Personal Stories: Susan Huenefeld's Father

 

I AM AN FP IN OHIO AND HAD THE UNFORTUNATE EXPERIENCE OF ACCOMPANYING MY FATHER TO THE ER WITH CHEST PAIN.  HE WAS A HEALTHY 63 YEAR OLD WITH WELL CONTROLLED HTN OF ~10-15YRS AND WELL CONTROLLED HLD    LDL< 100.

I ACTUALLY ARRIVED A FEW MINUTES BEFORE HE DID, AND GOT THE CATH LAB OPENED, AND THE CARDIOLOGIST ARRIVED WITHIN ABOUT 7-10 MINUTES.  IN THE CATH LAB WE FOUND THE DISSECTION GOING UP TO THE AORTIC ARCH.  THE CARDIOTHORACIC SURGEON WAS IMMEDIATELY CALLED AND SURGERY WAS UNDERWAY WITHIN AN HOUR.  I WAS PRESENT DURING THE WHOLE OPERATION. WE FOUND THE DISSECTION WENT INTO THE RCA, AND THE SURGEON THAT HE NEVER HAD GOT ANYONE OFF THE TABLE WITH THIS SEVERE OF A PROBLEM.  THE DISSECTION WAS ALSO SO SEVERE, THE TISSUE LEFT WAS LITERALLY THIN AS TISSUE PAPER. 

IT WAS AMAZING, MY DAD'S HEART STARTED BACK UP, JUMPING WITH JOY!      HOWEVER, HIS DIAPHRAGM WAS SO HIGH THAT HIS CHEST CAVITY WAS UNABLE TO BE CLOSED.  WE CALLED A VASCULAR, TRAUMA, AND TWO GENERAL SURGEONS CAME IN ALONG WITH THE TWO CARDIOVASCULAR SURGEONS.  THE CONCLUSION WAS THAT THERE WAS A RETRO PERITONEAL BLEED AND THAT IT SHOULD SEAL ITSELF OFF.  THE SUGGESTION WAS MADE THAT IT WOULD BE MORE DETRIMENTAL IT OPEN HIS ABDOMEN. 

I UNDERSTAND THAT IT COULD BE AN EXTENSION OF THE DISSECTION, OR A PERFORATION FROM THE ENTRY POINT( AS IT WAS EXTREMELY DIFFICULT).   HE ENDED UP DYING AFTER A HEROIC EFFORT FROM ALL, A NINE HOUR SURGERY, AND EIGHT HOURS POST OP, AND A FEW CARDIAC MASSAGE EFFORTS, ALONG WITH VASOPRESSERS ECT.   A FEW QUESTIONS.

HOW OFTEN DO PEOPLE REALLY MAKE IT AFTER AN RCA DISSECTION?    CAN DIVING 6 SCUBA DIVE IN 8 DAYS THREE WKS EARLIER HAVE ANYTHING TO DO WITH THE CAUSE OF THE DISSECTION?

HOW OFTEN DOES THE COMPLICATION OF A RETROPERITONEAL BLEED OCCUR?
 
THANKS FOR YOU TIME AND EFFORT, AND I'M CERTAINLY GLAD TO HEAR OF ALL THE SUCCESS STORIES ON THE SITE!
                                                                THANKS, 
 
        
                                                                      SUZETTE HUENEFELD M. D.

Dr. Liang's Reply:

When a dissection extends toward the heart it can sometimes propagate down the coronary arteries; most commonly right coronary artery - the RCA. It can certainly complicate the surgery. Most surgeons in this situation will try to repair the right coronary and at the same time place a bypass graft further down the right coronary past the dissected portion. I don't know exactly how much more risk it adds to the situation. it really depends how long the flow has been interrupted in the right coronary before the heart was stopped for the surgery.
 
I'm not sure that I have seen a retroperitoneal bleed in the setting of an acute type A dissection, but it certainly makes sense that there is the potential for such a complication. It can of course also simply occur spontaneously with the anti-coagulation that is necessary with bypass surgery.
 
I doubt that the scuba diving was a major factor in the dissection. He almost certainly had an underlying risk factor for dissection. The diving may have been the straw that broke the camels back, but it was probably not a big factor. Although you mention the hypertension and the cholesterol, it would be a mistake to attribute the dissection to the blood pressure. Very few 63 year olds with well controlled hypertension will suffer dissections. You need to make sure you look into possible underlying weaknesses in the aortic tissue, particularly given the surgeons description of the tissue. Many of these conditions can be inherited, so all your father's first degree relatives should be screened for possible aortic disease. Since many of these inherited conditions are not well characterized, it is important to know as much as you can about your father's condition as you can, so that the appropriate markers can be searched for in the remainder of the family. The information I would want if you were to see me would include;
1) Was you father's aortic valve normal - bicuspid aortic valve disease is a major cause of dissections.
2) Was the aorta enlarged and how much was it enlarged - this tells me whether looking for aortic enlargement with an echo, CT or MRI will be useful in screening other family members and also tells me if enlargement is found at what stage it should be considered for prophylactic repair.
3) Where was the initial tear in the intima and what was the appearance of the intima in that region - if the initial tear is at an atheroma, then we can guess that the dissection may have initiated as a plaque rupture and then atherosclerosis, even if mild becomes the primary suspect.
4. If tissue/blood is available - make sure the aortic tissue, especially adjacent to the dissected region is examined for degenerative changes. Blood if available should be kept for possible future DNA analysis. It's probably not worthwhile blindly checking for all known mutations associated with dissections, but in consultation with a geneticist or cardiologist familiar with genetically medicated aortic disease which if any syndromes should be investigated can be determined.
 
I know it is hard to think about some of these issues at this time, it is important to address it now. Tissue may not be available and the findings at surgery are still fresh in the surgeons mind, but will fade as time goes by.
 
David

 


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