BACKGROUND: Acute aortic dissection (AAD) with impaired perfusion of the left coronary artery has a poor prognosis, even after urgent radical aortic surgery, due to extensive myocardial damage. Although Impella, a microaxial-flow catheter pump, is useful in managing acute myocardial infarction, it is generally contraindicated in patients with AAD because it is an intra-aortic device and the aortic structure is compromised in these cases. Here, we introduce a novel intervention that allowed a planned aortic repair after managing circulation using Impella and venoarterial extracorporeal membrane oxygenation in a case of AAD with left main trunk malperfusion.
METHODS: A 40-year-old man presented with cardiogenic shock. Percutaneous coronary intervention was performed to address left main trunk obstruction using an intra-aortic balloon pump; however, circulatory instability persisted. The patient was transferred to our hospital after venoarterial extracorporeal membrane oxygenation. Impella CP™ was used to improve his circulatory status. However, a subsequent CT scan confirmed an AAD diagnosis. After 5 days of stable circulatory support, the patient underwent aortic root replacement and coronary artery bypass grafting.
CONCLUSIONS: In patients with AAD and coronary malperfusion, adjunctive circulatory management with Impella may be a valuable therapeutic option.

OBJECTIVE: Acute type A aortic dissection with coronary malperfusion syndrome is rare but associated with high mortality. Multi-organ malperfusion is an independent predictor of acute type A aortic dissection. Coronary malperfusion requires treatment, but it is not feasible to treat all malperfusions. The adequacy of \"central repair and coronary artery bypass grafting\" for patients with coronary and other organ malperfusion is unknown.
METHODS: Of the 299 patients who underwent surgery between 2008 and 2018, 21 patients with coronary malperfusion, who received cental repair with coronary artery graft bypass, were analyzed retrospectively. They were divided; into Group M (n = 13, coronary and other organ malperfusion) and Group O (n = 8, coronary malperfusion only). The patient background, surgical content, details of malperfusion, surgical mortality and morbidity, and long-term outcome were compared.
RESULTS: There was no difference in operation time (205 ± 30 vs. 266 ± 88, p = 0.49), but the time from arrival to circulatory arrest tended to be shorter in Group M (81 vs. 134, p = 0.05). Among Group M, cerebral malperfusion was the most common at 92%. Two of the three cases with mesenteric malperfusion died. The mortality of Group M and Group O was 13% and 15% (P = 0.85), respectively. There was no difference in long-term mortality (p = 0.62).
CONCLUSIONS: Central repair and coronary artery bypass grafting is a sufficiently acceptable treatment for patients with acute type A aortic dissection and multi-organ malperfusion, including coronary malperfusion.

BACKGROUND: Acute type A aortic dissection (ATAAD) is a fatal disease and requires emergency surgery. In particular, it is known that mortality is high when a coronary artery is involved. However, the degree of myocardial damage of the coronary acute artery involvement (ACI) varies and may or may not increase creatine kinase muscle and brain isoenzyme (CK-MB). It is unknown how CK-MB elevation affects the surgical outcome. This study compared the surgical results between the two groups of ACI with or without CK-MB elevation.
METHODS: Among 348 patients who underwent an emergency operation for acute type A aortic dissection, there were 28 (8.0%) patients complicated by ACI and underwent additional coronary artery bypass grafting. We divided 26 of those patients into two groups; the MI group ( with CK-MB elevation) and the NMI group (without CK-MB elevation), and compared both groups.
RESULTS: Of the 26, sixteen were in the MI group, and ten were in the NMI group. The average CK-MB in the MI group was 225.5 IU/L, and that in the NMI group was 13.5 IU/L. The mean time from onset to surgery was 248 min in the MI group and 250 min in the NMI group. There was statistical significance in mortality ( 69% vs. 13%, p = 0.03). There was no significance in major complications (ICU days, reintubation, reoperation, pneumonia, sepsis).
CONCLUSIONS: Acute coronary artery involvement was associated with 8.0% of patients with ATAAD, and 62% had myocardial ischemia with CK-MB elevation. The MI group had significantly higher mortality than the NMI group. It is crucial for cases with suspected ACI to obtain coronary perfusion as soon as possible to prevent CK-MB from elevating.

Background: Coronary malperfusion (CM) secondary to acute type A aortic dissection (ATAAD) is considered rare but has a high mortality rate. This study examined the incidence, management, and outcomes of patients with CM secondary to ATAAD and proposes a modified Neri classification. Methods: Between 2015 and 2020, out of 1018 patients who underwent surgical repair for ATAAD, 137 presented with CM, including 68 (49.6%), 43 (31.3%), and 15 (10.9%) with Neri types A, B, and C, respectively, and 11 (8.0%) with coronary orifice intimal tear (COIT), which we consider a novel category. Results: The occurrence rate of CM was 13.4%. CM was associated with higher in-hospital mortality (18.2% vs. 7.8%, p < 0.001). For Neri type A (98.5%) and most type B lesions (72.1%), coronary repair was adequate. Coronary artery bypass grafting (CABG) was necessary for type B patients unsuited for repair (23.2%) and for all type C patients (100%). Repair of COIT was possible (45.5%). The in-hospital mortality rates differed significantly among the four lesion groups (p = 0.006). Conclusions: The occurrence of CM secondary to ATAAD may be more frequent than previously reported. Surgical management based on lesion classification achieved acceptable outcomes. Repair was adequate for Neri type A and most type B lesions. Other type B and type C lesions could be treated by CABG. Coronary orifice intimal tear is a unique set of lesions, for which orifice repair was also possible.

Left coronary artery malperfusion is a fatal complication of acute type A aortic dissection. However, effective treatment strategies have not yet been established. Herein, we report two cases of left coronary artery malperfusion successfully treated with different preoperative catheter interventions, followed by a central aortic repair. Preoperative coronary intervention ensuring the blood flow to the left coronary artery might be essential if a coronary angiogram was performed prior to the diagnosis and treatment.

Coronary malperfusion with acute type A aortic dissection is a fatal complication. It is controversial whether to prioritize central repair or coronary reperfusion. Lifesaving becomes even more difficult if a patient has pericardial haemorrhage. Herein, we report a case of acute type A aortic dissection associated with left coronary malperfusion and pericardial haemorrhage, wherein reperfusion of the left coronary artery was performed using only guidewires, and central repair could be performed without major delay. Coronary reperfusion using only guidewires can be a revolutionary therapeutic strategy for this disease.

A 54-year old man suffering from back pain was diagnosed with Stanford type A aortic dissection in our emergency unit. During the preparation of the operating room, he developed coronary ischemia with chest pain and depressed blood pressure accompanied with abnormal electro- and echocardiography findings. He was transported to the catheter laboratory where stent placement into the left main coronary artery was successfully performed. Thereafter, he underwent total arch replacement, during which the stent was removed intentionally without performing coronary artery bypass graft. His postoperative course was uneventful and he is doing well without any ischemic event for 2 years after the surgery.

In the surgical treatment of acute aortic dissection, the attachment of the dissected wall using surgical glue can be an effective procedure to stabilize the fragile dissected wall. A 42-year-old man underwent aortic root replacement for acute type A aortic dissection. However, after aortic declamping, he experienced severe myocardial impairment, which required an additional procedure of coronary artery bypass grafting. The unexpected myocardial ischaemia can be attributed to the inattentional use of surgical glue.

Coronary malperfusion associated with aortic dissection usually requires aggressive surgical treatment or catheter revascularization. Here, we report a case of conservatively treated coronary malperfusion associated with acute type A dissection before aortic root replacement. An 81-year-old woman was rushed to our hospital in a state of circulatory shock after developing chest pain. She was severely hypotensive on admission, and the electrocardiogram (ECG) revealed anterior and lateral ST elevation. However, the initial fluid resuscitation increased her blood pressure to a normal level, and the ischemic ECG changes disappeared in about 20 min. ECG-gated cardiac multidetector computed tomography showed a type A aortic dissection complicated with left main trunk dissection. A primary entry tear was located 5 mm below the left coronary ostium. The patient successfully underwent composite graft replacement of the aortic root in a stable hemodynamic condition. .

Coronary malperfusion is one of the most dreadful complications of acute aortic dissection because it causes catastrophic acute myocardial infarction in patients who are already severely ill. Our strategy was as follows. After the administration of heparin, emergency percutaneous coronary intervention (PCI) was urgently performed at the same time as starting to prepare the operating room. A stent was then placed to cover the full length of dissected coronary artery. Patients whose cardiac function improved after successful coronary artery reperfusion were transferred to the operating room to undergo central repair surgery. If the cardiac function did not recover even after coronary reperfusion, and the patient required extracorporeal membrane oxygenation, we considered the best supportive care without performing central repair surgery. In patients with left coronary malperfusion, we believe that preoperative PCI must be performed immediately. Preoperative PCI might delay central repair surgery and potentially increase the risk of catastrophic cardiac tamponade. However, the benefit of PCI in preserving cardiac function exceeds the risk of cardiac tamponade. The indications of PCI before central repair in patients with right coronary malperfusion should be considered after assessing each patient\'s condition, including the presence or absence of cardiac tamponade and right ventricular infarction, left ventricular function, the immediate availability of cardiologists or cardiac surgeons, and the speed of preparing the operating room.