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Acute ascending aortic dissection complicating open heart surgery: cerebral perfusion defines the outcome
1Department of Cardiovascular Surgery, University Hospital Center, Lausanne, Switzerland. patrick.ruchat@chuv.hospvd.ch
Insights
Acute ascending aorta dissection (AAD) is a rare complication of open heart surgery. Prompt diagnosis and grafting improve prognosis, but prevention remains critical.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Surgical Complications
Background:
- Open heart surgery carries risks, including rare but severe complications.
- Acute ascending aorta dissection (AAD) is a potentially fatal complication following cardiac procedures.
Purpose of the Study:
- To assess the incidence and risks associated with acute ascending aorta dissection (AAD) after open heart surgery.
- To analyze outcomes and management strategies for iatrogenic AAD.
Main Methods:
- Retrospective analysis of 8624 cardiac surgical procedures performed between 1978 and 1997.
- Identification and review of 10 patients who developed secondary or iatrogenic AAD.
Main Results:
- AAD occurred in 0.12% of patients, with 7 cases intraoperative and 3 post-operative.
- Treatment involved grafting, plication, or aortic wrapping; mortality was 33% (3 patients).
- Intraoperative AAD can compromise supra-aortic artery perfusion.
Conclusions:
- Preventing AAD is a key aspect of standard cardiac surgical practice.
- Early diagnosis and surgical intervention, such as interposition grafting, are crucial for improving patient outcomes.
- Management strategies should address both intraoperative and postoperative AAD.
Objective:
This retrospective study was designed to assess the risks of acute ascending aorta dissection (AAD) as a rare but potentially fatal complication of open heart surgery.
Method:
Among 8624 cardiac surgical procedures under cardiopulmonary bypass (CPB) and cardioplegic myocardial protection from 1978 to 1997, 10 patients (0.12%) presented with a secondary or so called 'iatrogenic' AAD. There were seven men and three women, mean age 64 +/- 9 years, ranging from 47 to 79. The original procedures involved five coronary artery bypass grafts (CABG), one repeat CABG, one aortic valve replacement (AVR), one AVR and CABG, one mitral valvuloplasty (MVP) and CABG and one ascending aorta replacement. We retrospectively analyzed their hospital records.
Results:
Group I consisted of seven patients with AAD intraoperatively and group II consisted of three patients who developed acute AAD 8-32 days after cardiac surgery. In group I, treatment consisted of the original procedure, plus grafting of the ascending aorta in six patients and closed plication and aortic wrapping in one. In group II, two patients received a dacron graft and one patient developed lethal tamponnade due to aortic rupture before surgery. Postoperatively, six patients responded well and three died (33%), two patients from group I on the 2nd postoperative day with severe post-anoxic encephalopathy, and one from group II with severe peroperative cardiogenic shock.
Conclusion:
Preventing AAD with the appropriate means remains standard practice in cardiac surgery. If AAD occurs, it requires prompt diagnosis and interposition graft to allow a better prognosis. Intraoperative AAD happens at the beginning of CPB jeopardizing perfusion of the supra-aortic arteries.