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Fatal Complication of Type A Aortic Dissection

Pericardial Tamponade and Coronary MalperfusionCase Report

Dicky Aligheri, MD

National Cardiovascular Centre Harapan Kita,

Jakarta Indonesia 2014

• Disclosures : None

History• 46 yo female• History of uncontrole hypertension

and active smoking (>10 /d)• Abrupt onset (4 hours before admission)

– Chest pain– Unstable hemodynamic

• BP 88/35, HR 125 t/min, CVP 22• ECG : st elevation in lead II, III, aVF

• Lab : elevated D dimer level• Echo : RV hypokinetic, RA RV compression, Severe AI,

pericardial effusions

Operation Strategy

• Dissect all dissecting segment

• Elephant trunk insertion & arch replacement (4branched graft)

• Aortic valve & Root replacement (Mod Bentall)(composite graft)

• SVG to RCA

image5.pngimage5.png

Operation Strategy• Femoral & Bicaval Cannulation

• Retrograde CPG LCA Osteal SVG LAD

• LV venting

• Antegrade Selective Cerebral Perfusion-> Retrograde

• Systemic / Head cooling (DHCA)

Operative Finding• Hemopericardium, 850cc• Enlargement, bluish & hematoma of proximal

aorta & RVA ostium area• Intimal tear from aortic root to distal aortic arch

incl inominate artery. • Prolapse of All Aortic valve leaflets• Collapse RCA ostium

• Coagulopathy

• CPB weaning difficulties– Pump failure (RV mci)– Exc vasodilatation– IABP– SVG to LCX

• Coagulopathy

• CPB weaning difficulties– Pump failure (RV mci)– Exc vasodilatation– IABP– SVG to LCX

NTG 0.5Dop 12.5Epi 0.1Norepi 0.2IABPRV pacingABP 80/55 HR 100x/min on beat CVP 12

Urin output (-)Acidotic (BE -11)

• Coagulopathy

• CPB weaning difficulties– Pump failure (RV mci)– Exc vasodilatation– IABP– SVG to LCX

NTG 0.5Dop 12.5Epi 0.1Norepi 0.2IABPRV pacingABP 80/55 HR 100x/min on beat CVP 12

ECG changes LCATrop I ElevAnterior RWMA

Acute type A aortic dissection • The incidence of aortic dissection 5 to 30 cases per million

people per year,

• requires immediate surgical intervention • can be complicated by pericardial tamponade and malperfusion

(coronary, cerebral, renal, limb)

• the overall mortality in type A dissection was almost 3 times higher in the group with malperfusion (45- 66%) than with no malperfusion (15 – 22%%).

Ann Cardiothorac Surg 2013;2(2):205-211J Emerg Trauma Shock. 2011 Apr-Jun; 4(2): 273–278Circulation. 2004;90:2375-2378

Discussions

Discussions

Contin Educ Anaesth Crit Care Pain (2010) 10 (5): 138-142. doi: 10.1093/bjaceaccp/mkq024

Problems• Unstable pre op hemodinamik

– Preop optimized?• Myocardial infarction

– Heparin?• Myocardial protection

– All coronary perfusion?• CPB weaning difficulties

– Assist device– Excessive vasodilatation

• Coagulopathies– Effect on bypass graft

http://heart.templehealth.org/content/aortic_dissections.htm

Pericardial Tamponade

• cardiac tamponade complicating acute aortic dissection is associated with a high early mortality

• Performing pericardiocentesis may instead precipitate hemodynamic collapse and death

• it should be considered a surgical emergency, and pericardiocentesis should be avoided while every effort is be made to proceed as urgently as possible to the operating room

Pericardial Tamponade

JAMA. 2000 Feb. 16;283(7):897–903. PMID 10685714.Thorac. Cardiovasc. Surg. 2001 Mar.;121(3):552–560. PMID 11241091

Am. J. Cardiol. 2009 Apr. 1;103(7):1029–1031. PMID 19327436Circulation. 2012 Sep 11;126(11 Suppl 1):S97-S101.

Postgrad Med J. 2012;88(1046):729-730.

Neri E, Toscano T, Papalia U, Frati G, Massetti M, Capannini G, et al. Proximal aortic dissection with coronary malperfusion: presentation, management, and outcome. J. Thorac. Cardiovasc. Surg. 2001 Mar.;121(3):552–560

Coronary Malperfusions

Coronary Malperfusions

CONCLUSION•Acute type A aortic dissection complicated with pericardial tamponade and coronary malperfusion is a devastating event. It is associated with a high early mortality and extremely high mortality rate over the first 24 to 48 hours

•In tamponade, pericardiocentesis should be avoided

•In patients with coronary malperfusion, most patients received CABG and ascending / root aortic replacement because of its simplicity

Thank You