Case report
A 71-year-old man, who presented with dyspnea and severe back pain, was
referred to the emergency department. His medical history included
percutaneous catheter intervention (PCI) for AMI, caused by left
circumflex artery stenosis 11 years ago. At that time, AAORCA from the
left sinus of Valsalva was noted, but was followed up in the outpatient
clinic without intervention.
On admission, his vital signs were stable, and all four limbs had
adequate pulses. Laboratory data revealed no elevation of cardiac
enzymes. An electrocardiogram showed inferior wall ST-elevation without
bradycardia or atrioventricular block. Transthoracic echocardiogram
revealed a wall motion abnormality in the right ventricle. Enhanced
computed tomography (CT) showed a type A AAD that extended from the
aortic root to the descending thoracic aorta with a thrombosed false
lumen. The left coronary artery exhibited contrast enhancement, but the
right coronary artery (RCA) did not (Figure 1). An emergency surgery was
performed. Since there were only right ventricular infarction findings,
the dissection presumably did not extend into the sinus of Valsalva.
Rather, the compression occurred in the coronary artery after the RCA
bifurcation.
Upon administering anesthesia, the patient developed ventricular
fibrillation, which improved after 20 seconds of chest compressions. The
surgery was performed via median sternotomy. Transesophageal
echocardiogram showed mild to moderate aortic valve regurgitation. On
surgical inspection, the sinus of Valsalva was enlarged, and right
ventricular movement decreased. Cardiovascular bypass was established
between the left femoral artery and bicaval vena cava. Cardiac arrest
was achieved by selective anterograde cardioplegia and retrograde
cardioplegia. After circulatory arrest, the space inside the aorta was
observed, and the absence of an entry in the aortic arch was confirmed.
Thus, ascending aorta replacement was performed. The dissection cavity
was glued using Bovine serum albumin-glutaraldehyde glue (BioGlue®), and
proximal stump construction was done with inner and outer banded felts.
After spontaneous circulation had returned, the right ventricular
movement improved, and the procedure was completed without bypass
surgery.
He was extubated on postoperative day (POD) 2 and recovered quickly. A
coronary CT scan on POD 10 confirmed the absence of RCA stenosis or
compression (Figure 2A and 2B). He was discharged without complications
on POD 17. Coronary angiography (CAG) was performed one month
postoperatively, but there was no RCA stenosis.