Iatrogenic type A aortic dissection during cardiac surgery

We reviewed our experience of intraoperative type A aortic dissection during cardiovascular surgery. From January 1998 to May 2009, intraoperative aortic dissection occurred in 10 of 3421 cardiac surgical patients (M:F=4:6, 62.4+/-8.0 years). Preoperative diagnoses were valvular heart disease (n=6), ischemic heart disease (n=2), combined disease (n=1) and aortic aneurysm (n=1). All underwent total circulatory arrest (TCA) with retrograde cerebral perfusion and the torn aorta was replaced (n=8) or repaired (n=2). Iatrogenic type A dissection occurred in 0.29% of patients. It was related with cannulation of ascending aorta (n=4), axillary artery (n=2), aortic root (n=2), and femoral artery (n=1) and aortotomy repair (n=1). Mortality rate was 40% (4/10). After adoption of routine intraoperative transesophageal echocardiography, mortality rate decreased from 75% (3/4) to 17% (1/6) (P=0.190). We initiated TCA before achieving deep hypothermia in three of four non-survivors. There was a trend of increased mortality when the disease extended beyond aortic arch (67%, 4/6 vs. 0%, 0/4; P=0.076). Although intraoperative aortic dissection occurred in <0.3% of our patient population, mortality was high, especially when it extended beyond the arch vessels. Better results were expected when early recognition and proper treatment under deep hypothermic circulatory arrest could be performed.