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.
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
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Toscano
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Capannini
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Buklas
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Sassi
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