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J Thorac Cardiovasc Surg 2001;121:552-560
© 2001 The American Association for Thoracic Surgery

Cardiopulmonary Support and Physiology

Proximal aortic dissection with coronary malperfusion: Presentation, management, and outcome

From the Istituto di Chirurgia Cardiovascolare^a Università agli Studi di Siena, Unita' Operativa di Chirurgia dell' Aorta Toracica, Istituto di Istituto di Chirurgia del Cuore e Grossi Vasi,^b Università "La Sapienza," Rome, Italy.

Received for publication July 12, 2000. Revisions requested Sept 7, 2000; revisions received Oct 6, 2000. Accepted for publication Oct 26, 2000. Address for reprints: Eugenio Neri, MD, Istituto di Chirurgia Cardiovascolare Universita' agli Studi di Siena, Policlinico le Scotte, Viale M. Bracci, 53100 Siena, Italy (E-mail: euxneri{at}tin.it nerie@unisi.it).

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.

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