ‘Wait and Watch’. I had to keep a watch on the size of Aorta through MRI every six monthly. Fortunately there is no change in last one year.

I have to watch my blood pressure and to avoid all those activities which would increase my Blood Pressure even momentarily. I resumed all my activities and my routine work. I go for swimming but avoid all those steps that will increase my B.P. I go for my morning walk but avoid jogging or even brisk walk. I am now leading practically a normal life for a 72 yrs old individual. Now the false lumen of the dissection has a clot and I am watching it carefully and keep myself ready for the consequences any time, if at all, they come.

Dr. Vilas A. Bidaye,Baroda,India

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