Heart transplantation following a successful bridge-to-bridge strategy in acute type A aortic dissection with left
Tomoki Ushijima1,2, Tobuhiro Nita3, Takeo Fujino4,5
1Department of Advanced Cardiopulmonary Failure, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan. ushijima.tomoki.959@m.kyushu-u.ac.jp.
Insights
This case study highlights a successful sequential mechanical circulatory support strategy for a patient with acute aortic dissection. This approach, combined with careful surgical management, effectively bridged the patient to heart transplantation.
Area of Science:
- Cardiovascular Surgery
- Mechanical Circulatory Support
- Aortic Dissection
Background:
- Stanford type A acute aortic dissection can lead to severe complications, including coronary artery occlusion and cardiopulmonary impairment.
- Patients with extensive myocardial ischemia may require advanced circulatory support beyond initial surgical repair.
Purpose of the Study:
- To describe a successful sequential mechanical circulatory support strategy in a patient with complex acute aortic dissection.
- To illustrate the role of bridge-to-bridge surgery in facilitating long-term heart transplantation.
Main Methods:
- Emergency ascending aortic replacement with coronary artery bypass grafting.
- Initiation of central veno-arterial extracorporeal membrane oxygenation (ECMO) for cardiopulmonary support.
- Conversion to a paracorporeal left ventricular assist device (LVAD) followed by a durable LVAD as a bridge-to-bridge strategy.
- Simultaneous aortic valvuloplasty during bridge-to-bridge LVAD implantation.
Main Results:
- Successful weaning from cardiopulmonary bypass with ECMO support.
- Respiratory support was discontinued after conversion to paracorporeal LVAD.
- The patient remained supported by a durable LVAD for over 4 years before undergoing heart transplantation.
- The bridge-to-bridge strategy facilitated long-term survival and eventual heart transplantation.
Conclusions:
- Sequential mechanical circulatory support, including ECMO and LVADs, is a viable strategy for patients with acute aortic dissection and severe cardiopulmonary compromise.
- Meticulous surgical technique during bridge-to-bridge procedures is crucial for successful long-term outcomes.
- This approach can effectively bridge patients to heart transplantation, even in complex cases.
Abstract:
A 55-year-old woman developed Stanford type A acute aortic dissection complicated by occlusion of the left main coronary artery. The patient underwent an emergency ascending aortic replacement with concomitant coronary artery bypass grafting to the left anterior descending artery. Owing to extensive myocardial ischemia and the resultant severe cardiopulmonary impairment, the patient could not be weaned from the cardiopulmonary bypass. Therefore, central veno-arterial extracorporeal membrane oxygenation was initiated, with aortic perfusion via a branch of the ascending aortic graft and right atrial drainage. The central veno-arterial extracorporeal membrane oxygenation system was subsequently converted to a paracorporeal left ventricular assist device with an oxygenator, following which respiratory support was no longer required. The patient was listed for heart transplantation and underwent an elective conversion to a durable left ventricular assist device as a bridge-to-bridge strategy. During this operation, relocation of the outflow graft was necessary, and aortic valvuloplasty was performed simultaneously to address the mild residual post-dissection aortic insufficiency. Ultimately, the patient underwent heart transplantation more than 4 years after the bridge-to-bridge operation. An effective sequential mechanical circulatory support strategy, combined with meticulous technical management during bridge-to-bridge surgery, can successfully facilitate bridging to heart transplantation.
