A highly fatal intraoperative urgency - aortic dissection complicating heart surgery

Background: Aortic dissection is associated with high mortality. Despite its rarity, it is often fatal. Aim: We have retrospectively analysed acute aortic dissections occurring intraoperatively (IAAD). Methods: Patients' preoperative risk factors, and operative and postoperative courses were analysed from the hospital records retrospectively. Results: From 1985 to 2009, we performed 29 683 cardiac operations. Ten patients (0.43 parts per thousand) (mean age 66.5 +/- 7 years) were diagnosed with IAAD. There were type 2 dissections in 9 and one patient had it extending beyond the arcus. Four patients were operated on for coronary artery disease, 2 for mitral and 2 for aortic valve diseases. Two patients had concomitant valvular or valvular and coronary procedures. IAAD was identified after decannulation in 5, after creating the holes for proximal anastomoses in 3 and after declamping the aorta in 2 patients. Preoperatively, 6 (60%) patients had hypertension and 4 had hypercholesterolaemia (40%). No other significant risk factors could be identified. Hypothermic circulatory arrest was used in 6 operations. The dissected segment was replaced with a graft in 9 patients whereas the remaining patient had concomitant arcus aorta replacement and elephant trunk procedure. Aortoplasty with Dacron patch was used in one patient. All patients required inotropic and 4 patients IABP support postoperatively. Three (30%) patients died. Conclusions: The IAAD may occur in any patient at any phase of cardiac surgery. The surgeon should always be aware of the possibility of this complication. It is much better to prevent the IAAD than to treat it. When detected, abrupt change of the operation plan and reparative measures for the dissection should be undertaken.