Aortic Dissection

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David Benoit, The Ultimate Stress Test. JPMorgan Chase CEO Jamie Dimon felt a tear rip through his aorta -- jut as the pandemic began to ravage the economy. The two crises tested the foundations of America's largest bank. Wall Street Journal, Dec 26, 2020 (in the first page of business section, which on Saturday has the section called Exchange instead).
https://www.wsj.com/articles/jpm ... bulance-11608821876
https://postintrend.com/business ... e-for-an-ambulance/

Quote:

(a) "It was 4 am, [Mar 5, 2020,] and the JPMorgan Chase & Co chief executive dialed up his top lieutenants to deliver a message that couldn't wait: The economy is in trouble.

"Mr Dimon [2020 was his 15th year as CEO] hung up the phone and lay down on the couch to read the morning papers. He felt a rip in his chest. He sat up with a gasp and called his doctor. 'Jamie, take a cab,' the doctor told him. 'You don't have time for an ambulance.'  [It is unclear, from this paragraph, whether the doctor could tell aortic dissection from myocardiac infarction.]

"Hours later, Mr Dimon was clinging to life, surgeons perched above his chest repairing a gash in the artery that delivers blood from the heart to the rest of the body.

" 'I knew I might not make it,' Mr Dimon told The Wall Street Journal in his first interview about the aortic tear. The CEO's near-death experience came as the US economy was hurtling toward its own crisis [owning to incoming coronavirus pandemic]. The twin emergencies would test JPMorgan's foundations even more severely than the 2008 financial crisis.

The bank serves half of all US households and 400 of the Fortune 500. * * *

(b) " 'Everything is fubar,' Mr Dimon was telling some staff earlier this year. [The article did not say when the remark was made, but judging from the context, it night have been said after the pandemic started.] * * * [Prior to Mar 5, 2020. Dimon had traveled from Davon, Switzerland to Washington DC] for another annual gathering of the rich and famous, the Alfalfa Club dinner. * * * Mr Dimon was feeling under the weather but chalked it up to all the travel [again the article did not say exactly when]."

(c) "On March 5, Mr Dimon was supposed to be at St Patrick's Cathedral [a neo-gothic architecture; Catholic] on Fifth Avenue [between 50th and 51st Streets in Midtown Manhattan] for the funeral of Jack Welch, the longtime General Electric Co. CEO.

"Instead, he was 18 blocks uptown at NewYork-Presbyterian Hospital. The details of that morning are crystal clear in Mr Dimon's memory. Clutching his chest, he replayed the moment the lining of his aorta burst.

" 'I felt it,' Mr Dimon said. 'I thought I heard it [the tear of aorta].'

"His wife, Judy, ushered him downstairs and hailed a cab outside their Upper East Side apartment for a short ride to the hospital. He sent his secretary an email saying he didn't feel well and was getting checked out. His right arm ached and the vision in his right eye was sinking into a yellowy darkness [likely because his right side did not get enough blood, and hence oxygen. See next].

"At the hospital, a surgeon ran a quick test. The blood pressure in Mr Dimon's left arm was high, with the top number reading 140. But his right arm showed 60, dangerously low.

"Half his body wasn't getting enough blood.

"A heart surgeon who had once operated on Mr Dimon's late father explained that he was suffering from an aortic dissection, a tear in the inner wall [histology 组织学: intima] of the essential artery that delivers blood throughout the body. Mr Dimon's injury was to the part of the aorta closest to the heart, the ascending section just before the arch that plunges the artery downward.

"Left untreated, aortic dissections are typically fatal. Because they are thought to be rare—in 2018, dissections killed 9,923 in the U.S., according to the Centers for Disease Control and Prevention—doctors often miss them. Actor John Ritter died after an aortic dissection in 2003. His doctors thought it was a heart attack.

"In surgery, the doctor said, they would have a brief window to implant a tube [made of artificial material, to bypass the dissection site so that blood can supply the rest of his body, without use of Extracorporeal membrane oxygenation (ECMO)] and rebuild his aorta. At any moment, the whole thing could rupture. If that happened, there would be no way to save him.

"Mr Dimon told his wife to call Stacey Friedman, the bank's general counsel [who would call in his potential successors as acting CEOs].

(d) " * * * doctors patched up Mr Dimon during seven hours of surgery * * *

(e) In recuperation, "Mr Dimon lay in a bed at a hospital named for financier Sandy Weill [NewYork-Presbyterian/Weill Cornell Medical Center has two sets of hospitals in different parts of Manhattan: NewYork-Presbyterian (previously owned by Columbia University) and Cornell medical center. The two merged in 1998; the article did not name the hospital, but probably alluded to the latter]. Mr Weill, his [Dimon's] onetime mentor, had abruptly fired him from Citigroup two decades earlier in a power struggle.

"He ached all over. His heart, getting used to its new parts, thumped so strongly his daughters felt it when they hugged him. His scar looked like a zipper that would open a jacket right down the middle of his chest. There were tubes and probes in his lungs, arteries and jugular vein.

"After a few days, the medical staff started pulling the tubes and electrodes out of his body. On March 12, a week after surgery, Mr Dimon was released from the hospital.

(f) "Doctors cleared him to return to work full-time remotely the first week of April. He was warned to heed dizziness and pain. By then, he had decamped to his house in Bedford, a Westchester suburb. * * *
* * *
"Mr Dimon wanted to prepare for the worst-case scenario. But the most-likely picture, executives decided, was a grim second quarter during which unemployment would rise above 10% and gross domestic product would plunge at a breathtaking annualized rate of 25% [banks were preparing for massive defaults, that did not realize].
* * *
"They were surprised at how customers were behaving.

"Unemployment had soared, but customers were paying down credit-card debt instead of racking up balances. Customers flooded the bank with relief requests but kept paying on their loans. Spending on Chase credit cards plunged. Savings swelled. The usual correlation between rising unemployment and deteriorating consumer finances had broken down.

"Mr Dimon was convinced that the flood of government money was easing the symptoms of the recession while masking the economy's underlying illness [statistics showed that due to federal government's stimulus, average Americans, while unemployed, received more income than before the pandemic].
* * *
In October, JPMorgan surprised the market with its third-quarter [June to September] results: Profit had rebounded to pre-pandemic levels.

(g) "Mr Dimon's doctors aren't sure why his aorta burst. Old lab results didn't reveal missed signs or evidence of an aneurysm that could have caused the rupture. One doctor wondered if they had missed spikes in his blood pressure that had weakened his aorta. His surgeon chalked it up to a freak accident, and regular checkups have shown no lasting damage.
* * *
"One thing he says he is sure of: He is too busy to think about retiring.


Note:
(a)
(i) Online title: JPMorgan's Jamie Dimon and His Brush With Death: 'You Don’t Have Time for an Ambulance'
(ii) In print, this article was three pages long: half of the first page was Dimon in recuperation and many economic graphics.
(iii) A biologist by training, I am only interested in the portion of this article that deals with aortic dissection, not economics or the bank. This is what quotations and notes of this posting are about.

(b)
(i) "Everything is fubar"

fubar (adj; etymology: fucked up beyond all recognition): "US slang: thoroughly confused, disordered, damaged or ruined"
https://www.merriam-webster.com/dictionary/fubar
(ii) Alfalfa Club
ttps://en.wikipedia.org/wiki/Alfalfa_Club  
("a social club [ie, not physical] that exists only to hold an annual black tie banquet on the last Saturday of January at the Capital Hilton in Washington DC * * * The club was named in reference to the alfalfa plant's supposed willingness to 'do anything for a drink.' [a joke] * * * The club was formed by four southerners in the Willard Hotel [at Washington, DC' rebuilt twice, the last time in 1901] to celebrate the birthday of Confederate Civil War General Robert E Lee [January 19, 1807 (Monday) – 1870]")
(iii) under the weather
https://www.phrases.org.uk/bulletin_board/28/messages/325.html

(c) "Mr Dimon's injury was to the part of the aorta closest to the heart, the ascending section just before the arch that plunges the artery downward."

Aorta 主动脉 is made up of three portions: ascending aorta (length is about 5 centimetres (2.0 in)), aortic arch, and descending aorta (which is more than 1 meter long).  Judging from the fact that right side of his body lacks blood, the bulging of aortic wall on ascending aorta is away from aortic valves (located at the junction of heart and aorta to prevent blood flowing back to hear when heart relaxes after each contraction) and close to brachiocephalic artery, that supplies blood to both right arm and right brain. The blood supply to left side of brain and left arm are done by an artery each (called left carotid artery and left subclavian artery, separately). See graphic 2 in
https://en.wikipedia.org/wiki/Aorta
(d) John Ritter
https://en.wikipedia.org/wiki/John_Ritter
(1948 – 2003; in ABC sitcom Three's Company (1977–1984); section 4 Death)
(e) When reading the article, I was surprised that it (article) did not mention pain, and that a patient can feel or hear the tear. Before this article, I have wondered for decades how the disease was diagnosed, and why patients of this disease sought medical attention.  
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(2) David Levy, Amandeep Goyal, Yulia Grigorova, Fabiola Farci and Jacqueline K Le, Aortic Dissection. StatPearls NIH, last update Dec 17, 2020
https://www.ncbi.nlm.nih.gov/books/NBK441963/

Quote:

"Introduction[:] * * * A tear in the intimal [this is the adjective of the noun intima] layer results in the progression of the dissection (either proximal or retrograde [in either direction of the tear, along the aorta] ) chiefly due to the entry of blood in between the intima and media. An acute aortic dissection [AAD] is associated with very high mortality; the majority die even before reaching the emergency department. Patients with a chronic aortic dissection (more than two weeks) have a slightly better prognosis.

"Etiology[:] Predisposing high-risk factors for non-traumatic aortic dissection include:
• Hypertension (occurs in 70% of patients * * *  
• An abrupt, transient, severe increase in blood pressure (eg, strenuous weight lifting and use of sympathomimetic agents such as cocaine, ecstasy, or energy drinks)
* * *

"Epidemiology[:] The incidence of aortic dissection is reported to be 5 to 30 cases per 1 million people per year (compared to the much more common condition of acute myocardial infarction, which affects approximately 4400 cases per 1,000,000 person-years). Regarding emergency department presentations, three AADs are ultimately diagnosed out of every 1000 patients presenting with acute back, chest, or abdominal pain. Age is a risk factor * * * with the majority occurring between the ages of 50 and 65 years. * * *

"Pathophysiology[:] The aortic wall consists of three layers: the intima [innermost layer], media, and adventitia [outermost layer]. Constant exposure to high pulsatile pressure and shear stress leads to a weakening of the aortic wall in susceptible patients resulting in an intimal tear. Following this rent, blood flows into the intima-media space, creating a false lumen. Most of these tears take place in the ascending aorta, usually in the right lateral wall [the side of the aortic wall where brachiocephalic artery branches out] where the greatest shear force on the aorta occurs. An AAD can propagate anterograde and/or retrograde and depending on the direction the dissection travels, cause branch obstruction that produces ischemia of affected territory (coronary, cerebral, spinal, or visceral), and for proximal type A AADs [Type A in Stanford classification involves ascending aorta] can instigate acute tamponade, aortic regurgitation or aortic rupture.  In an AAD, the true lumen is lined by the intima whereas the false lumen is within the media. In most cases, the true lumen is smaller than the false lumen. * * * The media layer is formed by smooth muscle cells [mostly], elastic fibers, collagen fibers, and hyaluronic acid. * * *

"History and Physical[:] * * * "The pain of AAD is often sudden in onset, reaches maximal severity quickly, and can be tearing in nature. In about 10% of patients, the AAD is painless, which is more common in Marfan syndrome. The pain can be located in the anterior chest in case of ascending aorta and in the back if the dissection is descending. It may have a migrating character as dissection propagates caudally.


Note: AAD may bring about "can instigate acute tamponade, aortic regurgitation or aortic rupture."

Aortic regurgitation happens in this case, because Aortic dissection distorts aortic ring (guarded by three aortic valves).

More frequently aortic dissection leads to rupture and blood flows into, depending on location of the rupture, pericardium 心包膜 (the membrane surrounding the heart, rendering the heart unable to relax and expand) or thoracic cavity 胸腔. In either case, patient dies in no time.