The Unfriendly Neighbor: Pulmonary Artery Involvement in Acute Type A Dissection.

P0344 

Abstract Submission 

Salim Aziz (1), Jenna Aziz (2)

(1) George Washington University Hospital, Washington, DC, (2) Ohio State Wexner Medical Center, Columbus, OH

Salim Aziz    -  Contact Me
George Washington University Hospital

Jenna Aziz    -  Contact Me
Ohio State Wexner Medical Center

Salim Aziz    -  Contact Me
N/A

Objective:
Anatomically, the ascending aorta and pulmonary artery (PA) share a common adventitia. In acute ascending aortic dissection (AAD) blood can extravasate into the common aortopulmonary adventitia and cause pulmonary artery dissection or intramural hematoma. We describe our experience with the recognition and surgical management of associated pulmonary artery involvement in acute Type aortic dissection using bovine pericardium which enabled suitable hemostasis and successful separation from cardiopulmonary bypass.

Methods:
Case1.
A 40-year-old male presented to the ER with severe shortness of breath, left sided weakness and in extremis. He required urgent intubation. CT angiogram of the chest showed a Type 1 DeBakey dissection with extension into the innominate and right carotid artery, a pericardial effusion and blood around the pulmonary artery (PA) (Fig 1). He was emergently taken to the OR in extremis. TEE showed severe aortic regurgitation and pericardial tamponade. A bio-Bental procedure with Cabrol technique for the coronaries was performed using deep hypothermia circulatory arrest and antegrade perfusion. After coming off cardiopulmonary bypass and reversal of anticoagulation, persistent bleeding from the aorta and adjacent pulmonary artery near the root was noted. The patient was placed back on CPB and after cardioplegic arrest, a tear and hematoma in the PA adjacent to the ascending aorta near the root was identified. A patch of bovine pericardial was used to repair the involved area. He was transitioned to veno-arterial extracorporeal membrane oxygenation from which he was weaned successfully with recovery.

Case 2.
A 49-year-old hypertensive male presented with upper abdomen and chest pain. On CTA an AAD in an 8 cm ascending aortic aneurysm that was compressing the main PA was seen. In addition, there was a separate type B aortic dissection. Also present there was a small sinus tract leading from the dissected aortic aneurysm into the adjacent pulmonary artery. At operation an acute dissection in a chronic Type A aneurysmal dissection was seen which tracked into the wall of the adjacent main PA with a contained intramural hematoma. On preparing the ascending aorta for replacement the PA hematoma bled and required repair using a bovine pericardial patch. A Bio-Bental procedure was performed. The post-operative course was uneventful.

Results:
Bovine pericardial patch can be used to repair pulmonary artery dissection and a bleeding intramural hematoma associated with Type A aortic dissection.

Conclusion: Pulmonary artery dissection or intramural hematoma is infrequently seen in Type A dissection. CT scan findings can be variable. Use of bovine pericardium for repairing the involved pulmonary artery is advisable.

Dissection