INTRODUCTION

Heart transplant recipients are at risk for post-transplantation complications such as rejection, infection,and graft dysfunction[1]. Post-transplantation aortic dissection is rare. The course of the disease and its surgical management are reported here.

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CASE PRESENTATION

Chief complaints

A 58-year-old female patient was admitted to our center because of low back pain without precipitating causes.

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History of present illness

Magnetic resonance imaging (MRI) showed a type A aortic dissection involving the aortic arch and extending to the ascending aorta up to the end of the left common iliac artery with an anomalous right subclavian artery (ARSA) (Figure 1).

History of past illness

The patient had an ARSA, which is encountered in approximately 1% of the population. In this case,the dissection originated from an entry tear in the transverse arch. Of crucial importance, unilateral antegrade cerebral perfusion through the right axillary artery could not be performed.

Personal and family history

The patient also had hypertension and diabetes mellitus.

Physical examination

Arterial hypertension is one of the most important risk factors for aortic dissection in general and occurs in about 71% of heart transplant patients in the first year after transplantation[3]. Tacrolimus,corticosteroids[4], and post-transplant weight gain are also related to arterial hypertension[5].

Laboratory examinations

The value of D-dimer was 0.84 mg/L, and G and GM tests were negative.

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Imaging examinations

On September 3, 2020, MRI showed a type A aortic dissection involving the aortic arch and extending to the ascending aorta up to the end of the left common iliac artery with an ARSA (Figure 1). The echocardiogram showed mild aortic valve insufficiency. The patient was diagnosed with type A aortic dissection.

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FINAL DIAGNOSIS

Type A aortic dissection following heart transplantation is a rare complication that requires emergency surgery. The patient benefited from a hybrid procedure, which shortened the operation time and reduced complications.

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TREATMENT

The patient underwent a hybrid procedure which included ascending aortic and aortic arch replacement, subclavian artery reconstruction, and endovascular repair of abdominal and thoracic aortic aneurysms. A cardiopulmonary bypass was established through the right femoral artery and femoral vein when the core body temperature was lowered to 30-32 ℃. The aberrant right subclavian artery,innominate artery, left common carotid artery, and left subclavian artery were blocked, and the left and right common carotid arteries were cannulated for bilateral cerebral perfusion. The distal port of the No.24 four-branched artificial vessel was anastomosed with the proximal covered stent of the descending aorta. Cardiopulmonary bypass was resumed, and the body temperature was gradually turned to normal. The proximal port of the four-branched artificial vessel was anastomosed with the proximal autogenous aortic vessels padded with bovine pericardium. The heart restarted spontaneously. The four branches of the aortic arch were reconstructed one by one. A 30 mm × 200 mm aortic-covered stent was implanted through a femoral artery incision (Figure 2).

On the third day after surgery, the patient was diagnosed with pneumonia and was treated with sulbactam sodium/cefoperazone sodium. During the postoperative period, esmolol hydrochloride and urapidil hydrochloride were used to control blood pressure. Ulinastatin was used to reduce myocardial reperfusion injury. Sulbactam sodium/cefoperazone sodium was used to prevent and control infection.Omeprazole was used to inhibit gastric acid secretion. The patient was discharged home 25 d after surgery without low back pain. One month after discharge, the patient complained of cough and expectoration. Erythrocyte sedimentation rate was 34 mm/h, and C-reactive protein was 35.9 mg/L. The above laboratory tests were normal after anti-infection treatment for 7 d. The patient had no symptoms,cough, or sputum.

OUTCOME AND FOLLOW-UP

The procedure lasted 510 min, the cardiopulmonary bypass lasted 133 min, and the ascending aorta was blocked for 10 min. The duration of ventilator assistance was 64.5 h after surgery and the stay time in intensive care units was 8 d for a lung infection and blood pressure control.

DISCUSSION

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Blood pressure on admission was 147/104 mmHg, and body mass index (BMI) was 30.1 kg/m

.

The patient underwent orthotopic heart transplantation (Bicaval technique) 28 mo ago for dilated cardiomyopathy with a left ventricular ejection fraction of 23%. Her immunosuppressive protocol including tacrolimus (0.5 mg, qod), mycophenolate mofetil (0.5 g, q12h), and prednisone (20 mg, bid).The donor was a 24-year-old man with no reported medical history.

CONCLUSION

The patient was diagnosed with type A aortic dissection after heart transplantation.

FOOTNOTES

Zeng Z performed the conceptualization, data curation, project administration, resources,supervision, and visualization, and wrote the original draft; Yang LJ performed the data curation, formal analysis,software, validation, and visualization, and wrote and edited the manuscript; Xu F obtained the funding; Zhang C performed the investigation and methodology.

Natural Science Foundation of Hubei Province in 2016, No. 2016CFB644.

Informed written consent was obtained from the patient for publication of this report and any accompanying images.

Aortic dissection after heart transplantation is very rare and is a serious complication[2]. In this case, the hybrid procedure shortened the operation time and reduced complications. Because the patient had an ARSA, the right axillary artery could not be selected for cardiopulmonary bypass intubation.

The authors declare that they have no conflict of interest to disclose.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

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China

Zhu Zeng 0000-0002-7164-4431; Lin-Jie Yang 0000-0002-3231-7489; Chao Zhang 0000-0003-2028-6416;Fen Xu 0000-0003-2990-5455.

Fan JR

Wang TQ

Fan JR

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