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.