Interact CardioVasc Thorac Surg 2009;9:143. doi:10.1510/icvts.2009.205849A
© 2009 European Association of Cardio-Thoracic Surgery
eComment: Acute aortic dissection in children and young adults – the role of sildenafil
Frank Edwin,
Mark M. Tettey and
Kwabena Frimpong-Boateng
National Cardiothoracic Centre, Korle Bu Teaching Hospital, PO Box KB 846, Korle Bu, Accra, Ghana
Aortic dissection due to sildenafil abuse
The report by Tiryakioglu and colleagues [1] adds another dimension to the various predisposing factors of acute aortic dissection. What is commonly a disease of old age may affect children and young adults. In the aged, hypertension is a common predisposition. However, in the young, congenital cardiovascular anomalies (bicuspid aortic valve and coarctation among others) and certain heritable disorders of connective tissue are more prevalent. The most well known connective tissue disorder in this regard, Marfan's syndrome, represents only one end of a spectrum of conditions resulting from defective fibrillin-1 synthesis, collectively known as fibrillinopathies. Non-Marfan fibrillinopathy has been reported [2] as a predisposition to aortic dissection. In addition, newer predisposing factors such as cocaine abuse and weight lifting/weight training have been described [3]. Tiryakioglu and colleagues [1] have suggested another factor (sildenafil use/abuse) for inclusion as a predisposition.
The interplay of three factors is generally held accountable for the pathogenesis of most cases of aortic dissection – an abnormality or weakening of the aortic media (as may occur with ageing, certain congenital cardiovascular anomalies, and the fibrillinopathies), an agent of intimal injury or tear (as occurs with atherosclerosis or hypertension) and hemodynamic factors (systemic blood pressure) responsible for a pressure head that drives blood to dissect the aortic wall. It is difficult to conjecture the contribution of sildenafil to these three factors. The strong temporal relationship between sildenafil intake and the onset of dissection is the most potent argument. This was true in the cases reported so far [4].
Sildenafil has an antiproliferative effect on vascular smooth muscle cells in the pulmonary circulation [4]; possibly, similar effects on the aorta may lead to non-inflammatory smooth muscle cell loss in the aortic media rendering it more vulnerable to dissection.
On the other hand, all three reported cases of aortic dissection involving the use of sildenafil had other well established predisposing factors – old age and hypertension [4], cocaine abuse [5], and bicuspid aortic valve with ascending aortic aneurysm [1]. In addition, these patients had been taking sildenafil for months until the dissection. It may be speculated though that chronic sildenafil use induces some changes in the aortic wall that ultimately makes dissection a possibility. Nevertheless, until more evidence is accumulated, it appears the role of sildenafil in the causation of aortic dissection shall remain speculative.
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References
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- Kenar Tiryakioglu S, Tiryakioglu O, Tamer T, Kumbay E. Aortic dissection due to sildenafil abuse. Interact CardioVasc Thorac Surg 2009;9:141–143.[Abstract/Free Full Text]
- Hogan CJ. An aortic dissection in a young weightlifter with non-Marfan fibrillinopathy. Emerg Med J 2005;22:304–305.[Abstract/Free Full Text]
- Fikar CR, Koch S. Etiologic factors of acute aortic dissection in children and young adults. Clin Pediatr (Phila) 2000;39:71–80.[Abstract/Free Full Text]
- Nachtnebel A, Stöllberger C, Ehrlich M, Finsterer J. Aortic dissection after sildenafil-induced erection. South Med J 2006;99:1151–1152.[Medline]
- Famularo G, Polchi S, Di Bona G, Manzara C. Acute aortic dissection after cocaine and sildenafil abuse. J Emerg Med 2001;21:78–79.[CrossRef][Medline]
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Aortic dissection due to sildenafil abuse
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Interactive CardioVascular and Thoracic Surgery 2009 9: 141-143.
[Abstract]
[Full Text]
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