Dicky stnf a_complic
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Acute type A dissection, is on of the highest mortality cases in cardiovascular surgery. It doubled it incident with concomitant complication such as malperfusion or pericardial tamponade. In this presentation, the patient have both coronary malperfusion and pericardial tamponade
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Dicky stnf a_complic
- 1. Fatal Complication of Type A Aortic Dissection Pericardial Tamponade and Coronary Malperfusion Case Report Dicky Aligheri, MD National Cardiovascular Centre Harapan Kita, Jakarta Indonesia 2014
- 2. • Disclosures : None
- 3. History • 46 yo female • History of uncontrole hypertension and active smoking (>10 /d) • Abrupt onset (4 hours before admission) – Chest pain – Unstable hemodynamic • BP 88/35, HR 125 t/min, CVP 22 • ECG : st elevation in lead II, III, aVF • Lab : elevated D dimer level • Echo : RV hypokinetic, RA RV compression, Severe AI, pericardial effusions
- 5. Operation Strategy • Dissect all dissecting segment • Elephant trunk insertion & arch replacement (4branched graft) • Aortic valve & Root replacement (Mod Bentall)(composite graft) • SVG to RCA
- 7. Operation Strategy • Femoral & Bicaval Cannulation • Retrograde CPG LCA Osteal SVG LAD • LV venting • Antegrade Selective Cerebral Perfusion-> Retrograde • Systemic / Head cooling (DHCA)
- 10. Operative Finding • Hemopericardium, 850cc • Enlargement, bluish & hematoma of proximal aorta & RVA ostium area • Intimal tear from aortic root to distal aortic arch incl inominate artery. • Prolapse of All Aortic valve leaflets • Collapse RCA ostium
- 12. • Coagulopathy • CPB weaning difficulties – Pump failure (RV mci) – Exc vasodilatation – IABP – SVG to LCX
- 13. • Coagulopathy • CPB weaning difficulties – Pump failure (RV mci) – Exc vasodilatation – IABP – SVG to LCX NTG 0.5 Dop 12.5 Epi 0.1 Norepi 0.2 IABP RV pacing ABP 80/55 HR 100x/min on beat CVP 12 Urin output (-) Acidotic (BE -11)
- 14. • Coagulopathy • CPB weaning difficulties – Pump failure (RV mci) – Exc vasodilatation – IABP – SVG to LCX NTG 0.5 Dop 12.5 Epi 0.1 Norepi 0.2 IABP RV pacing ABP 80/55 HR 100x/min on beat CVP 12 ECG changes LCA Trop I Elev Anterior RWMA
- 15. Acute type A aortic dissection • The incidence of aortic dissection 5 to 30 cases per million people per year, • requires immediate surgical intervention • can be complicated by pericardial tamponade and malperfusion (coronary, cerebral, renal, limb) • the overall mortality in type A dissection was almost 3 times higher in the group with malperfusion (45- 66%) than with no malperfusion (15 – 22%%). Ann Cardiothorac Surg 2013;2(2):205-211 J Emerg Trauma Shock. 2011 Apr-Jun; 4(2): 273–278 Circulation. 2004;90:2375-2378 Discussions
- 16. Discussions
- 17. Contin Educ Anaesth Crit Care Pain (2010) 10 (5): 138-142. doi: 10.1093/bjaceaccp/mkq024
- 18. Problems • Unstable pre op hemodinamik – Preop optimized? • Myocardial infarction – Heparin? • Myocardial protection – All coronary perfusion? • CPB weaning difficulties – Assist device – Excessive vasodilatation • Coagulopathies – Effect on bypass graft
- 19. Pericardial Tamponade http://heart.templehealth.org/content/aor tic_dissections.htm
- 20. Pericardial Tamponade • cardiac tamponade complicating acute aortic dissection is associated with a high early mortality • Performing pericardiocentesis may instead precipitate hemodynamic collapse and death • it should be considered a surgical emergency, and pericardiocentesis should be avoided while every effort is be made to proceed as urgently as possible to the operating room JAMA. 2000 Feb. 16;283(7):897–903. PMID 10685714 .Thorac. Cardiovasc. Surg. 2001 Mar.;121(3):552–560. PMID 11241091 Am. J. Cardiol. 2009 Apr. 1;103(7):1029–1031. PMID 19327436 Circulation. 2012 Sep 11;126(11 Suppl 1):S97-S101. Postgrad Med J. 2012;88(1046):729-730.
- 21. Coronary Malperfusions Neri E, Toscano T, Papalia U, Frati G, Massetti M, Capannini G, et al. Proximal aortic dissection with coronary malperfusion: presentation, management, and outcome. J. Thorac. Cardiovasc. Surg. 2001 Mar.;121(3):552–560
- 23. CONCLUSION •Acute type A aortic dissection complicated with pericardial tamponade and coronary malperfusion is a devastating event. It is associated with a high early mortality and extremely high mortality rate over the first 24 to 48 hours •In tamponade, pericardiocentesis should be avoided •In patients with coronary malperfusion, most patients received CABG and ascending / root aortic replacement because of its simplicity
- 24. Thank You
Editor's Notes
- Tearing chest painPresentation of shock… CV line for resusitaion Realize RV prob.. Echo..ct… OR
- Dissect from root to inominate, to prox coeliac Multiple entru tear at the arch RCA osteal obstruction… surgical consult was made Pericardial effusion
- Alasan tiap segmen.. Fasilitasi tevar.. Bentall spy cepat Bicaval u retro kr pengalaman, Masalah di retro tdk efektif even direct..
- planning
- Alasan tiap segmen.. Fasilitasi tevar.. Bentall spy cepat Bicaval u retro kr pengalaman, Masalah di retro tdk efektif even direct.. Cpg failre.. Buka aoscenden.. No flow di RCA n minimal di LCA Retro jadi osteal Cpg jd svg lad Masalah di ascp krn ketendang..
- Proble intra op.. Koagulo sls dg lokal hemostatik, glue dsb, ffp, fresh blood, lots pericardial reinforced Cpb weaning, ga bisa.. RV hmpir ga gerak.. Flow meter LAD n RCA 1.7 n 1.6 Extra graft Lcx, flow 2 Problem prox anat ke graft
- Bisa ke icu dg 2 digit. 80/55 100x/min on beat cvp 12 Ecmo was all accu,.. No optio
- Pmi.. Ecmo n CVVH… expensive Renc graft revision… develop u responsive VF.. Died 18 hrs post op after 1 hurs ressusittion
- . The severity and consequences of adissection are related to the physical characteristics and anatomic location of the tear as well asthe underlying patient physiology and is associated with a significant surgical morbidity and mortality (fatal) Indo 200mill so.. Mor than 2000 cases Experience all. Complic.. But tjis pts is the worst
- Type2… yg plg sering.. Strategy umum.. Komplikasi malperfusi.. Retro type A
- Standart deep… and then moderate But for complicated.. Deeppp w scp.. No nirs so blindly use the scp… rscp only for “bad” arch
- Act… pts ini 340 after double doses.. Confident ??
- One of most co cod Even percin efecyive for other. But…… Pea.. death
- anatomic reconstruction of the coronary artery ostia, avoidance of complete graft-dependent perfusion of large areas of the myocardium, and preservation of antegrade flow in the coronary trees, thus avoiding the risk of competitive flow and coronary redissection.[27,54] However, mobilization and repair of acutely dissected coronary arteries is potentially dangerous and problematic.