[HSF] Aortic Dissection early after AVR with CABG

[Mark Levinson]

On May 15, 2008, at 7:17 AM, Igor Rudez wrote:

> Dear friends,
> Just to share my recent experience regarding this topic!

My 2 cents worth:

I have seen 3 such cases since beginning my OPCAB program, ... ...  
all died.    In my on-pump cases,
I have not had a peri-operative ascending dissection in almost 20  
years.    I do all my proximals under a single cross-clamp when
on pump.

However, when using a partial occlusion clamp for OPCAB, I had 3  
ascending dissections.    Two
died in the ICU within 1 day of surgery.    But.....the third patient  
was found dead at home by her family
about 1 week after surgery.    I was able to obtain the heart-lung  
block from the funeral home, and
performed the post-mortem myself (along with my pathologist).   The  
cause of death was a rupture of
the intima at the heal of RCA proximal, with the intima tearing away  
from the (otherwise intact) running
suture line causing an acute ascending dissection, and a full  
thickness perforation posterior to the left main.

In summary, I believe these are unstable lesions and should be  
operated on.    I cannot fault the wisdom
of Tom Martin who may have more experience with non-operative, or  
delayed operative management, but
I believe these can rupture.       Three weeks postoperative is a  
horrible time to re-operate for any reason, but
if anything is unstable, its an ascending dissection at the site of a  
proximal anastomosis.

If you use peripheral cannulation and lift the sternum with the  
Rultract to get safe access behind the inner table
of the sternum, I think you can get in safely and use circulatory  
arrest.    Then the ascending can be excised, leaving
an island where the proximals already exist.   If the dissection  
begins at a proximal anastomosis, then this graft will need
to be re-implanted.    If the entry site is somewhere else, maybe the  
graft island can be reimplanted as a whole.....



just my opinion.

Mark Levinson


> Two weeks ago operated on a 63-y.o. lady because of unstable  
> angina. As
> usually, I did OPCAB (LIMA to LAD, SVG OM2 jump OM1, SVG to PD) and  
> early
> postop course was uneventful. On the night prior to discharge she  
> suffered
> from hypertensive attack (systolic BP was over 250 mmHg!!!) which was
> treated with i.v. nitrates. She complained about strong pain in her  
> back, we
> did MSCT which showed dissection of asc.aorta from aortic valve  
> root till
> brachiocephalic trunk with moderate AR (2+). I did not hesitate  
> much, took
> her in the OR, replaced ascending aorta (circ arrest time 16 min),
> resuspended aortic valve, and reanastomosed venous proximals. There  
> was a
> tear in aortic wall originating from the graft for PD which caused
> dissection. At the end of surgery I checked graft flows and all  
> were well.
> She is off the ventilator and ready to leave ICU!
> Again Tohru, as Hal already said, I would not hesitate too much! In  
> fact, I
> would not hesitate at all!
> Anyway, good luck!
>
> Igor Rudez
>
>
> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com
> [mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of  
> Hgrmd at aol.com
> Sent: Thursday, May 15, 2008 1:14 PM
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] Aortic Dissection early after AVR with CABG
>
>
> Tohru,
>   I would operate know.  It will be much more difficult to do in  a  
> month.
> The natural history of this lesion is not favorable.
>   BTW, great seeing you in NY.
>
> Hal
>
>
>
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Mark Levinson, MD.
Founder, Editor-in-Chief
The Heart Surgery Forum®
Multimedia Cardiothoracic Journal
URL: http://www.hsforum.com
URL: http://newoptionsinheartsurgery.com
Emali:  mmlevinson at hsforum.com