Case report: Surgery combined with extracorporeal membrane oxygenation for a patient with type A aortic dissection complicated with myocardial infarction after percutaneous coronary intervention

Abstract

Background: Aortic dissection (AD) is a severe cardiovascular disease characterized by aortic rupture, aortic valve insufficiency, aortic branch lumen stenosis, and occlusion. Acute ST-segment elevation myocardial infarction may be the primary manifestation when aortic dissection affects the coronary artery, leading to delayed or missed diagnosis of aortic dissection, and preventing patients from receiving timely and comprehensive treatment. Simultaneous aortic repair and coronary artery bypass grafting surgery are controversial because of their high mortality rates. Personalized and optimal treatment plans for patients should be taken seriously based on their different conditions and treatment options.

Case presentation: A 42-year-old man who experienced 1 h of persistent precordialgia was admitted to a local second-level hospital for emergency treatment. Electrocardiogram (ECG) showed evidence of ST-segment elevation, and myocardial enzyme levels were CK-MB 18.35 ng/ml and troponin 0.42 ng/ml. The patient was treated for acute myocardial infarction (AMI) and urgently sent to the interventional catheter room. Coronary angiography showed stenosis of the starting part of the right coronary artery trunk. Thus, stent implantation was performed, and the stenosis section recovered patency; however, postoperative precordialgia was not alleviated. Computed tomography angiography (CTA) revealed a type A AD. The patient was immediately transferred to a higher-level hospital, underwent emergency surgery with cardiopulmonary bypass (CPB) ascending aorta replacement, SUN's procedure (total arch replacement and stented elephant trunk implantation), and simultaneous implantation of extracorporeal membrane oxygenation (ECMO), and regained consciousness within intensive care unit care. ECMO was discontinued when hemodynamics stabilized. The patient ultimately recovered well and was discharged.

Conclusion: This case demonstrated that precordialgia is not limited to myocardial infarction but may also be accompanied by aortic dissection. Percutaneous coronary intervention (PCI) can timely and effectively restore coronary artery perfusion, strive for the opportunity of aortic repair surgery, and can overcome pump failure caused by myocardial infarction, cardiopulmonary bypass, heart block time, and myocardial ischemia-reperfusion injury. Personalized treatment is crucial for patients with complex type A aortic dissection.

Keywords: SUN’s procedure; acute myocardial infarction; aortic dissection; case report; extracorporeal membrane oxygenation; percutaneous coronary intervention.

Figure 1

(A) Electrocardiogram (ECG) showing ST-segment elevation (II/III/aVF) and inferior acute myocardial infarction. (B) Coronary angiography showing irregular long-segment stenosis of the right coronary artery from the opening to the middle segment. (C) After stent implantation, the right coronary artery shows good morphology and an unobstructed vascular lumen.

Figure 2

Preoperative aortic CTA image. (A–D) CTA shows the false lumen of the ascending aorta compressing the true lumen, extending above the opening of the right coronary artery. They indicate a thick hematoma in the false lumen compressing the right coronary artery.

Figure 3

Postoperative aortic CTA image. (A) Artificial vessels in the aortic arch and the cephalobrachial artery are unobstructed. (B) Ascending aorta is unobstructed, and the stent is well dilated without internal leakage. (C) Opening of the right coronary artery is unobstructed, and stent implantation is visible. (D) Smooth morphology of the thoracic aorta.

Figure 4

Timeline of the case.