2024 FSA Podium and Poster Abstracts

P003: MASSIVE AORTIC DISSECTION PRESENTING AS MONOPARESIS OF RIGHT LOWER EXTREMITY REQUIRING AORTIC HEMIARCH REPLACEMENT
Harshvardhan Rajen, MD; Oleg Desyatnikov, DO; Valentina Rojas Ortiz, MD; Jackeline Porto, MD; Gian Paparcuri, MD; HCA Florida Kendall Hospital

Our patient is a 72 year old man with past medical history of hypertension and remote smoking history, having quit around 45 years prior, who presented with unilateral weakness of his right lower extremity. Per the patient he was preparing to go to the gym when he was unable to move his right leg. He was found to have a contained acute Type A dissection of his aorta that started just distal to the aortic root, and terminated in the right common femoral artery. Due to the massive extent of the dissection, the decision was made for a repair of his aortic arch at this time in order to repair the primary defect and then proceed at a later date with endovascular repair of the remaining dissection flap. The planned surgical procedure was a hemiarch replacement of the aortic arch, which included a bioprosthetic graft of the arch and of the brachiocephalic trunk.

General anesthesia was induced successfully and included high dose fentanyl and esmolol to prevent sympathetic response and hemodynamic changes including wall stress on the aorta upon direct laryngoscopy. After the patient was placed on cardiopulmonary bypass, they were then cooled in preparation for deep hypothermic circulatory arrest. Neuroprotective strategies were used to minimize risk of neurological insult. These included a target temperature of 18 degrees Celsius which was achieved with a combination of ice around the head of the patient and cooling the circulating blood volume as it passed through the bypass machine. Core temperature was monitored via a nasal temperature probe. The other neuroprotective interventions that the patient received were high dose corticosteroids, propofol bolus, as well as selective retrograde cerebral perfusion of cold packed red blood cells through a cannula placed in the superior vena cava. Once the target temperature was achieved, circulatory arrest was initiated, and replacement of the arch was started. The total circulatory arrest time was 19 minutes. The patient was then gradually rewarmed to a temperature of 34 degrees Celsius via nasal temperature, and then the patient was allowed to passively rewarm to normal temperature prior to cessation of bypass machine. Total bypass time was 160 minutes.

Postoperatively the patient was transferred to the intensive care unit. His postoperative course was complicated by new onset atrial fibrillation, failure to wean off the ventilator, and renal failure. Unfortunately on postoperative day 7, the patient was palliatively extubated and expired.