A 38-year-old woman with a history of three pregnancies and two normal deliveries, with an echocardiographic diagnosis of Marfan syndrome made in 2000, a history of rheumatic disease with mitral involvement and two brothers who died of aortic dissection.
The patient had a 37-week pregnancy, with good gestational control, without complications, until, without a specific trigger, she presented an intense pain in the retrosurgical echocardiography. The patient was referred to the hospital with a transthoracic needle.
Obstetrics of the Hospital El Pino and Cardiosurgical and Anesthetic Clinic of the National Thoracic Institute were coordinated, performing a double successive intervention.
Before surgery, a two-dimensional echocardiogram showed an ascending aortic dissection flap, which compromised 2.8 cm of the valve annulus, with moderate aortic insufficiency, severe mitral regurgitation and mild pericardial effusion.
Adequate ventricular function.
First, the obstetric part was approached to extract the fetus and avoid neonatal damage, performing an emergency cesarean section plus a subtotal hysterectomy and left adnexectomy.
The newborn presented a respiratory depression of short duration, probably associated to the anesthetic part, which did not determine subsequent sequels, with a habitual stay in the Neonatology Service of the Hospital el Pino.
In a second stage, immediately after cesarean section, the patient was placed on cardiopulmonary bypass (CPB) with cannulation by right subclavian artery and standard bicaval vein.
A dissecting hematoma was found in the usual position, without significant pericardial effusion.
During CPB, cooling began, aortic valve repair was performed with placement of the valve apparatus.
Subsequently, a circulatory arrest at 20°C with anterograde cerebral circulation was performed.
The false lumen was explored with permeability of the aortic arch, evidencing an intimate rupture site two centimeters from the valve plane.
Replacement of the ascending aorta was performed with a precoagulated microporous Dacron prosthesis of 26 mm. After this, proximal anastomosis and rewarming were performed, during this autologous ml pericardium anoplasty was performed.
The total time of circulatory arrest with selective anterograde cerebral perfusion was 23 min, aortic clamp 138 min and CPB 187 min the reperfusion time was 45 min.
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The patient required 5 days of hospitalization in the ICU with inotropic support, and the first 10 h on invasive mechanical ventilation.
Subsequently, the patient was admitted with fever episodes, so broad-spectrum empirical antibiotics were left (culture negative) and discharged without septic activity and in good general condition at 40 days.
The distant controls did not reveal any further complications.
Four months after surgery the patient was well, with grade II functional capacity, 2 pillow orthopnea and no edema.
Your child has a favorable outcome, without stigmata of Marfan's disease and remains under control in cardiology.
