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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 17  |  Issue : 2  |  Page : 151-153

Type A aortic dissection surgery in a pregnant woman: The hypothermic circulatory arrest as a double life-saving method


1 Department of Cardiovascular and Thoracic Surgery, University Hospital of Tingandogo, Ouagadougou, Burkina Faso; Department of Cardiovascular Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
2 Department of Cardiovascular and Thoracic Surgery, University Hospital of Tingandogo, Ouagadougou, Burkina Faso
3 Department of Cardiovascular Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France

Date of Submission06-Jul-2020
Date of Decision28-Sep-2020
Date of Acceptance06-Oct-2020
Date of Web Publication13-Nov-2021

Correspondence Address:
Dr. Adama Sawadogo
Department of Cardiovascular and Thoracic Surgery, University Hospital of Tingandogo, 11 BP 104 Ouagadougou CMS 11

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njc.njc_20_20

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  Abstract 


The authors report a case of a 44-year-old pregnant woman with Marfan syndrome who was diagnosed with type A aortic dissection at 25 weeks of pregnancy. She underwent a mechanical Bentall procedure with cardiopulmonary bypass and circulatory arrest. Postoperatively, the fetus was not distressed; echocardiogram and magnetic resonance imaging were repeated, and a prophylactic cesarean section was performed at 36 weeks. Both the mother and the baby were followed up for 1 year and presented no clinical issue.

Keywords: Aortic dissection, cardiopulmonary bypass, hypothermic circulatory arrest pregnancy


How to cite this article:
Sawadogo A, Belem F, Some NH, Camilleri L. Type A aortic dissection surgery in a pregnant woman: The hypothermic circulatory arrest as a double life-saving method. Nig J Cardiol 2020;17:151-3

How to cite this URL:
Sawadogo A, Belem F, Some NH, Camilleri L. Type A aortic dissection surgery in a pregnant woman: The hypothermic circulatory arrest as a double life-saving method. Nig J Cardiol [serial online] 2020 [cited 2021 Dec 4];17:151-3. Available from: https://www.nigjcardiol.org/text.asp?2020/17/2/151/330421




  Introduction Top


The use of cardiopulmonary bypass (CPB) during pregnancy is a high-risk procedure and has been previously shown to be associated with relatively high fetal and maternal mortality.[1] In case of acute type A aortic dissection that is a life-threatening condition, meticulous management in a multidisciplinary setting is paramount to secure the best outcomes for both the mother and the fetus.[2] In this case, the authors report their first experience in a successful management of a pregnant Marfan patient who presented type A aortic dissection.


  Case Report Top


A 40-year-old female patient with Marfan syndrome was admitted to the cardiac intensive care unit for acute Stanford type A aortic dissection. She was at 22 weeks of pregnancy. Her previous medical history included Harrington rod insertion for scoliosis when she was 13 and pericarditis that was medically treated when she was 16. Aortic dilatation (37 mm) was diagnosed, and since then, she was annually followed up. Furthermore, she already gave birth once after uneventful pregnancy during which bisoprolol was given. On the admission day, computed tomography (CT) showed dissection originating at 15 mm from the origin left subclavian artery. There was no distal ischemia. After consulting the Reference Center of Marfan, we decided to go for medical treatment with echocardiogram and magnetic resonance imaging (MRI) checks twice a week. Her clinical status progressively improved with antihypertensive drugs and pain killers. On day 13, she was discharged with normalized blood pressure and biology. Fetal echography showed normal flow in the umbilical cord and the two uterine arteries. A week after the discharge (25 weeks of pregnancy), the patient suddenly presented intense stress, tearing chest pain, and visual disturbances. The right upper limb was pulseless. Systolic blood pressure was 95 mmHg at the left arm. A new CT angiography scan revealed an extension of the dissection to the ascending aorta [Figure 1] and [Figure 2]. Due to fetal pulmonary immaturity, the staff privileged the mother's life. The plan was to perform surgery for aortic dissection without stopping the pregnancy. Then, we cannulated the right axillary artery, the left common carotid artery, and atriocaval cannula in the right atrium. A moderate hypothermic CPB (28°C) was conducted allowing circulatory arrest while the cerebral perfusion was maintained during 28 min. From the ascending aorta to the origin of the left subclavian artery, we did not find any entry point of the dissection. A mechanical Bentall procedure was performed with aortic prosthesis St Jude® N°21 and Tube of 22 mm. The total aortic cross-clamping time was 145 min and the CPB time lasted 203 min. 13,000 IU of heparin and 60 mg of protamine were given during CPB. The patient was transfused per-operatively with ×2 packed red blood cells, ×4 fresh frozen plasma, and ×1 platelet. The postoperative course was uneventful for both the patient and the fetus [Figure 3]. Particularly, obstetrical echography on postoperative day 7 did not show any sign of fetal distress. There was no cerebral structural abnormality. Doppler flows in the brain, umbilical cord, and placenta were normal. The patient was discharged on day 13 with obstetrical echography every week and 2 times cerebral magnetic resonance imaging (MRI) of the fetus on weeks 28 and 32 of pregnancy. A cesarean section was performed on week 36, and the newborn was normal. Both the mother and baby were satisfactorily followed up to 1 year.
Figure 1: Angio CT showing flap of ascending and descending aorta

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Figure 2: Angio CT showing dissection of arch

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Figure 3: Postoperative angio CT showing the tube as ascending aorta

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  Discussion Top


The main purpose of this report is to discuss the maternal and fetal management in pregnant patients undergoing cardiac surgery with the use of CPB associated with moderate hypothermic circulatory arrest. Wang et al.[3] reported a case series of nine pregnant women who underwent cardiac surgery with the use of CPB from the 9th to the 39th week of pregnancy. Five patients underwent heart surgery immediately after cesarean section. The other four patients terminated pregnancies after heart surgeries. We did not perform cesarean section concomitantly to cardiac surgery mainly because of the immaturity of the fetal lungs. In the same series, among the four patients who terminated pregnancies after heart surgeries, two of them underwent uterine curettage in the first trimester after embryonic death, one induction of labor in the second trimester, and one continued to be pregnant until 37 weeks' gestation. The use of moderate hypothermic circulatory arrest in our case gives it an added value as to the best of our knowledge; it has not been reported yet and not well described in Wang's series. In a setting, where immediate delivery before surgery is not permitted by gestational age or the emergent nature of the situation, Sepehripoura suggested (based on case review) the use of high-flow, high pressure, pulsatile, normothermic bypass, and fetal and uterine monitoring to allow cardiac surgery with the use of CPB with the greatest risk control in pregnant patients.[4] Patel et al. recently suggested a number of measures to improve the management. Pulsatile perfusion during CPB may be preferred because it enhances placental perfusion through vasodilation mediated by nitric oxide. Oxygen delivery to the placenta should be maximized with high normal blood flow, pressure, and hematocrit as well as preservation of maternal pH. Placental vasoconstriction should be minimized through minimizing exposure to hypothermia and systemic vasoconstrictors.[2] Pregnancy continuation after cardiac surgery with moderate hypothermic arrest is not yet described in the literature. Here, we also suggest a close monitoring of fetal development based on echography and MRI, particularly focused on embryonic or fetal cerebral growth.


  Conclusion Top


The occurrence of type A aortic dissection in a pregnant woman is a condition of life threatening for both the mother and the fetus. Optimal management may aim to preserve both lives. In some extents, CPB with hypothermic circulatory arrest can be used satisfactorily during the cardiac procedures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jahangiri M, Clarke J, Prefumo F, Pumphrey C, Ward D. Cardiac surgery during pregnancy: Pulsatile or nonpulsatile perfusion? J Thorac Cardiovasc Surg 2003;126:894-5.  Back to cited text no. 1
    
2.
Patel PA, Fernando RJ, MacKay EJ, Yoon J, Gutsche JT, Patel S, et al. Acute type a aortic dissection in pregnancy-diagnostic and therapeutic challenges in a multidisciplinary setting. J Cardiothorac Vasc Anesth 2018;32:1991-7.  Back to cited text no. 2
    
3.
Wang H, Zhang J, Li B, Li Y, Zhang H, Wang Y, et al. Maternal and fetal outcomes in pregnant patients undergoing cardiac surgery with cardiopulmonary bypass. Zhonghua Fu Chan Ke Za Zhi 2014;49:104-8.  Back to cited text no. 3
    
4.
Sepehripour AH, Lo TT, Shipolini AR, McCormack DJ. Can pregnant women be safely placed on cardiopulmonary bypass? Interact Cardiovasc Thorac Surg 2012;15:1063-70.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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