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Eur J Cardiothorac Surg 2006;29:264-265
© 2006 Elsevier Science NL
Letters to the Editor |
Department of Cardiovascular Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano 390-8621, Japan
Received 8 November 2005; accepted 9 November 2005.
* Tel.: +81 263 37 2657; fax: +81 263 37 2721. (Email: masasaka{at}hsp.md.shinshu-u.ac.jp).
Key Words: Aortic dissection • Pregnancy • Cardiopulmonary bypass
We would like to express our appreciation to Mr. Jahangiri for his letter regarding our article on surgery for acute type A aortic dissection in pregnant patients with Marfan syndrome [1]. He referred to our case of aortic surgery with the fetus in utero and pointed out the utility of mild hypothermia, pulsatile perfusion, and high flow rates for cardiopulmonary bypass (CPB) in pregnant patients. In past reports, the use of CPB during pregnancy has been associated with a maternal mortality rate of 3–15% and a fetal mortality rate of 20–33% [2]. The main mechanisms underlying these poor outcomes include hypothermia, placental vasoconstriction and contraction resulting in fetal hypoxia and bradycardia during CPB. Thus, as remarked by Mr. Jahangiri, full maternal and fetal monitoring is critical for improving outcomes [3].
In our study, a 33-year-old pregnant woman with Marfan syndrome and her fetus (26 weeks of gestation) died after surgical treatment of acute type A aortic dissection. At the time of the patient's presentation, we counseled the patient regarding the high risk of fetal loss if the procedure was performed with the fetus remaining in situ with deep hypothermia and circulatory arrest. However, in the year 1997, when this case was performed, there were no other alternative surgical techniques available to treat this condition. Thus, we recommended operative aortic repair following cesarean section of this immature fetus, but the patient and her family declined this treatment course.
Regardless, this case illustrated that minimization of deep hypothermic circulatory arrest was critical when performing this operation with the fetus remaining in situ, as was referred to by Mr. Jean Bachet in Appendix A. Editorial comment [4]. Mr. Bachet advised us that, in this situation, the aortic root and ascending aorta had to be replaced under full flow CPB with moderate hypothermia, even though the dissection involved the ascending aorta and the intimal tear was located in the ascending aorta. Further, careful attention must be made in regard to intraoperative malperfusion during CPB to maintain blood flow to both the mother and her fetus. These issues illustrate that surgery for acute aortic dissection in pregnant patients with Marfan syndrome poses many challenges, and the full availability of various surgical techniques are required to assure favorable outcomes for the mother and her fetus.
References
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