Discussion
Our case report describes the treatment of ruptured aortic root aneurysm
by the replacement of the aortic arch by vascular prosthesis with
reimplantation of CABG proximal anastomoses. Type A aortic dissection is
a life-treating situation with high associated mortality [1]. Open
surgical aortic repair is a typical option for aortic dissection
treatment. In modern surgical practice, hemiarch is a safe and effective
procedure, especially in high-volume cardiac centers with sufficient
experience [2]. If the patient previously underwent other cardiac
surgery procedures, it increases risks because of resternotomy and
altered mediastinum. There are a few case reports and small researches
in the medical literature about the outcomes of aortic dissection in
patients with previous cardiac surgery (PCS) [3-6]. Gillinov et al.
after analysis of 56 patients with a history of previous cardiac surgery
postulated that patients having type A dissection late after cardiac
surgery infrequently have cardiac tamponade and hemodynamic collapse;
they require coronary angiography. Authors underlined that postoperative
mortality is low on condition of sufficient preoperative diagnostics and
perioperative critical care [7]. Norton et al. found that despite
the patients with PCS usually having significantly more comorbidities
and the operation being more complicated, the perioperative outcomes,
including mortality, were comparable to those of patients with primary
operation. The long-term survival was significantly worse in patients
with previous surgery; however, this circumstance was not a risk factor
for operative mortality (OR= 1.6, p=0.36) or all-time mortality (HR=1.3,
p=0.33) [3]. Özçınar et al. confirm this conclusion: after analysis
of the medical history of 32 patients with aortic type A dissection
after PCS, they found that careful planning of perioperative tactic
provides results that are comparable with outcomes in patients without
PCS [8]. Sandhu et al. analyzed 456 redo sternotomy cases in
proximal aortic repair and found that resternotomy is associated with
increased risk for short- and long-term mortality, but the fact of PCS
(aortic) did not add further risk [9]. For patients with high risk,
hybrid operations can be an option [10,11].
Our patient underwent open surgery by redo sternotomy, which increased
risks. Authors strongly believe that scrupulous perioperative critical
care and diagnostics can dramatically reduce risks and improve
postoperative outcomes.
Conflict of interestsThe authors declare that there are no conflicts of interests.
Ethics statementEthics approval was not necessary, written and informed consent was
obtained from the patient. Written consent for publication of case and
images was obtained from the patient