Case 34

Type A Dissection into the Right Coronary Artery

        A 70 year old known hypertensive patient presents with tearing chest pain to the A and E department. The casualty officer suspects aortic dissection due to a widened mediastinum, so does not thrombolyse the patient. The ECG shows signs of inferior ischaemia. A CT scan confirms the diagnosis of a type A aortic dissection. What operative strategy, if any would you adopt?

The CT scan demonstrated that the dissection did not involve the aortic arch. So an RA aortic arch bypass setup can be used. To arrest the heart a retrograde cardioplegia cannula should be inserted. The RCA should be grafted and plegia given down the graft in an anterograde fashion. It should not be forgotten that inferior infarcts are associated with AV node conduction problems so pacing wires are needed at the end of the case. The coronary involved ahs to be the RCA and not the circ, because if the circ was involved the LMS would have to be involved which would mean the LAD would be involved, which would be fatal.

Resuspension or root replacement can only be decided intra-operatively.

If the patient is in established RV failure secondary to the infarct at presentation, depending on the length of time in the history a conservative approach may be taken if it is thought that the chances of any myocardial salvage is negligible.