Management of Patients With Coronary Artery Malperfusion Secondary to Type A Aortic Dissection

doi:10.1016/j.athoracsur.2018.09.065

The Annals of Thoracic Surgery

Volume 107, Issue 4, April 2019, Pages 1174-1180

https://doi.org/10.1016/j.athoracsur.2018.09.065 Get rights and content

Background

This study reviewed our experience with coronary artery (CA) malperfusion secondary to type A aortic dissection.

Methods

Between 2002 and 2017, 76 patients presented with CA malperfusion, with a dissection flap limited to the aorta in the region of the coronary ostium (type A lesion) in 26 (34%), with a dissection flap involving the CA itself (type B lesion) in 32 (42%), or with complete avulsion of the CA (type C lesion) in 18 (24%).

Results

Ostial repair was successfully performed in 23 type A patients (88%), in 20 type B patients (63%), and in no type C patient (0%). CA bypass grafting was performed when antegrade cardioplegia could not be applied in all 18 type C patients (100%) and in 5 type B patients (16%) because of a primary entry at the coronary ostium and in 7 patients (type A: 3 patients [12%], type B: 4 patients [13%]) with evidence of CA disease (p < 0.001). Perioperative mortality in patients with CA malperfusion was high (18 patients [24%]), but there was no difference in short-term (p = 0.153) or long-term survival (log-rank p = 0.542). Also, a landmark analysis showed equal survival of discharged patients with and without CA malperfusion (log-rank p = 0.645).

Conclusions

We recommend CA bypass grafting in patients with type C lesions or in patients with underlying CA disease for optimal delivery of cardioplegia and ostial pledgetted suture repair in patients with type A lesions or type B lesions when the administration of antegrade cardioplegia is successful.

Section snippets

Study Population and Classification

Of the 892 patients who were surgically treated for type A aortic dissection between January 2002 and May 2017 in our center, 76 patients (9%) presented with CA malperfusion and comprise this study population. The Hospital of the University of Pennsylvania Institutional Review Committee approved this retrospective study, and the need for informed consent was waived.

CA malperfusion was diagnosed clinically by the operating surgeon in conjunction with the transesophageal echocardiography

Patient Characteristics

Patient characteristics are summarized in Supplemental Table 1. Baseline variables did not differ among the three lesion type groups.

Clinical Presentation

Of the 76 patients with CA malperfusion, 19 patients (25%) were originally diagnosed as acute myocardial infarction, and a diagnostic coronary angiography was performed initially. In an additional 9 patients (12%), a coronary angiography was performed and caused iatrogenic catheter-induced aortocoronary dissection. In all coronary angiography patients, the

Comment

The most essential findings of this study can be summarized as follows:

1.
CA repair is possible in all patients with a type A lesion and in most patients with a type B lesion in the absence of CAD and no entry at the coronary ostia, but CABG seems necessary in patients with type C lesions to apply antegrade cardioplegia for optimal myocardial protection.
2.
In patients who reached the hospital, the right CA is significantly more often affected, and the right CA was affected in all but 1 patient with a

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Cited by (42)

EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ
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To assess the diagnostic value of coronary computed tomography angiography (CCTA) in acute type A aortic dissection (ATAAD) with coronary artery involvement and to evaluate whether CCTA could provide potentially useful information for selecting the surgical method.
Patients with ATAAD treated from January 2019 to December 2020 were reviewed retrospectively. Involvement of the coronary arteries based on CCTA findings were grouped into three major types and five subtypes. Interobserver and intraobserver diagnostic agreement for five subtypes were determined. The patients were divided into the coronary artery bypass grafting (CABG) and non-CABG groups, and the proportions of the five subtypes between the two groups were compared.
A total of 95 patients were enrolled in this study. Interobserver and intraobserver diagnostic agreement were both substantial in the left and right coronary arteries. Overall, the proportions of the five subtypes of coronary artery involvement were significantly different between the two groups (p<0.001). The proportion of Type A was elevated in the non-CABG group compared with the CABG group (22.6% versus 71.9%); by contrast, the proportions of Type B1 (35.5% versus 14.1%), Type B2 (19.4% versus 10.9%), Type C1 (6.5% versus 0%), and Type C2 (16.1% versus 3.1%) were elevated in the CABG group.
CCTA is reliable in evaluating coronary artery involvement by ATAAD. The present retrospective study indicated that CABG may be considered if the intimal flap disrupts the coronary orifice and causes luminal stenosis >50%, particularly Type B, or if an intimal tear occurs in the coronary orifice (Type C), which deserve further validation through prospective studies.
2021 The American Association for Thoracic Surgery expert consensus document: Surgical treatment of acute type A aortic dissection
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Citation Excerpt :
The second indication for CABG was an unsuccessful weaning from CPB mostly because right ventricular dysfunction. The strategy of myocardial protection, namely how to deliver cardioplegia, should be taken into consideration as stressed by other authors.17 In our analysis, retrograde cardioplegia, especially in patients who had post-CPB ventricular dysfunction, was not routinely used.
Coronary Artery Bypass Grafting (CABG) is sometimes necessary in acute Type A Aortic Dissection (AAAD) repair. The aim of this study is to analyze the incidence, indications and influence in-hospital outcomes of AAAD repair requiring concomitant CABG in a high-volume single-center experience. Retrospective study of all consecutive AAAD patients. Those who underwent concomitant CABG were identified. Preoperative, intraoperative, postoperative and follow-up data were collected and analyzed. Between January 1, 2010 and December 31, 2016, 382 patients underwent emergency surgery for AAAD. Forty-one (10.7%) underwent concomitant CABG. In this group, mean age was 64 ± 14 years, 32 were male (78%). Indication for CABG was coronary dissection in 28 patients (68.3%), post-cardiopulmonary bypass (CPB) right heart failure in 7 (17.1%), post CPB left heart failure in (7.3%) and native coronary pathology in 3 (7.3%). In 33 (80.5%) one graft was needed, in 7 (17%) two were performed and in 1 patient (2.4%) 3 were necessary. The right coronary artery (RCA) was the only revascularized vessel in 26 cases (63.4%), the left coronary artery (LCA) alone in 11 (26.8%), and both coronary systems in 4 (9.8%). In-hospital mortality was 51.2% (N = 21); eight (19.5%) patients had postoperative myocardial infarction (MI) and 11 (26.8%) had a major neurological event. Multivariable logistic regression identified concomitant CABG as a predictor of in-hospital mortality (Odds Ratio (OR) = 3.8115, 95% CI= 0.514–2.138, p = 0.001). In our study, concomitant CABG was performed in 10.7% of AAAD repair surgery and it was associated with high in-hospital mortality.
EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ
2024, European Journal of Cardio-thoracic Surgery

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Original articleAdult cardiacManagement of Patients With Coronary Artery Malperfusion Secondary to Type A Aortic Dissection

Background

Methods

Results

Conclusions

Section snippets

Study Population and Classification

Patient Characteristics

Clinical Presentation

Comment

Am J Emerg Med

J Cardiol

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Dissecting aneurysm of the aorta: a review of 505 cases

Medicine (Baltimore)

Acute type A aortic dissection involving right coronary artery orifice in a case presenting with anterior ST elevation: a rare case report

Cardiology

Original article
Adult cardiac
Management of Patients With Coronary Artery Malperfusion Secondary to Type A Aortic Dissection