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Acute Type A Aortic Dissection in a Parturient at 33 Weeks Gestation
Abstract Number: F1C-8
Abstract Type: Case Report/Case Series
A 32y G5P4004 at 33w gestation and no significant medical history presented to an outside hospital after suffering a syncopal event. Imaging revealed a Stanford A aortic dissection, beginning at the aortic root and extending past the origins of the great vessels. Bedside ultrasound demonstrated a normal fetus with an appropriate heart rate of 130. She was hemodynamically stable with significant back pain, and was transferred to a higher level of care.
Cardiac surgery, maternal and fetal medicine, neonatal intensive care (NICU), and cardiac anesthesia teams were mobilized to formulate a joint plan prior to proceeding to the operating room. Given the significant risks of the procedure and need for full anticoagulation, the plan was to perform a Cesarean delivery under general anesthesia, then proceed with the dissection repair once hemostasis was achieved in the abdomen.
The anesthesia team performed a bedside transthoracic echocardiogram which revealed significant aortic insufficiency and a pericardial effusion, thereby heightening concern for hemodynamic collapse upon induction of general anesthesia. Accordingly, as much surgical preparation as feasibly possible was performed prior to induction. The patient was prepped and draped in the usual sterile fashion for the aortic dissection repair, allowing for appropriate exposure of her abdomen for cesarean delivery.
After induction, the obstetric team performed a Cesarean delivery while the cardiac surgeons cannulated for cardiopulmonary bypass in the event of catastrophic hemodynamic collapse. The infant was delivered three minutes after skin incision with APGAR scores of 2/1/2 at 1, 5, and 10 minutes respectively, prompting aggressive resuscitation. Oxytocin was administered with appropriate contraction of the uterus. Intravenous heparin was given during fascial closure without evidence of further bleeding.
Therefore, upon closure of the abdomen, the cardiac surgeons performed a median sternotomy and cardiopulmonary bypass was initiated. The patient was placed in deep hypothermic circulatory arrest with antegrade cerebral perfusion for 28 minutes.
After weaning from bypass, she had good return of cardiac function, but rapidly digressed to bradycardia and asystolic arrest. The heart immediately recovered full function and she was successfully weaned. Unfortunately, transesophageal echo revealed a new massive type B dissection. A large false lumen produced near complete compression of the true abdominal aorta. However, mottling and perfusion of the lower extremities improved with an increase in systolic blood pressure, so she was treated for residual Type B dissection with medical management as opposed to surgical repair. She was extubated on POD 1 and weaned from all vasoactive drips by POD 3. The infant was transferred out of the NICU on day of life 16 on room air, taking full enteral feeds, and without evidence of intraventricular hemorrhage or significant organ dysfunction.