Type A Aortic Dissection Following Heart Transplantation

Abstract

Cannulation strategies in aortic arch surgeries are a matter of immense discussion. Majority of time deep hypothermic circulatory arrest (DHCA) is the way out, but it does come with its set of demerits. Here we demonstrate a case with aortic arch dissection dealt with dual cannulation strategy in axillary and femoral artery without need for DHCA and ensuring complete neuroprotection of brain and spinal cord without hinderance of time factor. Inception of new ideas like this may decrease the need for DHCA and hence its drawbacks, thus decreasing the morbidity and mortality associated.

Keywords: Catheterization; Deep Hypothermia Induced Circulatory Arrest; Neuroprotection, Aortic Diseases; Thoracic Aorta; Thoracic Aorta Dissection.

Fig. 1

Transthoracic echocardiogram performed before surgery. A) Aortic valve and sinotubular junction. B) Ascending aorta aneurysm. C) and D) Distal portion of ascending aorta and Doppler color suggesting dissection.

Fig. 2

Thoracic aortic angiography. Dissection flap associated with native ascending aortic aneurysm with normal aortic valve ring. A) Relation of the aortic aneurysm with right lung. B) Origin of left main coronary artery and bifurcation. C) Right coronary artery origin. D) and E) Origin and end of the ascending aorta.

Fig. 3

The anterior and sides of the aortic ascending aneurysm have been removed. Forceps are keeping together the aortic wall layers. Between them, right coronary artery ostium (black arrow) is visualized. Trileaflet aortic valve with excellent coaptation is observed, and the donor sinotubular junction is normal size. The posterior wall of the ascending aorta has not been dissected, and the recipient-donor aorta anastomosis suture line is shown (dash arrows). A circulatory arrest has been established at moderate hypothermia, and antegrade cerebral perfusion has been resumed by direct cannulation of the right and common carotid arteries (blue arrows).

Fig. 4

Replacement of the ascending aorta: proximal anastomosis is performed in the donor side aortic wall, and hemiarch (distal anastomosis) is completed with a 30 mm Dacron® graft tube and inclusion technique in the recipient aortic side (signaled by the arrows showing recipient aortic posterior wall remnants).