Ann Thorac Surg 2003;76:1286-1287
© 2003 The Society of Thoracic Surgeons
Case report
Successful treatment for intraoperatively evolving acute aortic dissection in a neonate
Thomas Walther, MD, PhDa*,
Herbert Kiefer, MDb,
Ingo Dähnert, MDc,
Martin Kostelka, MD, PhDa
a Klinik für Herzchirurgie, Universität Leipzig, Herzzentrum, Leipzig, Germany
b Anästhesie, Universität Leipzig, Herzzentrum, Leipzig, Germany
c Kinderkardiologie, Universität Leipzig, Herzzentrum, Leipzig, Germany
Accepted for publication March 17, 2003.
* Address reprint requests to Dr Walther, Klinik für Herzchirurgie, Universität Leipzig, Herzzentrum, Strümpellstr 39, 04289 Leipzig, Germany
e-mail: walt{at}medizin.uni-leipzig.de
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Abstract
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Acute aortic dissection is a life-threatening condition. We report the case of a neonatal one-stage correction of coarctation and hypoplastic aortic arch repair plus ventricular septal defect closure. While dissecting the head vessels after cannulation of the ascending aorta and commencing cardiopulmonary bypass, type A aortic dissection evolved. This required immediate ascending aorta and aortic arch reconstruction with coarctation of the aorta resection under hypothermic circulatory arrest. The surgical management of this rather unique situation is discussed here.
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Introduction
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Acute aortic dissection is a life-threatening condition associated with significant morbidity and mortality. Furthermore, in the presence of intraoperatively evolving acute dissection, an immediate adjustment in the operative strategy as well as immediate reparative surgery is required. Successful surgical treatment of acute aortic dissection in neonates has not yet been described in the medical literature. Only one case report is available on aortic dissection after arterial cannulation for extracorporal membrane oxygenation [1]. Thus, the aim of this report was to present the successful surgical management of acutely evolving aortic dissection in a neonate.
A 9-day-old patient (3.1 kg, 53 cm) with perimembranous ventricular septal defect (VSD), coarctation of the aorta (CoA) with hypoplastic aortic arch (HyAA), and a persistent ductus arteriosus (PDA) was scheduled for one-stage surgical correction by median sternotomy. After opening the pericardium, extracorporeal circulation (ECC) was established with bicaval and distal ascending aorta/proximal aortic arch cannulation. Both 10F and 12F venous return cannulas and a 2-mm curved-tip arterial cannula (DLP) were applied. Extracorporeal circulation was started, cooling down the patient’s temperature towards at 24°C. During further mobilization of the head vessels, a sudden increase in arterial line pressure from 210 mm Hg up to above 400 mm Hg as well as myocardial ischemia and an enlargement of the ascending aorta and aortic arch were noticed. The aorta was immediately cross-clamped and transected 5 mm above the commissures. This proved the diagnosis of circular ascending and partial aortic arch dissection originating from the concave aspect of the proximal aortic arch just opposite the aortic cannula. The cannula was repositioned to the innominate artery, ECC recommenced with 30% flow, and the patient was further cooled down to 24°C. Cardioplegic arrest (St. Thomas solution, 30 mL/kg) was induced by direct delivery into the coronary arteries. The aortic arch was longitudinally incised at its concave aspect beyond the level of the CoA in the descending aorta. Then, the CoA was resected and a partial end-to-side anastomosis of the descending aorta to the aortic arch was performed. The incised aortic arch was reconstructed using an autologous pericardial patch to repair the concave aspect. The aortic root was repaired using a circular suture to stabilize the dissection; then, during rewarming, the ascending aorta was reanastomosed to the reconstructed aortic arch. Pulmonary artery banding was performed to not prolong the procedure. The patient was weaned from ECC and then transferred to intensive care unit. Cross-clamp duration was 66 minutes and total perfusion time was 152 minutes. Secondary chest closure was performed on postoperative day (POD) 1, and the patient extubated on POD 5 and discharged after 2 weeks. He had a normal neurologic recovery. Repeat cardiac catheterization 6 months postoperatively revealed moderate residual supraaortic stenosis (gradient, 25 mm Hg). At the age of 7 months, complete correction, namely VSD patch closure, patch enlargement of the ascending aorta, and pulmonary artery debanding with patch enlargement, was performed successfully.
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Comment
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Acute aortic dissection is an extremely rare condition in neonates. However, intraoperatively evolving acute dissection can emerge in the presence of an aortic cannula used for ECC. Successful treatment of such a condition in a neonate has not yet been reported in the medical literature. Thus, the major message of this unfortunate adverse event we experienced is that surgical therapy can be performed successfully. When realizing the evolving dissection intraoperatively, we were struck by brief hesitation as to whether such therapy is fruitful at all. However, due to the fact that we did not have any other therapeutic option, we choose to perform complete aortic arch and ascending aorta repair.
The direct mechanism causing this severe adverse event remains partially unclear. Extensive mobilization of the descending aorta was required in order to perform surgical repair for CoA efficiently. However, further mobilization of the aorta with a cannula in place may have led to tearing of the intima causing aortic dissection that originated just opposite the cannulation site. The presence of additional pathologic alterations of the aortic wall as cofactors remains speculative.
Having successfully performed surgical reconstruction of the aorta in this patient, pulmonary artery bonding was elected instead of VSD closure in order to avoid any further cardiac arrest. We thought that this approach was quite legitimate to avoid any additional risks after performing major corrective surgery under initially reduced perfusion criteria.
In summary, acutely evolving aortic dissection is a rare condition. Surgical repair can be performed successfully if an immediate change of the intraoperative strategy is performed.
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References
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- Paul J.J., Desai H., Baumgart S., Wolfson P., Russo P., Tighe D.A. Aortic dissection in a neonate associated with arterial cannulation for extracorporeal life support. ASAIO J 1997;43:92-94.[Medline]
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[Abstract]
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Abstract
Introduction
