Proximal aortic dissection with coronary malperfusion: Presentation, management, and outcome

Background: Acute myocardial ischemia and infarction due to retrograde diss ection of the aortic root reaching the coronary ostia is a potentially fata l condition. Surgical treatment of these patients relies on the re-establis hment of an adequate coronary blood flow and on the rescue of jeopardized m yocardium. This article reports the results of a selected group of 24 patie nts with type A acute aortic dissection and coronary artery dissection. We review our experience and illustrate our approach to this condition, which evolved over a 15-year period. Methods: Between July 1985 and March 2000, 24 patients from a total of 211 (11.3%) treated for acute type A aortic dissection had dissection of at lea st one of the coronary ostia. There were 14 men and 10 women. The mean age was 65.5 years (median 61.7; range 41-78 years). The right coronary artery was involved in 11 patients, the left in 4 patients, and both coronary arte ries in 9 patients. At admission, 16 patients had Q waves (66%), inferior i n 6 (25%) and anterior, lateral, septal, or posterior in 10 (41%). All proc edures were done on an emergency basis within 10 hours (median 4 hours) aft er initial chest pain and within 2 hours after the patient's arrival. Results: Hospital mortality was 20% (5 patients); 3 patients could not be w eaned from cardiopulmonary bypass and died intraoperatively, and 2 patients died postoperatively of low cardiac output. Conclusions: As illustrated in this study, direct coronary repair is a safe alternative to bypass grafting. Aggressive myocardial resuscitation togeth er with early operation is a key factor in the management of these patients .