Acute Aortic Dissection Early after Off-Pump Coronary Surgery True Frequency Underestimated?

Jim Moran Heart & Vascular Center, Holy Cross Hospital, Fort Lauderdale, Florida 33308, USA.
Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital (Impact Factor: 0.65). 10/2009; 36(5):462-7.
Source: PubMed


Since the adoption of off-pump coronary artery bypass surgery (OPCAB), numerous investigators have compared its short- and long-term results with those of on-pump coronary bypass surgery. Some reports of OPCAB were quite favorable, whereas others were critical, claiming that it resulted in incomplete revascularization and reduced venous graft patency. A potentially serious complication of OPCAB, not heretofore sufficiently confronted, is the increased incidence of early postoperative acute aortic dissection, in comparison with the more familiar intraoperative and late-occurring aortic dissection after conventional on-pump bypass surgery.Early postoperative acute aortic dissection after OPCAB appears to be more frequent than was initially thought. Its clinical manifestations can be unusual and often neurologic in nature-rendering diagnosis difficult, causing delays in surgical intervention, and resulting in a high mortality rate.When the physician notes unusual developments in patients after OPCAB that lead to the suspicion of aortic dissection, immediate computed tomography of the chest and surgery should occur if dissection is confirmed. If not detected early, this sequela almost certainly leads to rapid death from aortic rupture. Prevention lies in the strict control of systolic blood pressure during the performance of proximal anastomoses; avoidance of aortic clamping through the use of sequential all-arterial grafts or new-generation mechanical connectors; and, at times, aggressive replacement of the aorta with a prosthetic graft.Herein, we present the cases of 4 patients who sustained acute aortic dissection early after OPCAB. We review the pertinent medical literature.

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    • "Such cases must be aggressively treated. However iatrogenic dissection can be clinically silent and found incidentally with conservative treatment as a solution [10]. In our patient neither the clinical presentation nor the dynamics of arising effusion indicated dissection. "
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    ABSTRACT: Background Off-pump coronary artery bypass (OPCAB) surgery can be associated with some intrinsic, but relatively rare complications. A pericardial effusion is a common finding after cardiac surgeries, but the prevalence of a cardiac tamponade does not exceed 2% and is less frequent after myocardial revascularization. Authors believe that in our patient an injury of a nutritional pericardial or descending aorta vessel caused by the Lima stitch resulted in oozing bleeding, which gradually leaded to cardiac tamponade. The bleeding increased after introduction of double antiplatelet therapy and caused life-threatening hemodynamic destabilization. According to our knowledge it is the first report of such a complication after OPCAB. Case presentation We present a case of a 61-year old man, who underwent elective surgical myocardial revascularization on a beating heart. On the 11th postoperative day the patient was readmitted emergently to the intensive care unit for severe chest pain, dyspnoea and hypotension. Coronary angiographic control showed a patency of the bypass grafts and significant narrowing of circumflex artery, treated with angioplasty and stenting. The symptoms and hemodynamic instability exacerbated. A suspicion of dissection of the ascending aorta and para-aortic hematoma was stated on 16-slice cardiac computed tomography. The patient was referred to the Cardiovascular Surgery Clinic. Transthoracic echocardiography revealed cardiac tamponade. On transesophageal echocardiography there were no signs of the ascending aorta dissection, but a possible lesion of the descending aorta with para-aortic hematoma was visualized. Emergent rethoracotomy and cardiac tamponade decompression were performed. 12 days after intervention the control 64-slice computed tomography showed no lesions of the ascending or descending aorta. On one-year follow-up patient is in a good condition, the left ventricular function is preserved and there is no pathology in thoracic aorta on echocardiography. Conclusions Mechanical complications of surgical myocardial revascularization on a beating heart should be considered as a cause of the clinical and hemodynamic instability relatively early in the postoperative period. Echocardiographic examination must be the first step in diagnostics process in a patient after cardiac surgery.
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    ABSTRACT: Aortic dissection as a complication of cardiac surgery is a rare but often lethal event. We sought to determine the frequency of this complication in the STS (Society of Thoracic Surgeons) database as well as the outcomes of patients who suffer intraoperative aortic dissection. We then developed a model to identify preoperative characteristics and intraoperative factors associated with the complication. All patients from the STS database who underwent coronary artery bypass grafting, aortic valve surgery, or mitral valve surgery were included. Exclusion criteria included any patient who had aortic dissection listed as a reason for urgent or emergent operation. Data collected were then analyzed to describe the frequency of aortic dissection as a complication as well as its consequences. We then analyzed a more recent era that included information on arterial cannulation site (femoral-other versus aortic) to identify risk factors for aortic dissection. Of 2,219,991 patients analyzed, 1,294 suffered aortic dissection as a complication of their surgery, for an incidence of 0.06%. This complication frequently led to catastrophic results, with 615 of 1,294 (48%) operative mortality. A logistic regression model was created based on 2004 to 2007 STS data. Of 680,025 patients analyzed, 436 patients suffered an aortic dissection. The analysis yielded nine significant risk factors including femoral arterial cannulation, preoperative steroids, and Asian race; the presence of diabetes appeared to be protective. Aortic dissection is a rare but catastrophic complication of cardiac surgery. Femoral cannulation is associated with an increased frequency of this complication.
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