CASE REPORTS  CARDIAC PAPERS 

The Journal of Cardiovascular Surgery 2000 June;41(3):395-7

Copyright © 2009 EDIZIONI MINERVA MEDICA

language: English

Swinging motion of intimal flap through the aortic valve in acute aortic dissection

Kotsuka Y., Ezure M., Kawauchi M., Takamoto S.

From the Department of Cardiothoracic Surgery Faculty of Medicine, University of Tokyo, Tokyo, Japan

The pur­pose of ­this arti­cle is to ­present a ­very ­rare ­case of Stanford ­type A ­acute aor­tic dis­sec­tion fea­tur­ing a swing­ing ­motion of the cyl­in­der-­shaped inti­mal ­flap ­through the aor­tic ­valve. The ­patient was a 62-­year-old ­male suf­fer­ing ­from ­severe car­di­o­gen­ic ­shock. A trans­tho­rac­ic ech­o­car­di­o­gram ­revealed aor­tic dis­sec­tion and ­severe aor­tic regur­gi­ta­tion. A tran­se­soph­a­geal ech­o­car­di­o­gram dem­on­strat­ed ­that the aor­tic dis­sec­tion in the ascend­ing aor­ta was cir­cum­fe­ren­tial and the prox­i­mal por­tion of the inti­mal ­flap was swing­ing ­through the aor­tic ­valve, i.e., fall­ing ­into the ­left ven­tri­cle dur­ing the dia­stol­ic ­phase and ­being eject­ed ­back ­into the ascend­ing aor­ta dur­ing the sys­tol­ic ­phase. An emer­gen­cy ­graft replace­ment of the ascend­ing aor­ta was per­formed. During ven­tric­u­lar fib­ril­la­tion ­under ­total car­di­o­pul­mo­nary ­bypass, we per­formed car­diac mas­sage to pre­vent myo­car­dial ische­mia, ­because ­blood ­flow ­from a ­heart ­lung ­machine invert­ed the inti­mal ­flap, ­which ­might ­have dis­turbed the cor­o­nary cir­cu­la­tion. The ­patient’s post­op­er­a­tive ­course was unevent­ful, and his post­op­er­a­tive ech­o­car­di­o­gram ­revealed ­only a ­trace of reg­ur­gi­tant ­flow ­through the aor­tic ­valve. Back-and-­forth move­ment of the cyl­in­der-­shaped inti­ma ­requires coex­is­tence of the fol­low­ing ­three con­di­tions: ­severe aor­tic regur­gi­ta­tion, cir­cum­fe­ren­tial dis­sec­tion, and com­plete tran­sec­tion of the inti­mal ­flap. We con­clude ­that ­this move­ment of the inti­mal ­flap ­should be regard­ed as one of the ­most seri­ous com­pli­ca­tions lead­ing rap­id­ly to car­di­o­gen­ic ­shock. From a sur­gi­cal ­point of ­view, it is ­most impor­tant to pre­vent myo­car­dial ische­mia dur­ing car­di­o­pul­mo­nary ­bypass espe­cial­ly in cas­es in ­which ven­tric­u­lar fib­ril­la­tion has ­occurred. We ­describe the ­ways to pre­vent myo­car­dial ische­mia in ­this ­rare sit­u­a­tion.