Emergency Repair of an Acute Type A Aortic Dissection in a Patient with Heritable Aortopathy and Refusal of Blood Products
Presented During:
Saturday, May 6, 2023: 5:00PM - Tuesday, May 9, 2023: 5:00PM
Los Angeles Convention Center
Posted Room Name:
ePoster Area, Exhibit Hall
Abstract No:
6227
Submission Type:
Cardiothoracic Resident Case Report Competition
Authors:
Trenton Gluck (1), Katie Nordick (2), Lauren Barron (2), Marc Moon (1)
Institutions:
(1) Baylor College of Medicine / Texas Heart Institute, Houston, TX, (2) Baylor College of Medicine, Houston, TX
Submitting Author:
Trenton Gluck
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Baylor College of Medicine / Texas Heart Institute
Baylor College of Medicine / Texas Heart Institute
Co-Author(s):
Katie Nordick
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Baylor College of Medicine
Baylor College of Medicine
Lauren Barron
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Baylor College of Medicine
Baylor College of Medicine
*Marc Moon
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Baylor College of Medicine / Texas Heart Institute
Baylor College of Medicine / Texas Heart Institute
Presenting Author:
Trenton Gluck
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Abstract:
Background
Acute type A aortic dissection (ATAAD) is a life-threatening surgical emergency that requires prompt intervention. However, controversy over the extent of distal repair remains. A conservative approach limiting replacement to the ascending aorta or hemiarch is safer in the short term but may increase long-term complications necessitating late reintervention, especially in patients with heritable thoracic aortic disease (HTAD) and residual dissection. A more aggressive distal approach with total arch replacement can mitigate long-term risks but adds substantial operative complexity, morbidity, and mortality. However, when patient factors preclude a complex operation, the operative plan should be deconstructed prioritizing the aspects that impact immediate survival.
Case Description
We report on a 63-year woman with Loeys-Dietz syndrome, chronic hypotension, and acute onset chest pain who presented elsewhere and was diagnosed with DeBakey type 1 dissection extending from just distal to the coronary ostia to the left iliac artery. After transfer, she was hemodynamically stable and had no evidence of malperfusion but had ongoing back and chest pain. Given her heritable aortopathy, the initial operative strategy was an extended repair replacing the aortic root, ascending aorta, and the entire arch using hypothermic circulatory arrest. However, the patient did not consent for transfusion of blood products due to her religious observance. Both an extended repair and hypothermic circulatory arrest are associated with increased risk of bleeding and transfusion. With these challenges in mind, we decided to prioritize coronary protection and valve repair, limiting the extent of operative intervention as much as possible. Cardiopulmonary bypass was performed using right axillary artery cannulation, and the heart arrested with retrograde cardioplegia. An intimal tear was visualized distal to the right coronary ostium with retrograde dissection into the sinuses destabilizing the commissures and compromising the valve (severe aortic regurgitation [AR] on intraoperative echocardiography). We transected the involved aorta, resected the originating tear, and obliterated the false lumen using surgical adhesive while protecting the coronary ostia. Using inner and outer felt strips, we resuspended the commissures and provided additional support at the sinotubular junction. A 30-mm graft was used to replace the ascending aorta. Possibly because of her chronic hypotension, the aortic arch was of normal diameter without aneurysmal dilatation, reducing immediate need for intervention on the arch. The patient tolerated the procedure well, with post-repair echocardiography showing restored valvular function. She was discharged home on postoperative day 8 and has remained well in the 3 months since operation.
Conclusion
Patients with HTAD and ATAAD should be considered for total arch replacement at the time of repair to reduce the risk of subsequent dilatation of residual aortic tissue. In complex cases where the risks may outweigh the benefits of this preferred approach, alternative options for intervention should be considered. Deconstructing the surgical approach to prioritize those repairs which offer an immediate survival advantage is warranted in patients with religious considerations.
Acute type A aortic dissection (ATAAD) is a life-threatening surgical emergency that requires prompt intervention. However, controversy over the extent of distal repair remains. A conservative approach limiting replacement to the ascending aorta or hemiarch is safer in the short term but may increase long-term complications necessitating late reintervention, especially in patients with heritable thoracic aortic disease (HTAD) and residual dissection. A more aggressive distal approach with total arch replacement can mitigate long-term risks but adds substantial operative complexity, morbidity, and mortality. However, when patient factors preclude a complex operation, the operative plan should be deconstructed prioritizing the aspects that impact immediate survival.
Case Description
We report on a 63-year woman with Loeys-Dietz syndrome, chronic hypotension, and acute onset chest pain who presented elsewhere and was diagnosed with DeBakey type 1 dissection extending from just distal to the coronary ostia to the left iliac artery. After transfer, she was hemodynamically stable and had no evidence of malperfusion but had ongoing back and chest pain. Given her heritable aortopathy, the initial operative strategy was an extended repair replacing the aortic root, ascending aorta, and the entire arch using hypothermic circulatory arrest. However, the patient did not consent for transfusion of blood products due to her religious observance. Both an extended repair and hypothermic circulatory arrest are associated with increased risk of bleeding and transfusion. With these challenges in mind, we decided to prioritize coronary protection and valve repair, limiting the extent of operative intervention as much as possible. Cardiopulmonary bypass was performed using right axillary artery cannulation, and the heart arrested with retrograde cardioplegia. An intimal tear was visualized distal to the right coronary ostium with retrograde dissection into the sinuses destabilizing the commissures and compromising the valve (severe aortic regurgitation [AR] on intraoperative echocardiography). We transected the involved aorta, resected the originating tear, and obliterated the false lumen using surgical adhesive while protecting the coronary ostia. Using inner and outer felt strips, we resuspended the commissures and provided additional support at the sinotubular junction. A 30-mm graft was used to replace the ascending aorta. Possibly because of her chronic hypotension, the aortic arch was of normal diameter without aneurysmal dilatation, reducing immediate need for intervention on the arch. The patient tolerated the procedure well, with post-repair echocardiography showing restored valvular function. She was discharged home on postoperative day 8 and has remained well in the 3 months since operation.
Conclusion
Patients with HTAD and ATAAD should be considered for total arch replacement at the time of repair to reduce the risk of subsequent dilatation of residual aortic tissue. In complex cases where the risks may outweigh the benefits of this preferred approach, alternative options for intervention should be considered. Deconstructing the surgical approach to prioritize those repairs which offer an immediate survival advantage is warranted in patients with religious considerations.
Category:
Adult Cardiac
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