U.S. Envoy Richard Holbrooke undergoes emergency heart surgery-UPDATED

U.S. Envoy to Afghanistan and Pakistan, Richard Holbrooke is in critical condition today at George Washington University after undergoing surgery to repair what is being called a “tear in the aorta.” The 69 year old veteran diplomat is probably best-known for brokering the 1995 Bosnian peace accords in Dayton, Ohio, that ended the ended the bloody ethnic conflict in the former Yugoslav republic. Holbrooke became ill yesterday, while in a meeting with Secretary of State Hillary Clinton at the State Department.

A tear in the aorta is medically known as an aortic dissection. Readers of this website will recall that this is the condition that killed actor John Ritter in 2003. Since that time, Ritter’s wife Amy Yasbeck has become an advocate for people with this disease, and has established the John Ritter Foundation for Aortic Health. This organization is working to increase public awareness of new Treatment Guidelines for Thoracic Aortic Disease released in March of 2010, part of which includes what are now called the Ritter Rules, life-saving reminders to recognize, treat and prevent thoracic aortic dissection.

What is aortic dissection?

The aorta is the main blood vessel that takes blood from the heart to the rest of the body. Like all blood vessels, its walls are made up of three layers:

  • the inner lining (which is in contact with the blood) called the tunica intima (commonly called the intima), which is made up of endothelial cells- thin smooth cell which reduce friction through the blood vessels.
  • the tunica media which is made up of smooth muscles and elastic tissues
  • the tunica adventia, the outer layer of the blood vessel made of a more fibrous material.

Blood dissecting from the tunica intima to the tunica media →

In aortic dissection, damage to the intima layer allows blood to dissect its way into the media layer. Over time, the wall of the blood vessel balloons out. This weakens the wall of the aorta, and if it reaches a critical point, the wall can rupture, leading to sudden death. The dissection can occur anywhere along the length of the aortic, either close to the heart (proximal dissection) or lower down in the abdomen (distal dissection). Aortic dissection occurs more frequently in men, and between the ages of 50-55 for proximal dissection, 60-70 years old for distal dissection. Factors that can increase the risk of aortic dissection include high blood pressure, an abnormal aortic heart valve (especially one called a bicupsid valve where the valve is made of two instead of the normal three leaflets), family history of aortic dissection, and certain genetic conditions, such as Marfan’s Disease and Turner’s Syndrome.

The standard and most common type of surgery for aortic aneurysms is open abdominal or open chest repair. It involves a major incision (cut) in the abdomen or chest and is performed under general anesthesia. The aneurysm is removed, and the section of aorta is replaced with a graft made of material such as Dacron® or Teflon.® The surgery takes 3 to 6 hours, and patients typically remain in the hospital for 5 to 8 days.

It often takes a month to recover from open abdominal or open chest surgery and return to full activity. Most patients make a full recovery.

For more information, click here to go to the Resounding Health Casebook on aortic dissection.

UPDATE: December 13, 2010

It is reported tonight that Richard Holbrooke has died. The 69-year-old diplomat was admitted on Friday to George Washington University Hospital in Washington. Holbrooke underwent a 21-hour operation on Saturday to repair an aortic dissection (see above). he . He had additional surgery on Sunday and remained in very critical condition until his death.

Secretary of State Hillary Clinton has said that “True to form, Richard was a fighter to the end. His doctors marveled at his strength and his willpower, but to his friends, that was just Richard being Richard.”

President Obama called Holbrooke “a true giant of American foreign policy… [He was]a truly unique figure who will be remembered for his tireless diplomacy, love of country, and pursuit of peace.” Obama also said that Richard Holbrooke deserves credit for much of the progress in Afghanistan and Pakistan.

Michele R. Berman, M.D. was Clinical Director of The Pediatric Center, a private practice on Capitol Hill in Washington, D.C. from 1988-2000, and was named Outstanding Washington Physician by Washingtonian Magazine in 1999. She was a medical internet pioneer having established one of the first medical practice websites in 1997. Dr. Berman also authored a monthly column for Washington Parent Magazine.

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