Perioperative Stanford Type A Aortic Dissection (TAAD) in an 84 year old patient undergoing coronary-artery bypass grafting (CABG): a case report.

Background: Iatrogenic aortic dissection is a rare complication of elective cardiac surgery, occurring in 0.06-0.23% of cases1,2. Despite this, its impact is significant, due to high mortality and morbidity, with early mortality as high as 60%2.
Case report: An 84 year old male suffering of left main coronary artery disease, clinically manifest by exertional dyspnoea, was scheduled to undergo surgical revascularization. Pre-operative co-morbidities included a moderately-severe depressed left ventricular ejection fraction (LVEF) and calcification of thoracic aorta. 
CABG was performed using bilateral internal thoracic artery technique, allowing complete revascularization. Routine monitoring included transoesophageal echocardiography (TOE).
TOE evaluation while weaning from cardiopulmonary bypass (CPB) revealed acute type A aortic dissection. Immediate replacement of the ascending aorta with a tubular aortic graft was performed, leading to a total CPB time of 170 min and cross clamping time of 104 min (70 min for aortic procedure). 
Perioperative complications were cardiogenic shock, with bi-ventricular dysfunction requiring high doses of dobutamine, noradrenaline and inhaled nitric oxide (iNO) and diffuse bleeding, treated by transfusion of packed red blood cells, platelets and 4.5 g of fibrinogen concentrate.
Other post-operative life-threatening complications were ischemic stroke, late-onset septic shock of pulmonary origin and aortic graft infectious endocarditis. 
The patient was transferred to the ward after 42 days in the ICU, having made a full neurological and cardiac recovery.
Discussion: While a rare complication of cardiac surgery, TAAD can be managed if a high index of suspicion is maintained. Nonetheless, these patients have high rates of mortality and morbidity and their ICU course poses a significant challenge.
References:
1. Fleck, T., Ehrlich, M., Czerny, M., Wolner, E., Grabenwoger, M., & Grimm, M. Interactive cardiovascular and thoracic surgery, 2006;5(1), 11-14.
2. Leontyev, S., Borger, M. A., Legare, J. et al European Journal of Cardio-Thoracic Surgery, 2012;41(3), 641-646.
Learning points: Routine perioperative TOE monitoring in cardiac surgery can help early detection and prompt management of complications, such as TAAD.