Treatment of coronary malperfusion in type A acute aortic dissection

Abstract

Coronary malperfusion is one of the most dreadful complications of acute aortic dissection because it causes catastrophic acute myocardial infarction in patients who are already severely ill. Our strategy was as follows. After the administration of heparin, emergency percutaneous coronary intervention (PCI) was urgently performed at the same time as starting to prepare the operating room. A stent was then placed to cover the full length of dissected coronary artery. Patients whose cardiac function improved after successful coronary artery reperfusion were transferred to the operating room to undergo central repair surgery. If the cardiac function did not recover even after coronary reperfusion, and the patient required extracorporeal membrane oxygenation, we considered the best supportive care without performing central repair surgery. In patients with left coronary malperfusion, we believe that preoperative PCI must be performed immediately. Preoperative PCI might delay central repair surgery and potentially increase the risk of catastrophic cardiac tamponade. However, the benefit of PCI in preserving cardiac function exceeds the risk of cardiac tamponade. The indications of PCI before central repair in patients with right coronary malperfusion should be considered after assessing each patient's condition, including the presence or absence of cardiac tamponade and right ventricular infarction, left ventricular function, the immediate availability of cardiologists or cardiac surgeons, and the speed of preparing the operating room.

Malperfusion syndromes in acute type A aortic dissection do not affect long‐term survival in Chinese population: A 10‐year institutional experience

“…Early reperfusion strategy improved the outcomes of surgery for type A acute aortic dissection with malperfusion, and enables surgeons to avoid unproductive surgeries in patients with irreversible damages. However, preoperative PCI might delay central repair surgery and increase the risk of catastrophic cardiac tamponade 25 …”

Percutaneous coronary intervention for left main coronary artery malperfusion in acute type A aortic dissection

“…The in-hospital mortality rate in AAAD patients without any complications ranges from 8 to 19%, whereas that in AAAD patients with coronary malperfusion ranges from 20 to 30% [1][2][3]. Malperfusion in the left main coronary artery (LMCA) is particularly associated with catastrophic outcomes, because it can cause cardiogenic shock or cardiac arrest [3,4]. Immediate revascularization is necessary for AAAD patients with LMCA malperfusion to treat myocardial ischemia and provide hemodynamic stability.…”

“…The current guidelines suggest surgical resection and thoracic aorta replacement as the gold standard for the treatment of AAAD [5,6]. According to previous research, any delay in the door-to-balloon time in patients with ST elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) is associated with higher inhospital mortality [7], and preoperative PCI is effective for coronary malperfusion caused by AAAD [4,[8][9][10][11][12]. However, regarding LMCA malperfusion in AAAD, its analytical treatment data are scarce because of its low incidence, and, therefore, which treatment should take priority, surgical correction or reperfusion therapy, remains controversial.…”

Brachiocephalic artery dissection is a marker of stroke after acute type A aortic dissection repair

“…Generally, malperfusion is diagnosed in patients who had clinical symptoms as well as occlusion of the corresponding arteries 15,16 . In the brain, only patients with both acute neurological symptoms and significant stenosis or obstruction in the carotid arteries are defined as brain malperfusion.…”