Ritter was victim of a rare tear

Special to The Times

When John Ritter arrived at the hospital Sept. 11, 2003, he was nauseated and vomiting, and he felt a dull tightening in his chest. Doctors ordered an EKG, which proved inconclusive. But an hour or so later, Ritter’s chest tightness was worse, and a second EKG was more dire. Besides, his blood pressure had gone down, his heart rate had gone up, and he seemed to be developing congestion in his lungs.

These were all signs of a man having a heart attack.

The standard of care for heart attack victims is to try to open their arteries as soon as possible, and that is what doctors did for the popular actor, treating him in the cardiac catheterization lab where they inserted an intra-aortic balloon pump.

Unfortunately, this was exactly what Ritter didn’t need.


Ritter’s heart attack was not typical. It was not caused by plaque blocking his arteries but by a sudden tear in the inner lining of his aorta, a very dangerous, and rare, condition known as an aortic dissection.

The aorta, leading from the heart, is the body’s largest blood vessel. The lining of Ritter’s aorta tore in a critical spot: The flap of loose tissue intermittently covered his left main coronary artery, interrupting the supply of blood -- and oxygen -- to the left ventricle of his heart.

What Ritter needed was emergency surgery to repair the tear.

After Ritter’s death, his widow, Amy Yasbeck, and his children sued the cardiologist who treated Ritter in the emergency room that night, as well as a radiologist who had examined Ritter two years before. They contended that the cardiologist should have diagnosed Ritter’s real problem and given him more appropriate treatment and that the radiologist should have found that Ritter had an enlarged aorta, which increases the risk for a dissection.


Earlier this month, the doctors were found blameless, with a jury saying they had done all they could.

That may have done little to reassure Americans afraid of suffering their own aortic dissection -- and of not being diagnosed correctly.

So, the first thing to remember is that you probably won’t have an aortic dissection. Only about 10,000 Americans a year do, says Dr. Kim Eagle, a cardiology professor at the University of Michigan at Ann Arbor and a director of the university’s Cardiovascular Center, who testified for the defense in the Ritter case. (Heart attacks are far more common; there are 450,000 of them annually in the U.S.)

A second thing to know is that your risk for having an aortic dissection is largely determined by your genes, although some lifestyle choices can affect your chance of having one and recovering from it.


Finally, if you ever think you might be having a dissection -- or a heart attack -- be sure to go to a hospital immediately. Early diagnosis and treatment can make all the difference.

Aortic dissections come in two kinds -- varying by where they occur. Type A’s, the kind Ritter had, occur in the upper part of the aorta where it first leaves the heart. Type Bs occur farther along, at or below the point where arteries branch off to the arms.

Type A dissections -- the most common and most serious kind -- can cause hemorrhaging in the sac around the heart or interfere with the blood supply to heart or brain. Ritter’s intermittently blocked the supply to his heart, causing his heart attack. About 3% to 5% of dissections cause heart attacks, Eagle says.

Type B dissections can interfere with the blood supply just about anywhere at or below the chest, including the pancreas, liver, kidneys, intestines and legs.



Symptoms vary a lot

Symptoms of a dissection of either type can vary from something as small as a painful jaw or cold leg to paralysis or stroke. In fact, because dissections are so rare, and so many of their symptoms can have other, more likely causes, “between 35% and 45% of patients with dissections are initially suspected of having something else,” Eagle says.

“It’s the great masquerader,” says Dr. John Elefteriades, professor and chief of cardiac surgery at Yale University in New Haven, Conn., who testified for the plaintiffs in the Ritter trial.


The most common symptom among dissection patients is sudden, catastrophic pain that some describe as worse than childbirth. “They have almost a freeze-frame memory of what they were doing when the dissection occurs,” Eagle says. “A heart attack takes places over a period of minutes. With a dissection, there’s a moment.”

But such catastrophic moments aren’t universal. Ritter didn’t complain of one.

Usually, a dissection occurs when the aorta has developed an aneurysm, or bulge, causing weakened walls susceptible to tears. These happen suddenly, like an over-full grocery bag that suddenly gives way.

Elefteriades has found that aortic aneurysms grow slowly, but surely, at about 0.12 centimeters a year, and the risk of rupture, dissection or death within a year grows right along with them -- gradually when the aneurysm is from 4.0 to 5.9 centimeters, and sharply after 6.0 centimeters. In fact, the risk gets so high then -- more than 15% -- that he recommends surgery to remove aneurysms at 5.5 centimeters, even though such surgery is extremely risky.



Treatment for dissection

After a dissection has occurred, medical treatment is sometimes effective for type B dissections, but the appropriate treatment for type A dissections is always surgery to repair the tear, unless the patient isn’t strong enough. Without surgery, the chance of dying is 1% per hour for the first 24 hours. The chance of dying within a week is more than 40%, and within 30 days, more than 50%.

Of course, before the problem can be treated, it has to be diagnosed. CT scans and transesophageal echocardiography are the two best imaging techniques to find dissections, according to Dr. William Armstrong, a cardiology professor at the University of Michigan.


The International Registry of Aortic Dissection -- an international study group with its core lab at the University of Michigan -- is looking for a biomarker that it believes may be released into the blood just after the aorta tears. That could lead to a quick and inexpensive diagnostic screen for patients who come to the emergency room with chest pain.

The same group is also studying the use of aortic stent grafts to see if they might be preferable to surgical repair for some dissection patients.

Almost one-third of patients with type A aortic dissections die before they leave the hospital, according to a 2002 study in the journal Circulation. This figure includes a 25% risk of death during surgery. Among patients who don’t have surgery to fix the tear, more than half die.

In the same study, researchers found that more than 11% of patients with type B dissections die.


On the other hand, if patients survive their tear-repair surgery and hospital stay, the outlook is quite good. Three years later, 90% are still alive, according to a 2006 study. And the patients at greatest risk of death in those three years are those who already had atherosclerosis or cardiovascular surgery before their dissections. (Eating right and exercising and doing all the things you’re supposed to do to keep your heart healthy could have a bonus for some.)

Ritter was not the first famous person to die from an aortic dissection. As Elefteriades pointed out in a 2005 article in Scientific American, others include Albert Einstein and Lucille Ball -- and might have included Abraham Lincoln if he hadn’t been assassinated. That follows from the speculation of some medical historians that Lincoln had Marfan syndrome. Aortic dissections, though rare in the general population, are the leading cause of death among people with Marfan, a connective tissue disorder affecting more than 100,000 Americans that, among other things, weakens the aorta.

Other special risk factors include an aortic valve with two cusps instead of the usual three; a family history of aortic aneurysms, ruptures or dissections; a family history of any sudden or unexpected collapse and death; long-term high blood pressure problems; pregnancy; weight lifting; and cocaine use. “Now that Ritter has had one, his children should be screened for dissections,” Eagle says.

Aortic dissections are very tough customers. You never know when one might strike. And if you do get laid low, you may not know what hit you.


The doctors who treated Ritter in the ER that night in 2003 didn’t know what had hit him. “They made a very heroic effort trying to treat him and save his life,” Eagle says, “and they just couldn’t.”

Still, as reported in The Times immediately after the trial, Yasbeck feels the publicity about her husband’s death has been able to do some good.

“So many people have reported to me that they go into an emergency room with chest pains and say, ‘I’m not going out of here until you check me for that John Ritter thing.’ It has saved their lives,” she said. “It’s in the front of their minds now.”