Postoperative Extracorporeal Membrane Oxygenation Support for Acute Type A Aortic Dissection

Preoperative left ventricular dysfunction is a risk factor for postoperative mortality and morbidity in cardiovascular surgeries with cardiopulmonary bypass, including thoracic aortic surgery. Using a retrospective study design, this study aimed to clarify the short- and mid-term outcomes of patients who underwent acute type A aortic dissection (ATAAD) repair with reduced left ventricular function.Between July 2007 and February 2018, a total of 510 adult patients underwent surgical repair of ATAAD in a single institution. The patients were classified as having left ventricular ejection fraction (LVEF) <50% (low EF group, n = 86, 16.9%) and LVEF ≥50% (normal group, n = 424, 83.1%) according to transesophageal echocardiographic assessment at the operating room. Preoperative demographics, surgical information, and postoperative complication were compared between the two groups. Three-year survival was analyzed using the Kaplan-Meier actuarial method. Serial echocardiographic evaluations were performed at 1, 2, and 3 years postoperation.Demographics, comorbidities, and surgical procedures were generally homogenous between the 2 groups, except for a lower rate of aortic arch replacement in the low EF group. The averaged LVEFs were 44.3 ± 2.5% and 65.8 ± 6.6% among the low EF and normal groups, respectively. The patients with low EF had higher in-hospital mortality (23.3% versus 13.9%, P = .025) compared with the normal group. Multivariate analysis revealed that intraoperative myocardial failure requiring extracorporeal membrane oxygenation support was an in-hospital mortality predictor (odds ratio, 16.99; 95% confidence interval, 1.23-234.32; P = .034), as was preoperative serum creatinine >1.5 mg/dL. For patients who survived to discharge, the 3-year cumulative survival rates were 77.8% and 82.1% in the low EF and normal groups, respectively (P = .522). The serial echocardiograms revealed no postoperative deterioration of LVEF during the 3-year follow-up.Even with a more conservative aortic repair procedure, the patients with preoperative left ventricular dysfunction are at higher surgical risk for in-hospital mortality. However, once such patients are able to survive to discharge, the midterm outcome can still be promising.

Section: Discussionmentioning

confidence: 88%

Impact of reduced left ventricular function on repairing acute type A aortic dissection

Lin¹,

Lee²,

et al. 2018

“…In the meantime, the long-term clinical outcomes of cardiac arrest due to hemorrhagic tamponade complicated by AAAD depend on the quality of cerebral resuscitation. In addition, based on recent experiences with the treatment of AAAD in the perioperative [14] and postoperative periods [15] using extracorporeal membrane oxygenation (ECMO), it is necessary to investigate the feasibility of long-distance transfer of such patients. To this end, large clinical trials should be designed to verify whether ECMO could help maintain organ perfusion during this period of transportation.…”

Section: Discussionmentioning

confidence: 99%

A case report of hemorrhagic cardiac tamponade with rapid blood clot formation

Feng¹,

Wan

Guo

2018

Rationale:Acute type A aortic dissection (AAAD) remains a life-threatening disease. We previously reported a case with ultrasound findings of a homogeneous hemopericardium and evidence highly indicative of hemorrhagic cardiac tamponade complicated by AAAD. Here, we report a similar case who presented with a more serious situation and for whom critical care ultrasound revealed fast blood clot formation within the hemopericardium.Presenting concerns:A 63-year-old man was admitted to our emergency department with a complaint of a tearing chest pain for 10 minutes. Asymmetric blood pressure was detected in the upper limbs and AAAD was highly suspected. An electrocardiogram (ECG) monitor was placed in a timely manner. However, during this procedure, he went into cardiac arrest and cardiopulmonary resuscitation (CPR) was initiated.Diagnoses:Critical care ultrasound revealed hemorrhagic cardiac tamponade with blood clot formation surrounding the epicardium, strongly indicating the rupture of an ascending aortic root dissection.Interventions:Standard CPR continued for 30 minutes.Outcomes:Spontaneous cardiac rhythm was not restored and the patient died.Lessons:Critical care ultrasound is a useful tool for assessing emergency cardiac arrest. Ultrasound findings of fast clot formation within the hemopericardium may indicate faster bleeding due to the rupture of an AAAD and may predict poor clinical outcomes.

“…Several cases of acute aortic dissection successfully treated by postoperative ECMO have been reported, [ 11 , 12 ] and a recent pilot study has indicated that thoracic acute aortic dissection (TAAD) patients supported by postoperative ECMO exhibit a long-term survival comparable to patients who did not receive ECMO. [ 13 ] However, whether it is worth the effort to use ECMO as a rescue therapy in critically ill patients remains an argument in the field because of its numerous complications. Research has indicated that nosocomial infection is a fatal complication linked with ECMO: among 75 ECMO patients, 20 patients developed NI (infection rate 26.7%); 58 pathogens were isolated, including 43 strains of gram-negative bacteria (74.1%) and 15 strains of gram-positive bacteria (25.9%).…”

Section: Discussionmentioning

confidence: 99%

Iatrogenic acute aortic dissection induced by off-pump coronary artery bypass grifting

Guan

Gong

et al. 2017

Rationale:Iatrogenic acute aortic dissection (IAAD) induced by cardiac surgery is a fatal complication, with 0.04% of therapeutic procedures and worse outcomes than spontaneous aortic dissection.Patients concerns:A 64-year-old male complaining of intermittent chest tightness for 4 years received an off-pump coronary artery bypass grifting (OPCABG) and IAAD was found during surgery.Diagnosis:Unstable angina, coronary artery triple vessel lesion, IAAD.Interventions:An ascending aorta replacement surgery was implemented immediately and extracorporeal membrane oxygenation (ECMO) was applied during surgery. The patient suffered from oliguria symptoms and began to receive continuous renal replacement therapy (CRRT) after surgery. What was worse, osteofascial compartment syndrome (OCS) was also confirmed the day after surgery.Outcomes:The CRRT and ECMO were both removed and the condition of the right leg was also stable. But the patient passed away because of uncontrollable sepsis 18 days after the surgery.Lessons:OPCABG is clearly the riskiest type of surgery associated with IAADs in cardiac surgical procedures, which should be considered with great concern. Whether ECMO should be used postoperatively in IAAD patients is still a controversial subject, due to some fatal complications linked with it.