Management of Patients With Coronary Artery Malperfusion Secondary to Type A Aortic Dissection

Abstract

This study reviewed our experience with coronary artery (CA) malperfusion secondary to type A aortic dissection. Between 2002 and 2017, 76 patients presented with CA malperfusion, with a dissection flap limited to the aorta in the region of the coronary ostium (type A lesion) in 26 (34%), with a dissection flap involving the CA itself (type B lesion) in 32 (42%), or with complete avulsion of the CA (type C lesion) in 18 (24%). Ostial repair was successfully performed in 23 type A patients (88%), in 20 type B patients (63%), and in no type C patient (0%). CA bypass grafting was performed when antegrade cardioplegia could not be applied in all 18 type C patients (100%) and in 5 type B patients (16%) because of a primary entry at the coronary ostium and in 7 patients (type A: 3 patients [12%], type B: 4 patients [13%]) with evidence of CA disease (p < 0.001). Perioperative mortality in patients with CA malperfusion was high (18 patients [24%]), but there was no difference in short-term (p= 0.153) or long-term survival (log-rank p= 0.542). Also, a landmark analysis showed equal survival of discharged patients with and without CA malperfusion (log-rank p= 0.645). We recommend CA bypass grafting in patients with type C lesions or in patients with underlying CA disease for optimal delivery of cardioplegia and ostial pledgetted suture repair in patients with type A lesions or type B lesions when the administration of antegrade cardioplegia is successful.