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Ruptured aortic dissection after aortic valve replacement (AVR) is uncommon and rarely diagnosed premortem. We report a patient with a ruptured type I aortic dissection and biatrial tamponade 2 months after AVR caused by loculated intrapericardial hematoma. The diagnosis was made by transthoracic echocardiography and confirmed at operation.
Aortic dissection is the most common acute disease of the aorta. It can occur in different clinical ways depending on the particular anatomical segments involved. The sudden appearance of claudicatio in the lower limbs may be indicative.
During the last year, the role of noninvasive studies for aortic dissection--magnetic resonance imaging, computed tomography scanning, and transesophageal echocardiography--has become better defined. Both magnetic resonance imaging and transesophageal echocardiography are highly accurate in detecting aortic dissection. On transesophageal echocardiographic imaging of the ascending aorta, artifacts may be present that mimic an intimal flap (septum). These linear echo densities have characteristic features which distinguish them from a true intimal flap (septum). Their recognition is critical in avoiding false positive transesophageal echocardiography findings. The general consensus on operations for ascending aorta and aortic arch dissection is that patients should be operated upon immediately. Controversy still remains, however, as to whether the aortic arch needs replacement at the time of the ascending and proximal aortic arch repair. Most authors agree that deep hypothermia with circulatory arrest is the preferable technique for acute aortic dissection repair and for surgery on the aortic arch in adults. Retrograde perfusion of the jugular veins is an added advantage. For acute aortic dissection involving the descending thoracic or thoracoabdominal aorta, evidence continues to accumulate that initial medical therapy with beta-blockers and antihypertensives is the preferable mode of treatment unless complications requiring surgery arise. Percutaneous techniques are increasingly being described, including fenestration of the aortic dissection septum, stenting of the aorta or aortic branches, and insertion of intraluminal aortic tube grafts. The safety of surgery on the thoracoabdominal aorta and on the descending thoracic aorta, including the prevention of complications, is reviewed.
Aortic dissection (AD) is a disease with a high-risk of mortality. Late deaths are often related to complications in nonoperated aortic segments. Between 1984 and 1996, we retrospectively analyzed the data of 109 patients with acute AD (81 men and 28 women; average age 61 +/- 14 years). All imaging examinations were reviewed, and a magnetic resonance imaging examination was performed at the time of the study. Aortic diameters were measured on each aortic segment. Predictive factors of mortality were determined by Cox's proportional hazard model, in univariate and multivariate analyses, using BMDP statistical software. Follow-up was an average of 44 +/- 46 months (range 24 to 164). Actuarial survival rates were 52%, 46%, and 37% at 1, 5, and 10 years, respectively, for type A AD versus 76%, 72%, and 46% for type B AD. Predictors of late mortality were age >70 years and postoperative false lumen patency of the thoracic descending aorta (RR 3.4, 95% confidence intervals 1.20 to 9.8). Descending aorta diameter was larger when false lumen was patent (31 vs 44 mm; p = 0.02) in type A AD. Furthermore, patency was less frequent in operated type A AD when surgery had been extended to the aortic arch. Thus, patency of descending aorta false lumen is responsible for progressive aortic dilation. In type A AD, open distal repair makes it possible to check the aortic arch and replace it when necessary, decreases the false lumen patency rate, and improves late survival.
Aortic branch occlusion may constitute the mode of presentation or become an important focus of treatment in patients sustaining acute aortic dissection. We reviewed the outcome of 187 consecutive patients (149 males and 38 females, mean age 58 yrs) with acute dissection of the thoracic aorta who were admitted and operated in our clinic during a 13-year period. We assessed the incidence, the consequences and the specific management of stenotic and obstructive lesions of the aorta and its branches. Noncardiac vascular complications occurred in 59 patients (32%); out of these complications, 38 were associated with dissection type A (incidence 28%) and 21 with dissection type B (incidence 48%). Trend towards decreasing overall surgical mortality was observed in the second part (1983-1989) of the study when compared with the first part (1977-1982): it was 28% versus 12%. Although aortic rupture and cardiac tamponade were the strongest correlate of morbidity and mortality, death specifically related to vascular complication was more common when such malperfusion occurred in the carotid, coelio-mesenteric and renal circulation. Proximal aortic repair at the site of the intimal tear with obliteration of the false lumen may have restore adequate distal circulation in 27 patients in whom improvement of the visceral or peripheral ischemia was observed after the thoracic aortic repair. Additional procedures (immediately after the thoracic repair or later on) were necessary in 15 patients to restore adequate perfusion in the compromised area. Early aggressive thoracic aortic repair followed in selected patients by additive vascular procedures can save some patients with compromise visceral or peripheric circulation.(ABSTRACT TRUNCATED AT 250 WORDS)
From a disease that just a few decades ago carried an ominous prognosis, aortic dissection has become a highly treatable condition. Similar development has occurred in regard to the treatment of thoracic aortic aneurysms. Treatment options are medical, surgical, or endovascular. Aortic dissection always presents as a hypertensive emergency and requires parenteral antihypertensive agents to control blood pressure (BP) and prevent target organ damage. Diligent control of BP is of utmost importance in order to stop the progression of dissection with possible aortic branch malperfusion. Treatment for hypertensive emergency begins in the intensive care unit and continues during and after surgery. Improved surgical techniques as well as newer, safer agents that reduce BP to acceptable levels have reduced the risk of mortality and improved prognosis in the postoperative period. Nevertheless, mortality rates remain high, and successful management of aortic dissection and aortic aneurysm still poses a clinical challenge.
A case of acute aortic dissection (Stanford Type A) with severe aortic regurgitation successfully treated by postoperative ECMO was reported. The patient was 41-year-old man in shock condition and was transferred to Kobe University Hospital. Chest CT scan and echocardiogram revealed acute aortic dissection with severe aortic regurgitation. An emergent operation by Collins' method and resuspension of aortic valve were carefully performed. Consequent ECMO was necessitated because of postoperative left ventricular and respiratory failure. Thereby, ECMO using heparin-coated CBAS-MAXIMA membrane oxygenator, centrifugal pump, and tubes was established by arterial cannulation via the anastomotic site of the ascending aorta to prevent the obstruction of the aortic true lumen by the false lumen which may be enlarged by retrograde perfusion via the femoral artery. Left ventricular function and pulmonary function were improved after 6 hours and 20 minutes, thus ECMO was successfully weaned without any complications.
Type A aortic dissection occurs in 0.6% of patients late after aortic valve replacement. However, little information is available about risk factors for developing this complication, nor are recommendations for elective replacement of the ascending aorta available. The authors present a 78-year-old woman who developed type A aortic dissection thirty months after aortic valve replacement; ascending aorta was normal at the time of aortic valve replacement.
Twenty-four cases of acute type-A aortic dissection with aortic valvular insufficiency were treated in our institution by means of an emergency operation in which the aortic valve, ascending aorta, and aortic arch were resected and replaced with a valved conduit that had been lengthened with a tubular Dacron graft. The procedure included the use of deep hypothermia for cerebral protection, as well as extracorporeal circulation. Aortic resection was performed from the aortic valve to the origin of the descending thoracic aorta; the aortic graft was anastomosed proximally to the valve annulus and distally to the descending aorta. The carotid orifices were connected to the side of the graft in a single tissue button. The coronary arteries were then reconnected by means of double venous bypass grafts to the innominate artery, to allow for inclusion of the graft. Within 1 month after operation, four patients died of the consequences of dissection. Six months postoperatively, one patient succumbed to an infarction. Six months to 5 years after operation, the remaining 19 patients are still alive. On the basis of this experience, we believe that acute type-A aortic dissection with aortic valvular insufficiency should be treated during the first hours after the onset of symptoms. The above-described procedure proved effective in the control of bleeding, which is the major risk in emergency operations of this type.
OBJECTIVE: Diagnostic work-up and treatment strategies have improved the prognosis of acute thoraco-abdominal aortic dissection. Little attention to aortic branch artery ischemia or even failed restoration following prosthetic repair of thoraco-abdominal dissection still merit a problem with high morbidity and mortality. SETTING: Department of Vascular Surgery, Technische Universität München, Germany. PURPOSE: Reflecting on visceral and neurological ischemic complications in acute thoraco-abdominal aortic dissection indications and limitations of the abdominal-aortic-fenestration procedure are discussed with a review on our own clinical experience and the results reported in the literature. CONCLUSIONS: The abdominal-aortic-fenestration procedure is accomplished with minimal deterioration of the critically ill patient. In new onset or relief of aortic branch ischemia, following initial prosthetic repair of either type A or B dissection aortic fenestration is found to be an effective and secure adjunctive procedure to restore the blood flow of compromised organs. Primary abdominal aortic fenestration is recommended instead of prosthetic repair in cases of acute type B dissection. It is the treatment of choice because of branch artery ischemia becoming the focal point of deterioration.
Congenital bicuspid aortic valve is a risk factor of aortic dissection, but the case is rare in Japan. Several reports described ascending aortic aneurysm after aortic valve replacement. In these reports, most of aneurysms were false aneurysm, but the cases of ascending aortic dissection were rare. In this case, dissecting aneurysm of the ascending aorta occurred 4 years after aortic valve replacement, which was performed with mechanical prosthesis because of infective endocarditis, and it was repaired successfully by the modified Cabrol's method. This case was congenital bicuspid aortic valve, and had already been complicated with moderate aortic dilatation in the ascending aorta. In patients of congenital bicuspid aortic valve with aortic dilatation, consideration of complete replacement of the ascending aorta with aortic valve replacement is important.
Little information is available regarding the incidence of aortic dissection after previous aortic valve replacement (AVR), and factors associated with its development. Therefore, a meta-analysis of the literature was performed, and a patient population was studied retrospectively. Data from published studies showed that 87% of 31 patients were men (mean age 60 years), and 68% were known to have systemic hypertension. A dilated ascending aorta was observed at the time of AVR in 88% of patients. AVR was performed because of pure aortic regurgitation in 55% of patients, and combined aortic stenosis and regurgitation in 23%. More than 50% of patients did not survive dissection. The present series consisted of 7 patients. Four patients were known to the department before dissection occurred, and the other 3 were referred by other hospitals. Eighteen of 330 patients with previous AVR whose data were stored in an echocardiographic data base had an ascending aortic diameter > 50 mm. Of these 18 patients, aortic dissection occurred in 4. Three of the remaining 14 patients underwent elective ascending aortic replacement. Characteristics including sex, age, severity of dilatation, presence of progression in diameter, left ventricular function and time interval after AVR were not helpful in determining a cumulative risk for developing dissection. Because dissection occurred in 4 of 18 patients (22%) with an ascending aorta diameter > 50 mm, it is suggested to consider replacement of the ascending aorta during AVR when a value of 50 mm is exceeded.
A 58-year-old Japanese woman who had a history of aortic valve replacement for congenital bicuspid valve, was admitted for investigation of facial edema and of pulselessness of the right leg. Physical examination disclosed the patient suffering from a superior vena cava syndrome. On auscultation, a continuous murmur was heard at the left lower sternal border. Computed tomographic scans revealed aortic dissection extending from the ascending aorta to the bifurcation. Echocardiography showed an intimal flap in the dilated ascending aorta, but not abnormal blood flow from the aorta to the right atrium was detected. Cardiac catheterization and aortography, however, allowed a correct diagnosis of aortic dissection with fistula to the right atrium and with obstruction of the right common iliac artery. The patient received emergency aortic root replacement and reconstruction of the coronary arteries and then recovered uneventfully.
A 74-year-old man underwent standard aortic valve replacement. The aortotomy was closed by use of strips of Teflon felt because of somewhat friable thin aortic wall. After the termination of cardiopulmonary bypass, aortic cannulation site was carefully sutured enforcing with a piece of pericardium, since some bleeding persisted. The intraoperative diagnosis of acute aortic dissection (Stanford type A) was made with transesophageal echocardiography. Since extension of the dissection toward the aortic root was hardly possible due to the Teflon felt enforced aortotomy closure, further surgical intervention was not considered at this time. Thiry-two hours later after admission to CCU, sudden bleeding through the mediastinal tube prompted the patient back to OR for exploration Bleeding was noted from the posterior wall of the ascending aorta. Ascending aorta and transverse arch were significantly enlarged with notable discoloration. With the aid of extracorporeal circulation and selective cerebral perfusion, the total graft replacement of the ascending aorta and aortic arch was performed. The intimal tear located at the aortic cannulation site. The postoperative course was uneventful. Prompt recognition and appropriate surgical management are necessary to improve patient outcome.
AIM: The standard approach for treating acute Type A aortic dissections (TAD) is replacement of the ascending aorta utilizing hypothermic circulatory arrest (HCA), which is associated with significant morbidity and frequently leaves a residual aortic arch dissection. We describe a staged surgical and endovascular technique of ascending aorta replacement and simultaneous aorto-innominate artery bypass without HCA, followed 4 weeks later by carotid-carotid bypass and endovascular exclusion of the remaining arch dissection with a thoracic endograft. METHODS: From December 2004 to December 2005, 5 consecutive patients (mean age 58 +/- 6.9 years) with TADs underwent the staged procedure. All patients underwent replacement of the ascending aorta and aorto-innominate bypass. Two patients subsequently underwent the second endovascular stage. In one patient the aortic false lumen completely thrombosed following the first surgical stage and two patients are currently awaiting the endovascular stage. RESULTS: There were no major adverse events (death, cerebrovascular accident or paraplegia) following the first surgical stage. One patient suffered a transient minor stroke. The 2 patients who underwent the second endovascular stage showed no immediate adverse events. Postoperative CT scans have demonstrated that the false channel was excluded from the aortic arch down to the distal end of the endograft in the descending aorta in each case, but became patent further downstream. CONCLUSIONS: This procedure appears safe and feasible. It may allow for a more definitive treatment of TADs than the standard surgical approach. It can be adapted by low volume centers, surgeons untrained in aortic arch repair, and in high risk patients.
OBJECTIVES: To prove whether different indications for valve sparing aortic root reconstruction may have an impact on the outcome and longevity of the repair. METHODS: From July 1993 to March 2003, the reimplantation technique for valve sparing aortic root reconstruction was applied to 232 patients. In 44 patients, indication for operation was acute aortic dissection type A (AADA). These patients were compared with 44 randomised patients operated for aortic root aneurysm (root) by matched pair analysis with respect to age, gender, time point of operation and presence of Marfan's syndrome. Peri- and post-operative courses with focus on survival and valvular stability were analysed. RESULTS: Pre-operative grade of aortic insufficiency was 2.4+/-1 in root vs. 1.5+/-1.7 in AADA (P = 0.004) Mean CPB-time (214+/-60 vs. 171+/-42 min;P < 0.001), aortic cross clamp time (158+/-40 vs. 129+/-39 min; P = 0.001) and stay on ICU (5.2+/-9 vs. 1.7+/-1 days; P = 0.034) were longer for AADA, while hospitalisation was comparable (14+/-10 vs. 14+/-7 days; P = 0.88). Five patients (11.4%) from AADA died peri-operatively compared to no patient from root (P = 0.055). None of the early deaths were valve-related. Re-thoracotomy rate was 6.8% for both groups. Mean follow-up was 19+/-21 months for AADA vs. 28+/-21 months for root (P = 0.038) Survival at 3 years was 88+/-5% for AADA and 100% for root (P = 0.028). Freedom from valvular reoperation was 97+/-2.7% for root and 97+/-3% for AADA at 3 years (P = 0.44). At last investigation, mean grade of aortic insufficiency for AADA was 0.2+/-0.3 compared to 0.3+/-0.3 for root (P = 0.34) CONCLUSIONS: Regardless of the underlying indication, the aortic valve preserving reimplantation technique can be performed with favourable functional results.
From 1986 to 1994, 10 patients were observed to have developed an acute aortic dissection at some stage after an aortic valve replacement (AVR). Study of the characteristics of these patients showed that all patients had an aortic diameter of 50 mm or more (range 50 to 80 mm, mean 64 mm), and 70% suffered from systemic hypertension. Subsequently, the echocardiographic database, containing data from 33,105 studies in 21,484 patients, was searched for cases of AVR in which an accurate aortic dimension could be measured. Of 524 patients who had undergone AVR, an accurate aortic diameter was recorded in 419. Thirty-seven patients had an aortic size greater than 50 mm. All acute dissections occurred in this group of patients. The incidence of acute dissections among patients with significant aortic dilatation following AVR was 27%, whereas the overall incidence of acute dissection after AVR is 0.6%. Although there was a preponderance of tilting disc mechanical valves in the dissecting patients, the type of valve implanted does not seem to be of any importance. From these observations, we conclude that implantation of a valved conduit is indicated even in the presence of mild annuloaortic ectasia (aortic size = 50 mm). Patients who have had an AVR and show an enlarging aortic diameter exceeding 50 mm should have an elective reoperation at an early stage, especially when systemic hypertension is present.
It is presented the case of acute type II aortic dissection in a patient with aneurysmal ascending aorta, hypoplastic arch and isthmic coarctation. One single step replacement of the ascending aorta, arch and the isthmus was performed by ensuring simultaneous optimal perfusion above and below the coarctation through the femoral and subclavian artery.