doiSerbia

Acute type A aortic dissection - a case beyond the guidelines

Kočica Mladen J. (Clinical Centre of Serbia, Clinic for Cardiac Surgery, Belgrade, Serbia + University of Belgrade, Faculty of Medicine, Belgrade, Serbia), kocica@sbb.rs
Karadžić-Kočica Milica M. (Clinical Centre of Serbia, Clinic for Cardiac Surgery, Belgrade, Serbia + Clinical Centre of Serbia, Centre for Anesthesiology, Reanimatology and Intensive Therapy, Belgrade, Serbia)
Cvetković Dragan D. (Clinical Centre of Serbia, Clinic for Cardiac Surgery, Belgrade, Serbia + University of Belgrade, Faculty of Medicine, Belgrade, Serbia)
Grujić Miloš B. (Clinical Centre of Serbia, Clinic for Cardiac Surgery, Belgrade, Serbia + University of Belgrade, Faculty of Medicine, Belgrade, Serbia)
Lavadinović Lidija (Clinical Centre of Serbia, Clinic for Infectious and Tropical Diseases, Belgrade, Serbia + University of Belgrade, Faculty of Medicine, Belgrade, Serbia)

Introduction. There are not many cases among acute type-A aortic dissection survivors who get to be called “incredible.” Here we present such a case followed-up for more than five years. Case outline. A 48-year-old male with acute type A aortic dissection, complicated with cardiac tamponade and severe aortic valve regurgitation, was submitted to emergent surgical treatment. Distal reconstruction was performed by complete aortic arch replacement with “elephant trunk” extension and separate arch branch bypasses, while the proximal reconstruction was done with Bentall procedure. Total of 11 anastomoses was necessary to complete this procedure. Straight profound hypothermic (18o C) circulatory arrest, with a saturation of the venous blood from the jugular bulb of 97%, lasted 133 minutes. The patient was discharged stable without any neuro-cognitive deficit. Two years later, he was admitted with late prosthetic valve endocarditis and subvalvular abscess. Good response on treatment with efficient combined antibiotics and stabile hemodynamic allowed us to avoid barely feasible re-do surgery. Subvalvular myocardial abscesses evolved into periprosthetic pseudoaneurysms without infectious, thrombo-embolic, or hemodynamic deterioration. The patient is still alive and stable, more than four years after this event. Conclusion. Fortunate outcome of these life-threatening conditions is a reason to reconsider our understanding of cerebral function and metabolism during the profound hypothermic circulatory arrest, and it emphasizes the importance of measuring individual patient response against disease treatment guidelines, as we did, treating the late, complicated prosthetic valve endocarditis with medicaments, instead of high-risk surgery.

Keywords: aortic dissection, circulatory arrest, brain protection, prosthetic valve endocarditis

Project of the Serbian Ministry of Education, Science and Technological Development, Grant no. 41002