Simultaneous C-section & Aortic Dissection Repair: A Challenging Surgical Feat

When acute aortic dissection occurs during pregnancy, it’s a rare and life-threatening scenario. And the severity is even greater when the disorder occurs during labor. This was the complex case presented to the team at Sanger Heart & Vascular Institute.

Acute Aortic Dissection During Labor

A 39-year-old woman who was 39 weeks pregnant, with prior history of caesarean section delivery, presented to an Atrium Health emergency room with both chest pain and contractions. She had a known diagnosis of Marfan syndrome, which exacerbated the hyperdynamic state and hormonal effects of pregnancy on the vasculature.

Initial vital signs and lab results were not compatible with life for the mother. The patient had a BMI of 48, systolic blood pressure of ≤90 mm Hg on maximal pressor support, pH of 7.12 and a lactate of 9 mmol/L, indicating severe pathophysiologic distress. Patients with similar findings often have a survival rate of less than 5 percent.

Physicians diagnosed acute type A aortic dissection, and following Atrium Heath’s Code Dissection protocol, they quickly transferred the patient to Carolinas Medical Center for immediate surgery.

Multidisciplinary Team Formulates Bold Plan

While the patient was en route, Jeko Madjarov, MD, a cardiothoracic surgeon with Sanger Heart & Vascular Institute, assembled a 20-person multidisciplinary team, including anesthesiology, neonatology, cardiothoracic surgery and obstetrics, to care for the mother and deliver the baby by a C-section and a simultaneous type A dissection repair.

With the mother severely malperfused and at risk of cardiac fibrillation and potential sudden cardiac death, Dr. Madjarov and his team determined that the C-section could not be performed prior to the dissection repair, as is ordinarily the case with third-trimester deliveries. To save the lives of the mother and child, who was also under severe distress, the operations needed to be performed at the same time.

Simultaneous C-section and Aortic Dissection Repair

Dr. Madjarov cannulated the right axillary artery, then opened the mother’s chest, fully anticoagulated the patient and placed her on cardiopulmonary bypass while the baby was delivered by C-section. The patient was cooled to 24 degrees Celsius. The team provided antegrade cerebral perfusion/protection with moderate hypothermic circulatory arrest through the axillary artery, using an 8 mm vascular graft.

Dr. Madjarov then performed a hemi-arch replacement and repaired the aortic root. While patients with Marfan syndrome often have a damaged aortic root, this patient did not require total root replacement, but rather a precise and meticulous repair. Once the patient was warmed and her chest and abdomen closed, she was transferred to the intensive care unit for further resuscitation and care. The two surgical procedures lasted a total of six hours.

Both the mother and child survived and experienced full recovery. The mother now sees a cardiac surgeon and a cardiologist once a year for a routine follow-up, including CT-angiography. The baby is healthy and thriving.

Advanced Cardiovascular Care at Sanger Heart & Vascular Institute

At Sanger Heart & Vascular Institute, our aortic and vascular programs are at the forefront of delivering lifesaving care, with some of the world’s most skilled teams and the nation’s top outcomes. With Code Rupture and Code Dissection protocols for treating aortic aneurysms and dissections, we’re capable of quickly assessing patients while simultaneously coordinating our medical teams to provide rapid-response care.

For more information, or to make a referral, call 877-999-7484.