A 62-year-old man was admitted to a community hospital after experiencing acute pain in his jaw and head. He also had a near syncope but did not faint. At admission, his blood pressure was 97/39 mm Hg, and his pulse regular with

Figure 9.3. An acute Stanford type A dissection in a 62-year-old man. Note the completely destroyed intima and perfusion of the false lumen with no protective thrombus lading to an early rupture.

a rate of 58. An ECG revealed a 2 mm ST-elevation in leads II, III, aVF, and V2-4. Blood tests revealed a small increase in the myocardial markers CK-MB and Troponin-T. The condition was diagnosed to be an acute coronary syndrome, and LMWH, clopoidogrel, and nitroglycerine were administered. The patient was transferred to the IRAD unit for a coronary arteriograhy. On admission, the blood pressure was 115/63, and a clear diastolic aortic murmur was observed. An echocardiogram in the ER was diagnostic for a Stanford type A dissection. A CT scan was obtained while an OR was prepared (Figure 9.3), but the patient suddenly collapsed and was resuscitated while taken by the emergency team to the OR. He was immediately connected to a CPB circulation trough cannulation in the groin, and the sternum was opened. A very large cardiac tamponade was relieved when opening of the pericardium was performed, with all four chambers compressed.

The operation was from this point uneventful, and the ascending aorta was replaced by a supracoronary graft while the root was conserved. However, the patient did not recover consciousness, and a CT scan demonstrated diffuse cerebral damage compatible with global hypotension. He died after two days, and an autopsy revealed diffuse cerebral damage.

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