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Ann Thorac Surg 2003;76:1476
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Invited commentary

^a 1st Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu 431-3192, Japan

e-mail: tkazui{at}hama-med.ac.jp

Acute myocardial ischemia or infarction due to retrograde dissection extending into the coronary artery is not uncommon in acute aortic dissection, as witnessed by the 5%–10% incidence of this complication. Although emergent coronary revascularization associated with aortic repair is mandatory to salvage these critically ill patients, few reports have been published so far. Furthermore, it is well recognized that coronary malperfusion requiring concomitant CABG is one of the risk factors for early mortality in acute type A aortic dissection.

In 2001, Neri et al described the mechanism of coronary malperfusion in acute aortic dissection and divided it into three groups depending on the extension of coronary artery dissection. Neri claimed that direct coronary artery repair was preferable to CABG. Meanwhile, Dr Kawahito and colleagues advocate that CABG is a useful technique in revascularizing a dissected coronary artery regardless of the mechanism of coronary dissection, even though the number of patients is too small to draw a definitive conclusion.

I believe there are two technical issues here when dealing with revascularization of jeopardized myocardium. One is how to protect the myocardium in patients presenting with acute myocardial ischemia or infarction during the operation. Our way follows: after cardiopulmonary bypass is instituted, blood cardioplegia is administered retrograde via the coronary sinus, and also antegrade through the nondissected coronary ostium. Subsequently, after the dissected coronary artery is revascularized, blood cardioplegia is administered through the vein bypass graft. Controlled reperfusion after ischemia seems only rational.

The other issue is how to restore blood flow to the jeopardized myocardium. The surgical techniques used vary from local direct coronary repair to CABG, depending on the mechanism of the coronary dissection. Type A lesions with ostial dissection can be directly repaired. On the other hand, type B lesions with a coronary false channel or type C lesions with circumferential detachment and an inner cylinder intussception can both be treated by either direct coronary repair or CABG. If the dissection extends to the distal coronary artery, CABG is preferable to direct coronary repair.

CABG can be used in all types of coronary artery dissection, as suggested by Dr Kawahito and colleagues, but its potential disadvantages include complete graft-dependent perfusion of the myocardium, risk of closure of the vein graft attached to a woven Dacron graft, competitive flow, and coronary redissection.

Even with earlier referral for surgery and enhanced myocardial protection and refined surgical technique, which have all contributed to the improvement of surgical outcomes of acute type A dissection, the salvage rate in patients with extensive myocardial infarction remains dismal and is not likely to improve much. Therefore, it is advisable to establish exclusion criteria for emergency operation in these patients.

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Coronary malperfusion due to type a aortic dissection: mechanism and surgical management

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Ann. Thorac. Surg. 2003 76: 1471-1476. [Abstract] [Full Text] [PDF]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kazui, T. Search for Related Content PubMed Articles by Kazui, T. Related Collections Great vessels Related Article