Proximal aortic dissection with coronary malperfusion: presentation, management, and outcome.
BACKGROUND
Acute myocardial ischemia and infarction due to retrograde dissection of the aortic root reaching the coronary ostia is a potentially fatal condition. Surgical treatment of these patients relies on the re-establishment of an adequate coronary blood flow and on the rescue of jeopardized myocardium. This article reports the results of a selected group of 24 patients with type A acute aortic dissection and coronary artery dissection. We review our experience and illustrate our approach to this condition, which evolved over a 15-year period.


METHODS
Between July 1985 and March 2000, 24 patients from a total of 211 (11.3%) treated for acute type A aortic dissection had dissection of at least one of the coronary ostia. There were 14 men and 10 women. The mean age was 65.5 years (median 61.7; range 41-78 years). The right coronary artery was involved in 11 patients, the left in 4 patients, and both coronary arteries in 9 patients. At admission, 16 patients had Q waves (66%), inferior in 6 (25%) and anterior, lateral, septal, or posterior in 10 (41%). All procedures were done on an emergency basis within 10 hours (median 4 hours) after initial chest pain and within 2 hours after the patient's arrival.


RESULTS
Hospital mortality was 20% (5 patients); 3 patients could not be weaned from cardiopulmonary bypass and died intraoperatively, and 2 patients died postoperatively of low cardiac output.


CONCLUSIONS
As illustrated in this study, direct coronary repair is a safe alternative to bypass grafting. Aggressive myocardial resuscitation together with early operation is a key factor in the management of these patients.
Neri
E
E
Istituto di Chirurgia Cardiovascolare Università agli Studi di Siena, Unita' Operativa di Chirurgia dell' Aorta Toracica, Istituto di Istituto di Chirurgia del Cuore e Grossi Vasi, Università "La Sapienza," Rome, Italy. euxneri@tin.it
Toscano
T
T
Papalia
U
U
Frati
G
G
Massetti
M
M
Capannini
G
G
Tucci
E
E
Buklas
D
D
Muzzi
L
L
Oricchio
L
L
Sassi
C
C
D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000453:epidemiology / Q000401:mortality / Q000601:surgery*; D001014:Aortic Aneurysm / Q000453:epidemiology / Q000401:mortality / Q000601:surgery*; D015897:Comorbidity; D003323:Coronary Aneurysm / Q000453:epidemiology / Q000401:mortality / Q000601:surgery*; D005260:Female; D006324:Heart Arrest, Induced; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors