Coronary malperfusion due to type A aortic dissection: mechanism and surgical management.
BACKGROUND
Coronary malperfusion associated with aortic dissection is relatively rare, but when it occurs, it is fatal to the patient. To salvage such moribund patients, aggressive coronary revascularization concomitant with aortic repair is essential. We review the surgical results and mechanism of malperfusion in a group of 12 patients with coronary malperfusion caused by type A aortic dissection, and we discuss our surgical approach.


METHODS
Between March 1990 and March 2003, 12 patients (6.1%) from a total of 196 consecutive patients with acute type A aortic dissection undergoing surgery suffered coronary malperfusion associated with the dissection. There were 4 men and 8 women (mean age, 60.8 +/- 8.3 years). Nine patients had acute myocardial infarction due to dissection before surgery, and 3 patients suffered coronary malperfusion after aortic declamping.


RESULTS
Hospital mortality rate was 33.3% (4 patients). The mortality rate was higher than that in patients without coronary malperfusion (33.3% vs. 8.2%, p = 0.019). Three patients could not be weaned from cardiopulmonary bypass, and 1 patient died of heart failure in the intensive care unit. Involved coronary arteries included the right coronary artery (8 patients), left coronary (2 patients), and both (2 patients). Mechanisms of coronary obstruction were compression (2 patients), coronary dissection (7 patients), and coronary disruption (3 patients). Coronary artery bypass grafting was performed concomitant with aortic repair.


CONCLUSIONS
Acute type A aortic dissection with coronary involvement is associated with high mortality rate, aggressive coronary revascularization and early aortic repair with simple techniques are necessary to salvage these critically ill patients.
Kawahito
Koji
K
Department of Cardiovascular Surgery, Omiya Medical Center, Jichi Medical School, Saitama, Japan. kawahito@omiya.jichi.ac.jp
Adachi
Hideo
H
Murata
Sei-ichiro
S
Yamaguchi
Atsushi
A
Ino
Takashi
T
D000368:Aged; D000784:Aortic Dissection / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000601:surgery*; D000792:Angiography / Q000379:methods; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000601:surgery*; D015897:Comorbidity; D017023:Coronary Angiography / Q000379:methods; D001026:Coronary Artery Bypass / Q000379:methods / Q000401:mortality; D003327:Coronary Disease / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality; D011336:Probability; D012189:Retrospective Studies; D018570:Risk Assessment; D012494:Sampling Studies; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods / Q000401:mortality