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J Thorac Cardiovasc Surg 1994;107:314-315
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Repair of acute type A aortic dissection after cesarean section in the thirty-ninth week of pregnancy

Department of Thoracic and Cardiovascular Surgery
Department of Anesthesia^a
Hannover Medical School
Hannover, Germany

To the Editor:

Acute aortic dissection during pregnancy is a rare phenomenon. Because the operative treatment is complicated by concerns for the child's and mother's lives, we report here a case of successful repair during the thirty-ninth week of pregnancy.

A 31-year-old pregnant woman in her thirty-ninth week of pregnancy was referred for acute severe breast pain to the gynecology outpatient department. Initially, lung embolism was suspected because the patient's history revealed recurrent episodes of back pain with dyspnea and numbness of the left leg throughout the preceding days. Aortic insufficiency was detected by auscultation and transesophageal echocardiography was subsequently performed. Aortic insufficiency of grade III was verified and a flap in the ascending aorta was found. Minor pericardial effusion was present. Pulses in the left leg were impaired compared with those on the right side. Until this time, the patient's pregnancy had been uneventful, with a healthy fetus located in the normal position and with a cranial biparietal diameter of 8.6 cm and an estimated weight of 3.2 kg.

Operation was planned as a cesarean section with subsequent aortic repair. With the patient under local anesthesia, a central venous line, a left femoral artery, and a right radial artery were placed. Hypertension was controlled with nitroglycerin infusion. Despite treatment, the patient had systolic blood pressures of more than 160 mm Hg. Anesthesia was introduced and intubation was performed concomitant with the cesarean section. After median laparotomy, a healthy child with Apgar scores of 8 at 1 minute, 9 at 5 minutes, and 9 at 10 minutes was born without problems. The cervix was dilated and the uterotomy was closed with single sutures.

After temporary closure of the abdomen, the right femoral artery was cannulated. The thorax was subsequently opened. Minor hemorrhagic pericardial effusion was present and the ascending aorta showed signs of aortic dissection, without evidence of enlargement. The heart was beating in sinus rhythm. The patient was placed on cardiopulmonary bypass by means of a two-stage catheter in the right atrium. A vent catheter was applied through the right lower pulmonary vein. Rapid cooling was instituted. After aortic opening, a tear 2 cm distal to the noncoronary aortic cusp and 2 cm in width was detected, representing the proximal entry. Dissection was semicircular, resulting in the observed aortic insufficiency. After infusion of 1 L St. Thomas' Hospital cardioplegic solution, the aortic basis was reconstructed with Resorcin-Formalin glue (Trigon GmbH, Mönchengladbach, Germany). ¹ After a nasopharyngeal temperature of 22° C was reached, the extracorporal circulation was stopped and the aortic arch was inspected. The dissection continued into the supraaortic branches. After total separation of the aortic arch, glue was used for the reattachment of the aortic layers. A 26 mm vascular prosthesis was then sutured into the aortic arch. After evacuation of residual air, extracorporeal circulation was restarted and antegrade perfusion through the prosthesis was initiated with a second arterial line. Finally, the prosthesis was reanastomosed to the repaired ascending aorta. Bypass was discontinued without any problems after a bypass time of 74 minutes. The total aortic crossclamp time was 41 minutes, with a circulatory arrest of 16 minutes. Postoperative recovery was uneventful with respect to hemodynamic status; however, the patient needed repeated bronchoscopic treatment for atelectasis of the left lower lobe. The patient was extubated 36 hours after the procedure. Histologic examination of the aortic material revealed mucoid degeneration of the media. Subsequent Doppler-flow examination of the abdominal aorta showed unimpaired flow characteristics in all intraabdominal arteries. Pulses were identical in the lower extremities.

This report of a successful intervention for acute aortic dissection during pregnancy demonstrates several important points of the disease. Primarily, dissection during pregnancy is rare. A review of the literature revealed only two cases showing a similar time pattern. ^2,3 Because the operative strategy inaortic dissection meanwhile has been established, ¹ one of the most important problems remains the accurate diagnosis of the disease in these special circumstances. On the basis of our experience, we think that transesophageal echocardiography represents the most effective tool with respect to accuracy and avoidance of side effects. The intraoperative procedure is complicated only with regard to anesthesiologic and coagulatory problems. ⁴ Aggressive blood pressure control until delivery seems mandatory, to prevent aortic rupture. In addition, median laparotomy seems advantageous because the cesarean section can be performed easily and adequate visualization of the intestine and liver is facilitated by laparotomy. Finally, the application of a uterotonic drug after extracorporeal circulation is relevant to hemostasis. With these guidelines, the repair of the aorta in the last part of pregnancy presents a risk comparable with that in other time periods.

References

1. Laas J, Jurmann MJ, Heinemann M, Borst HG. Advances in aortic arch surgery. Ann Thorac Surg 1992;53:227-32.[Abstract/Free Full Text]
   
2. Ayzenberg O, Oettinger M, Kracoff OH, Caspi A, Salomon J. Aortic dissecting aneurysm during pregnancy. Harefuah 1990;118:201-3.[Medline]
   
3. Maruyama Y, Oguma F, Kosuge T, Yokoswa T, Eguchi S. Successful repair of an acute type A dissection during pregnancy. Harefuah 1990;38:2296-9.
   
4. Hayashi M, Terai T, Nishikawa K, Yukioka H, Fujimori M. General anesthesia for cesarean section in a patient with Marfan's syndrome associated with dissecting aortic aneurysm. Masui 1991;40:622-6.[Medline]
   

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