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DOI: 10.1055/s-0044-1780686
Concomitant Coronary Artery Bypass Grafting in Acute Type A Aortic Dissection Complicated by Coronary Malperfusion—Experience and Decision Making
Authors
Background: The management of acute type A aortic dissection (ATAAD) complicated by coronary malperfusion can be challenging. In this study, we report a single center experience and revascularization strategy for patients with ATAAD and coronary malperfusion.
Methods: From 01/2000 to 12/2021, 195 patients with preoperative coronary malperfusion and involvement of the aortic root underwent surgery for ATAAD. Coronary malperfusion included presence of elevated cardiac enzymes, electrocardiographic signs of ischemia and/or new wall motion abnormalities in ultrasound. Patients were divided into four subgroups according to their pattern of coronary dissection (Neri A = ostial involvement by the dissection, Neri B = dissection extending into the coronary artery, Neri C = circumferential detachment or complete avulsion of the coronary artery). A novel subclass called “Neri negative” defined by aortic root dissection without coronary dissection was added. Additional subgroup analysis was performed involving patients receiving concomitant CABG either as part of a planned strategy or unplanned as a bailout strategy in case of persisting low cardiac output.
Results:
|
Perioperative variables, n (%) |
Total (n = 195) |
Neri negative (n = 43) |
Neri A (n = 43) |
Neri B (n = 74) |
Neri C (n = 35) |
p-Value |
|
Aortic root replacement |
79 (41) |
13 (30) |
16 (37) |
25 (34) |
25 (71) |
< 0.001 |
|
LCA dissection |
53 (27) |
0 (0) |
20 (47) |
29 (39) |
4 (11) |
< 0.001 |
|
RCA dissection |
131 (67) |
0 (0) |
33 (77) |
63 (85) |
35 (100) |
< 0.001 |
|
Concomitant CABG |
62 (32) |
4 (9) |
5 (12) |
21 (28) |
32 (91) |
< 0.001 |
|
30 day mortality |
82 (42) |
21 (49) |
12 (28) |
30 (41) |
19 (54) |
0.087 |
|
Planned CABG (n = 46) |
Bailout CABG (n = 16) |
|||||
|
Neri B |
10 (22) |
11 (69) |
0.001 |
|||
|
Neri C |
29 (63) |
3 (19) |
0.005 |
|||
|
30 day mortality |
22 (48) |
13 (81) |
0.042 |
|||
Conclusion: In case of Neri negative and Neri A patients, concomitant CABG may be restricted to isolated cases and may therefore not be necessary in general. Neri C patients should undergo concomitant CABG as well as liberal decision for aortic root replacement. Planned CABG in Neri B patients may be advisable as bailout CABG in this group is associated with poor outcome.
Publication History
Article published online:
13 February 2024
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