Emergency Aortic Dissection Surgery

Redo Aortic Root Replacement, Valve Removal, and Arch Reconstruction in a 62-Year-Old with a History of Bicuspid Aortic Valve Replacement

Surgeon: Dr. Vishal Khullar, Director, Cardiothoracic & Vascular Surgery, Heart and Lung Transplant
Procedure: Redo Sternotomy with Aortic Root Replacement, Removal of Previous Aortic Valve, and Aortic Arch Reconstruction for Acute Aortic Dissection

Patient details below are recorded in line with confidentiality conventions for written case studies. Patient identity has been withheld.

Condition

The patient presented to the emergency department with acute abdominal pain and absent distal pulses. Three years earlier, the patient had undergone aortic valve replacement at another hospital for a bicuspid aortic valve. Given that history and the absent pulses on examination, a CT scan of the chest, abdomen, and pelvis was performed. It revealed an extensive acute aortic dissection extending all the way from the aortic root down to the iliac bifurcation and into the legs. The patient was taken to the operating room emergently.

Impact on the Patient

By the time the patient reached the operating room, the left leg had no pulse and was cold and numb, a sign that the dissection had already cut off meaningful blood flow to the limb. A dissection extending from the aortic root to the legs is about as extensive as this condition gets, and the fact that it had developed in a patient with a prior bicuspid valve replacement added real complexity to the surgical planning. Cases at this level of urgency and complexity are exactly why a patient’s best chance rests with an experienced cardiac surgeon in Mumbai who can move from diagnosis to the operating table without delay.

What the CT Scan Showed Was Needed

• A redo sternotomy, given the patient’s prior open-heart surgery
• Removal of the previously implanted aortic valve
• Aortic root replacement
• Aortic arch reconstruction

Why Circulatory Arrest and Specific Cannulation Were Required

• Aortic arch reconstruction typically requires circulatory arrest under deep hypothermia to allow the surgical team to work on the arch safely
• Because the brain is highly sensitive to anoxia, the right axillary artery and right femoral vein were cannulated to perfuse the brain during circulatory arrest
• A redo operation of this kind carries added risk at the very first step: with the heart and major vessels adherent to the breastbone from the previous surgery, there was no room for error during the redo sternotomy itself

Step-by-Step Surgical Overview

1. Right axillary artery and right femoral vein cannulated to allow brain perfusion during circulatory arrest
2. Redo sternotomy performed with extreme care, as the heart and major vessels were adherent to the breastbone from the prior surgery
3. Aortic root dissection undertaken; Bioglue from the previous operation was found to have seeped around the origins of the coronary arteries, leaving the aortic root frozen and making dissection of the coronary buttons extremely difficult
4. Previous aortic valve removed
5. Aortic root replaced
6. Deep hypothermic circulatory arrest instituted to allow safe aortic arch reconstruction
7. Aortic arch reconstructed
8. Patient rewarmed and weaned off bypass
9. Left leg pulse confirmed to have returned
10. Intraoperative transesophageal echocardiography performed, confirming normal left and right ventricular function

Procedure Facts

These CT images formed the basis for the diagnosis of an extensive acute aortic dissection and the surgical plan that followed, alt text suggestion: “CT angiogram acute aortic dissection Dr Vishal Khullar Mumbai.”

The footage shows two of the most critical moments of the operation: the dissection plane itself, with blood tracking longitudinally through the aortic media, and the circulatory arrest phase, with NIRS holding steady to confirm the brain was safely protected at depth, cardiopulmonary bypass running solely for antegrade cerebral perfusion, and a flat arterial trace confirming the circulatory arrest under deep hypothermia at 18°C.

The surgery took almost 12 hours. By its conclusion, the pulse in the left leg had returned, a direct sign that limb perfusion had been restored along with repair of the dissection. Intraoperative transesophageal echocardiography showed normal left and right ventricular function, with an LVEF of 60–65%.

Outcomes at a Glance

PATIENT TESTIMONIAL

“I came to the hospital with severe abdominal pain and was found to have an extensive aortic dissection involving the aorta from the root to the iliac bifurcation and into the legs. I was taken for emergency surgery, which involved a redo sternotomy, aortic root replacement, removal of my previous aortic valve, and aortic arch reconstruction. The surgery was complex and lasted almost 12 hours, but by the end, the pulse in my left leg had returned and my heart was functioning well.”

Profile: 62 years · Patient identity withheld
Procedure: Redo Aortic Root Replacement and Arch Reconstruction for Acute Aortic Dissection
Surgeon: Dr. Vishal Khullar · Director, Cardiothoracic & Vascular Surgery, Heart and Lung Transplant

POST-PROCEDURE CARE AND RECOVERY

This case underscores the importance of regular checkups for patients with a bicuspid aortic valve. A bicuspid aortic valve is a congenital condition present from birth and can run in families. It is associated with aortopathy and a tendency to develop aortic aneurysms, which can enlarge over time and rupture once the aorta reaches a particular threshold, an event known as an aortic dissection and a medical emergency. Regular monitoring of the aorta is therefore important, as is screening family members for a bicuspid aortic valve. Our guide on lifestyle after aortic dissection surgery covers what the recovery period and long-term monitoring generally involve.

Have a bicuspid aortic valve, or a family history of one?

If you or a family member has a bicuspid aortic valve, or has had prior aortic valve surgery, regular monitoring of the aorta is essential. Dr. Vishal Khullar and his team are happy to review your imaging and talk through a monitoring plan with you.

Dr. Vishal Khullar
Director, Cardiothoracic & Vascular Surgery, Heart and Lung Transplant
Fortis Hospital Mulund / Fortis S.L. Raheja Hospital, Mumbai | +91-99870 77880 | appointments@drvishalkhullar.com