Post-Cardiopulmonary Bypass Surgery with Sequential ECMO Therapy for the Management of Aortic Dissection Complicated with Myocardial Infarction: a case report

Post-Cardiopulmonary Bypass Surgery with Sequential ECMO Therapy for the Management of Aortic Dissection Complicated with Myocardial Infarction: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Post-Cardiopulmonary Bypass Surgery with Sequential ECMO Therapy for the Management of Aortic Dissection Complicated with Myocardial Infarction: a case report H Honghao, Geng Gao, Z Jinbao, W Xiaohong, J Li, L Shunbi, Ke Yang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4945556/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Aortic dissection, a critical cardiovascular condition, poses a significantly high risk of mortality. The clinical manifestations associated with myocardial infarction can complicate the diagnosis of aortic dissection, thereby hindering timely and comprehensive treatment administration and aggravating patient prognosis. However, the administration of ECMO therapy postoperatively for aortic dissection has been shown to effectively enhance patient outcomes. Case presentation A 45-year-old male patient presented to our hospital's emergency department complaining of back pain. Upon urgent electrocardiogram examination, he was diagnosed with acute inferior ST-segment elevation myocardial infarction complicated by third-degree atrioventricular block. Promptly, the patient underwent treatment for acute myocardial infarction and was urgently transferred to the interventional catheterization laboratory. Coronary angiography revealed a 60% stenosis in the distal portion of the circumflex artery, attributed to plaque accumulation. Despite the subsequent performance of balloon angioplasty and thrombectomy, the patient's precordial pain persisted. Subsequently, an emergency thoracic aortic computed tomography angiography (CTA) and echocardiography were conducted, revealing the presence of a DeBakey Type I aortic dissection. Prompt action was taken, and the patient was immediately transferred to the cardiac surgery department. There, he underwent an emergency surgical procedure involving cardiopulmonary bypass (CPB) for the replacement of the ascending aorta and aortic sinus. Postoperatively, he was supported with extracorporeal membrane oxygenation (ECMO) and gradually regained consciousness under the intensive care unit's vigilant supervision. Once hemodynamic stability was achieved, ECMO support was discontinued. The patient ultimately recovered and was successfully discharged from the hospital. Conclusion This case underscores that precordial pain is not exclusively confined to myocardial infarction, but may also coexist with aortic dissection. The implementation of ECMO therapy postoperatively can effectively mitigate adverse prognoses stemming from myocardial infarction, cardiopulmonary bypass procedures, prolonged cardiac arrest, and myocardial ischemia-reperfusion injury. Furthermore, individualized treatment holds utmost significance in managing complex aortic dissections. case report aortic dissection acute myocardial infarction extracorporeal membrane oxygenation Figures Figure 1 Figure 2 Introduction Acute Type A aortic dissection (AD), the most common subtype across the spectrum of aortic dissection diseases, is distinctively characterized by the tearing of the inner layer of the ascending aorta wall, extending at least to the aortic arch [ 1 ]. This pathological process subsequently leads to the disruption of aortic blood flow, resulting in severe clinical consequences. These consequences may include a range of fatal symptoms such as stroke, coronary artery occlusion, renal failure, cardiac tamponade, and heart failure [ 2 ]. Myocardial infarction primarily arises from a significant reduction or cessation of blood supply to the coronary arteries, causing prolonged myocardial ischemia and ultimately triggering myocardial necrosis [ 3 ]. Notably, when aortic dissection affects the coronary artery opening, disrupting its normal blood flow, or in extreme scenarios such as shock and hypotension triggered by aortic dissection, insufficient coronary perfusion can concurrently induce myocardial infarction, further compounding the severity of the condition [ 3 ]. Moreover, myocardial infarction not only causes necrosis of myocardial cells, severely compromising the contractile and diastolic functions of the heart, but it also disrupts the normal electrophysiological activities of the heart, predisposing it to arrhythmias. This, in turn, can lead to systemic circulatory disorders. Additionally, it can trigger ischemia and hypoxia in other crucial organs, such as the brain, liver, and kidneys, ultimately resulting in their dysfunction [ 4 ]. Extracorporeal membrane oxygenation (ECMO) is primarily utilized to provide sustained extracorporeal respiratory and circulatory support to patients with severe cardiopulmonary dysfunction, which effectively ensured that the compromised heart and lungs receive the requisite oxygenation and circulatory assistance, thereby mitigating the cardiopulmonary burden [ 5 ]. Additionally, ECMO stabilizes the circulatory system, guaranteeing adequate blood supply to vital organs, including the brain and kidneys [ 6 ]. Herein, we present a case study involving a patient with aortic dissection complicated by myocardial infarction, who underwent successful ECMO treatment. Case description A 45-year-old male patient presented to our hospital's emergency department complaining of back pain, having a prolonged history of hypertension and hyperlipidemia. Upon emergency electrocardiogram examination, he was diagnosed with acute inferior ST-segment elevation myocardial infarction and third-degree atrioventricular block. With the consent of the patient and his family, a coronary angiography was promptly conducted in accordance with the chest pain center protocol. The procedure revealed the presence of a plaque in the distal segment of the circumflex artery, causing a 60% stenosis, with a TIMI 3 flow grade. Additionally, occlusion was observed in the mid-segment of the right coronary artery, resulting in a TIMI 0 flow grade. Consequently, a temporary pacemaker was implanted, followed by balloon angioplasty and thrombectomy. Postoperatively, the patient was transferred to the cardiology intensive care unit for further management. His treatment plan included temporary cardiac pacing, anticoagulation therapy, antiplatelet agents, intensive lipid-lowering measures to stabilize plaques, enhancement of myocardial metabolism, reduction of myocardial oxygen consumption, retardation of myocardial remodeling, blood pressure control, acid suppression to mitigate the risk of gastrointestinal bleeding, electrolyte balance maintenance, bowel regularization, and sedative therapy to promote restful sleep, among other symptomatic treatments tailored to his specific condition. Upon admission, the patient's monitoring revealed frequent atrial premature contractions, ventricular premature contractions, paroxysmal atrial tachycardia, and brief bursts of ventricular tachycardia. Consequently, esmolol was administered via infusion pump for antiarrhythmic therapy. Subsequently, an emergency thoracic aortic computed tomography angiography (CTA) and ultrasonography were conducted, revealing an aortic dissection of DeBakey Type I. The dissection originated from the root of the ascending aorta and extended through the ascending aorta, descending aorta, and abdominal aorta within the scanning range. Notably, the true lumen was relatively small, whereas the false lumen was enlarged. The tear was approximately located above the root of the ascending aorta. The brachiocephalic trunk, left common carotid artery, left subclavian artery, and the celiac artery within the scanning range arose from the true lumen (as depicted in Fig. 1 . After discussing the patient's condition with their family members, it was emphasized that the patient was suffering from aortic dissection complicated by acute myocardial infarction and cardiac dilation. This posed a significant risk of aortic dissection rupture, cardiac arrest, malignant arrhythmias, cardiogenic shock, multiple organ failure, and sudden death at any given moment. Therefore, the patient was promptly transferred to our department for scheduled surgical intervention. The surgery was performed within a median sternotomy incision, involving a longitudinal incision of the pericardium to suspend the heart for external exploration. The innominate artery, left common carotid artery, and left subclavian artery were isolated and ligated. After intracardiac heparinization, cannulation was sequentially inserted into the right femoral artery, right subclavian artery, superior and inferior vena cava, and ligation was performed. Cardiopulmonary bypass was initiated, the aorta was occluded, and the right atrium was opened. A left heart drainage tube was inserted through the root of the right superior pulmonary vein. The aortic root was then incised, and retrograde perfusion of cardioplegia solution was administered through the coronary veins. During the exploration, significant dilation of the ascending aorta, severe edema of the vascular wall, and extensive tearing of the intima and adventitia were observed, with only the adventitia remaining intact. A tear in the dissection was identified, located approximately 2 cm above the non-coronary sinus, with a diameter of about 2 cm. Notably, the dissection did not involve the brachiocephalic trunk, left common carotid artery, left subclavian artery, or the left and right coronary arteries. The aortic valve leaflets were assessed to be of good quality, without evidence of rheumatic or calcific lesions. Repeated water testing confirmed satisfactory closure, thus obviating the need for aortic valve replacement. The proximal resection extended from the diseased non-coronary sinus to the aortic valve annulus, while the distal resection terminated at the proximal branch of the innominate artery. the affected aortic valve junction was suspended to the corresponding position of the aortic wall using a 2 − 0 imported valve replacement suture. An artificial biological patch, approximately shaped like the non-coronary sinus, was first cut and a 5 − 0 sliding suture was employed to perform a sandwich reinforcement suture on the proximal autologous vascular intima + adventitia + artificial biological patch of the aorta. Additionally, a 5 − 0 sliding suture was utilized for the replacement of the non-coronary sinus with an artificial biological patch. A 26 artificial blood vessel was selected for end-to-end suture with the proximal incision of the ascending aorta using a 4 − 0 sliding suture, ensuring the suture was tightly sealed. A 4 − 0 sliding suture was then used to perform a sandwich-style end-to-end anastomosis between the distal end of the artificial blood vessel and the normal vascular wall of the distal aorta. After the anastomosis was completed, an exhaust needle was placed. The aortic cross-clamping was released to initiate circulation, and the heart automatically resumed beating. Temporary pacing leads were sutured on the epicardium and subcutaneously, connected to a temporary pacemaker, and pacing parameters were set. After the circulation stabilized, the inferior vena cava cannula was removed, and the internal environment was adjusted. The flow was gradually reduced and the machine was turned off. However, the heart rate and blood pressure could not be maintained after the machine was turned off, so cardiopulmonary bypass assistance was reinitiated. Despite repeated cardiopulmonary bypass assistance, the machine could not be successfully turned off. After communicating with the patient's family about the condition, intraoperative extracorporeal membrane oxygenation (ECMO) was installed, and a left femoral venous cannula was placed. The femoral artery and venous cannulas were connected to the ECMO connection tube, and ECMO assistance was initiated while stopping the cardiopulmonary bypass machine. The axillary arterial cannula was removed, and the blood vessels and incisions were sutured. Careful hemostasis was performed on the chest due to extensive wound bleeding. Intraoperative blood recovery was initiated, and hemostatic gauze and sterile bandages were applied to the bleeding sites. A pericardial longitudinal drainage tube was placed, and due to osteoporosis of the sternum, a sternal retractor and steel wire were used for layered interrupted suturing to close the chest. The surgery was successful with no omissions during the procedure. Due to intraoperative bleeding amounting to 1000ml, significant destruction of blood cells by extracorporeal circulation, and insufficient cardiac filling during the priming of the extracorporeal circuit, we administered 4.5 units of red blood cells and 600ml of plasma for supportive treatment. There were no adverse reactions, such as anaphylactic rash, observed in the patient either during or after the transfusion. The time of selective cerebral perfusion was 44 minutes, the total circulatory arrest time was 45 minutes, and the CPB time was 229 minutes. When the patient was taken to the ICU, the BP was 90/70mmHg and CVP was 11cm H 2 O. Three hours later, the patient recovered consciousness. The patient was extubated in 8 hours post-operation. We regularly monitored the changes of cardiac function through bedside transthoracic echocardiogram (TTE) (Fig. 2 ). The movement of the right ventricular wall gradually improved. On day 3 post-operative, ECMO was removed. The final postoperative TTE revealed that the left ventricular ejection fraction was 55% and the right ventricular wall moved normally. The patient recovered uneventfully. Discussion Acute type A AD was the most critical complication of cardiovascular surgery. The mortality rate of acute type A AD increases by 1% every hour within 48 h of onset. Conservative treatment has a high mortality rate of 50% within 2 days [ 7 ]. Surgery was the preferred treatment for acute type A AD. The most prevalent causes of mortality in aortic dissection cases were rupture of the dissection, incompetent aortic valve closure, and ischemia and necrosis of vital organs resulting from occlusion of blood supply to aortic branches. The primary factor contributing to insufficient perfusion in branch vessels was the absorption of a significant portion of blood by the false lumen arising from the intimal tear in the branch vessel. Consequently, this leaded to dilation of the false lumen and compression of the true lumen, ultimately causing insufficient blood supply to organs [ 8 ]. When aortic dissection involves organs or other crucial branch arteries, the surgical treatment strategy remained controversial. For instance, aortic dissections typically required the urgent repair of ruptured or impending ruptures in the aortic wall to avert fatal hemorrhages and subsequent sudden death. Conversely, acute myocardial infarctions necessitate the prompt restoration of blood flow to obstructed coronary arteries in order to salvage myocardial mitigate further damage [ 9 ]. Patients with acute Type A aortic dissections and myocardial infarctions commonly exhibited persistent chest and back pain as the primary clinical manifestation [ 10 ]. Consequently, during the acute phase of coronary artery syndromes, relying solely on chest pain symptoms for diagnosis can easily lead to misdiagnosis. This was because acute aortic dissections were not limited to simple coronary artery pathologies. Acute myocardial infarctions may also represent the initial manifestation of acute aortic dissections [ 8 ]. Therefore, for the rapid diagnosis of such diseases, cardiac ultrasound examinations are particularly crucial, and when necessary, aortic computed tomography angiography (CTA) may be required for further confirmation [ 11 ]. Additionally, Pace Maker Originated Cardiac Ultrasound (POCUS) can rapidly diagnose Type A aortic dissections, allowing for the adjustment of treatment strategies for patients with ST segment elevation myocardial infarctions [ 12 ]. There existed significant conflicts and limitations between the therapeutic approaches for these two diseases. Specifically, at the level of pharmacological intervention, myocardial infarction and aortic dissection require different anticoagulation protocols. In terms of blood pressure management, patients with myocardial infarction needed to maintain relatively higher blood pressure levels to ensure adequate perfusion of the coronary arteries; whereas patients with aortic dissection necessitate a rapid reduction in blood pressure to significantly minimize the risk of aortic rupture. As for the selection of treatment strategies, thrombolytic therapy may be required in emergency situations for myocardial infarction to reopen the obstructed coronary artery. However, thrombolytic therapy is absolutely contraindicated for patients with aortic dissection [ 13 ]. Therefore, in the field of clinical medicine, it is crucial to identify a treatment regimen that can simultaneously address both diseases. Extracorporeal Membrane Oxygenation (ECMO) was primarily utilized to provide continuous extracorporeal respiratory and circulatory support for patients with severe cardiopulmonary insufficiency [ 14 ]. It played a pivotal role in the treatment of critical illnesses such as cardiogenic shock resulting from acute myocardial infarction [ 15 ], fulminant myocarditis [ 16 ], and severe respiratory failure [ 17 ]. In the management of aortic dissection combined with myocardial infarction, ECMO can partially or fully substitute for the cardiac pump function, alleviating the workload of the heart and affording it ample rest and recovery [ 18 ]. Multiple studies have demonstrated that ECMO significantly improved the prognosis of patients with aortic dissection complicated by myocardial infarction [ 19 , 20 ]. It holded considerable value not only in supporting right heart function but also in ensuring the stability of aortic dissections involving the coronary artery and facilitating myocardial recovery [ 21 ]. Careful postoperative management was also vital for ensuring the survival of patients who have undergone extracorporeal membrane oxygenation (ECMO). In our case, the femoral artery served as the arterial cannulation site for the ECMO cannula. When the patient presented with unstable hemodynamic conditions, femoral cannulation was found to be a more facile and expeditious procedure, and fortunately, the patient did not manifest any symptoms of calf ischemia [ 22 ]. As the same time, in most medical centers, patients receiving ECMO support were typically maintained on mechanical ventilation and sedation [ 23 , 24 ]. Conversely, our ECMO patients were actively encouraged to undergo early extubation, which offered three distinct advantages. Firstly, prompt extubation aids in reducing the incidence of ventilator-associated complications [ 25 ]. Secondly, patients experienced a significant boost in confidence following extubation. Lastly, oral feeding stimulated appetite, thereby facilitating the administration of nutritional supplements. Additionally, we regularly monitored activated clotting time and platelet counts to ensure hemostasis. Bleeding remained a significant complication associated with ECMO support. However, fortunately, our case had not experienced fatal bleeding complications. Therefore, rigorous postoperative management was paramount for achieving optimal outcomes. Declarations Consent for publication Informed Consent for the publication of this case has been obtained from the patient. Competing interests The authors declare no competing interests. Financial support National Natural Science Foundation of China (82102506), Sichuan leading carder health care research project (2023 − 1301) and Sichuan Science and Technology Program (2023NSFSC1477). Author Contribution Honghao Huang contributed substantially to the conception, design, analysis, and interpretation of data for the work; and drafted and revised the work. Mei Xin contributed substantially to the acquisition, analysis, interpretation of data, and revising the intellectual content. Ke Y made substantial contributions to the interpretation of data and revising the intellectual content. Jinbao Z made substantial contributions to the interpretation of data and revising the intellectual content. Xiaohong W and Feng Gao made substantial contributions to the interpretation of data and revising the intellectual content. Shunbi L and Li J made substantial contributions to bedside transthoracic echocardiogram (TTE). Ke Yang and Mei Xin contributed substantially to the conception, design, acquisition, analysis, and interpretation of data for the work; and drafted and revised the work. All authors read and approved the final manuscript. Acknowledgements The authors are grateful to a patient who has allowed us to conduct this case report in proper shape. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4945556","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":357370452,"identity":"59abb3dd-ab1e-49f9-ba93-5613433b4e51","order_by":0,"name":"H Honghao","email":"","orcid":"","institution":"General Hospital of Western Theater Command (Chengdu Military General Hospital)","correspondingAuthor":false,"prefix":"","firstName":"H","middleName":"","lastName":"Honghao","suffix":""},{"id":357370453,"identity":"f38cf81e-5327-45e7-b7f0-c16f15edf67f","order_by":1,"name":"Geng Gao","email":"","orcid":"","institution":"General Hospital of Western Theater Command (Chengdu Military General Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Geng","middleName":"","lastName":"Gao","suffix":""},{"id":357370454,"identity":"dfee680f-a07a-4405-bb7f-c7ccc0790482","order_by":2,"name":"Z Jinbao","email":"","orcid":"","institution":"General Hospital of Western Theater Command (Chengdu Military General Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Z","middleName":"","lastName":"Jinbao","suffix":""},{"id":357370455,"identity":"48ff32c1-5db8-4941-a7f3-4b56dcba2ed3","order_by":3,"name":"W Xiaohong","email":"","orcid":"","institution":"General Hospital of Western Theater Command (Chengdu Military General Hospital)","correspondingAuthor":false,"prefix":"","firstName":"W","middleName":"","lastName":"Xiaohong","suffix":""},{"id":357370456,"identity":"a8da1a16-ea94-4bee-bb64-f51865a9b93b","order_by":4,"name":"J Li","email":"","orcid":"","institution":"General Hospital of Western Theater Command (Chengdu Military General Hospital)","correspondingAuthor":false,"prefix":"","firstName":"J","middleName":"","lastName":"Li","suffix":""},{"id":357370457,"identity":"6772160b-9633-4a18-81ad-a66879bf142a","order_by":5,"name":"L Shunbi","email":"","orcid":"","institution":"General Hospital of Western Theater Command (Chengdu Military General Hospital)","correspondingAuthor":false,"prefix":"","firstName":"L","middleName":"","lastName":"Shunbi","suffix":""},{"id":357370458,"identity":"56fecfee-57ba-48ea-a981-902690748395","order_by":6,"name":"Ke Yang","email":"","orcid":"","institution":"General Hospital of Western Theater Command (Chengdu Military General Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Ke","middleName":"","lastName":"Yang","suffix":""},{"id":357370459,"identity":"0a175926-fd4a-479d-be55-31c2ac7a15f8","order_by":7,"name":"Mei Xin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIie2QvQrCMBSFEwLtEu0aERXf4EqhOBR9llKIi4OjkyQEnPoAfYw+ghrURXBt0cFJ144dOvgzS1s3h3zDnc7H4VyEDIZ/hLwPsP70KOUtB3/SVBm76KTVKF7wsGnXMhDpbN2l+Q6LuiwcW/skX7BAikB0fdgQZOt9UqV0VJtnMTBXoa1w53BtI8p5WqU4hHoXCqy3xlKEc7gTxKhXqVhvpQSGI4KFHoPGok75tLyePIwtLBVqonQU9bLotQUoVjgCHlp1W+B88tKiXPVh8HgURelPHFsfKpUv636LGwwGg+EbT41bSF7U6lgRAAAAAElFTkSuQmCC","orcid":"","institution":"General Hospital of Western Theater Command (Chengdu Military General Hospital)","correspondingAuthor":true,"prefix":"","firstName":"Mei","middleName":"","lastName":"Xin","suffix":""}],"badges":[],"createdAt":"2024-08-20 13:59:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4945556/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4945556/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":66744113,"identity":"958761ad-a15a-44ef-9eac-6659beb30a31","added_by":"auto","created_at":"2024-10-16 06:13:14","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":313910,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative aortic CTA image. (A–D) CTA shows an enlargement of the ascending aorta, with the intima and adventitia being torn.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4945556/v1/1694cdabf20000a2396530a7.jpg"},{"id":66744114,"identity":"3875f755-9f69-4ffd-8168-42c38d9e4737","added_by":"auto","created_at":"2024-10-16 06:13:15","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":240180,"visible":true,"origin":"","legend":"\u003cp\u003e(A-D) Postoperative bedside transthoracic echocardiogram (TTE).\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4945556/v1/d214e3d67acfe7764da3e8b7.jpg"},{"id":66745498,"identity":"80ce0992-c1a5-4701-9c5c-46bd3b5a8a4d","added_by":"auto","created_at":"2024-10-16 06:29:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":827282,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4945556/v1/cdb656c6-a221-446a-8050-c1fac565f32f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Post-Cardiopulmonary Bypass Surgery with Sequential ECMO Therapy for the Management of Aortic Dissection Complicated with Myocardial Infarction: a case report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute Type A aortic dissection (AD), the most common subtype across the spectrum of aortic dissection diseases, is distinctively characterized by the tearing of the inner layer of the ascending aorta wall, extending at least to the aortic arch [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This pathological process subsequently leads to the disruption of aortic blood flow, resulting in severe clinical consequences. These consequences may include a range of fatal symptoms such as stroke, coronary artery occlusion, renal failure, cardiac tamponade, and heart failure [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Myocardial infarction primarily arises from a significant reduction or cessation of blood supply to the coronary arteries, causing prolonged myocardial ischemia and ultimately triggering myocardial necrosis [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Notably, when aortic dissection affects the coronary artery opening, disrupting its normal blood flow, or in extreme scenarios such as shock and hypotension triggered by aortic dissection, insufficient coronary perfusion can concurrently induce myocardial infarction, further compounding the severity of the condition [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Moreover, myocardial infarction not only causes necrosis of myocardial cells, severely compromising the contractile and diastolic functions of the heart, but it also disrupts the normal electrophysiological activities of the heart, predisposing it to arrhythmias. This, in turn, can lead to systemic circulatory disorders. Additionally, it can trigger ischemia and hypoxia in other crucial organs, such as the brain, liver, and kidneys, ultimately resulting in their dysfunction [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eExtracorporeal membrane oxygenation (ECMO) is primarily utilized to provide sustained extracorporeal respiratory and circulatory support to patients with severe cardiopulmonary dysfunction, which effectively ensured that the compromised heart and lungs receive the requisite oxygenation and circulatory assistance, thereby mitigating the cardiopulmonary burden [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Additionally, ECMO stabilizes the circulatory system, guaranteeing adequate blood supply to vital organs, including the brain and kidneys [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Herein, we present a case study involving a patient with aortic dissection complicated by myocardial infarction, who underwent successful ECMO treatment.\u003c/p\u003e"},{"header":"Case description","content":"\u003cp\u003eA 45-year-old male patient presented to our hospital's emergency department complaining of back pain, having a prolonged history of hypertension and hyperlipidemia. Upon emergency electrocardiogram examination, he was diagnosed with acute inferior ST-segment elevation myocardial infarction and third-degree atrioventricular block. With the consent of the patient and his family, a coronary angiography was promptly conducted in accordance with the chest pain center protocol. The procedure revealed the presence of a plaque in the distal segment of the circumflex artery, causing a 60% stenosis, with a TIMI 3 flow grade. Additionally, occlusion was observed in the mid-segment of the right coronary artery, resulting in a TIMI 0 flow grade. Consequently, a temporary pacemaker was implanted, followed by balloon angioplasty and thrombectomy. Postoperatively, the patient was transferred to the cardiology intensive care unit for further management. His treatment plan included temporary cardiac pacing, anticoagulation therapy, antiplatelet agents, intensive lipid-lowering measures to stabilize plaques, enhancement of myocardial metabolism, reduction of myocardial oxygen consumption, retardation of myocardial remodeling, blood pressure control, acid suppression to mitigate the risk of gastrointestinal bleeding, electrolyte balance maintenance, bowel regularization, and sedative therapy to promote restful sleep, among other symptomatic treatments tailored to his specific condition. Upon admission, the patient's monitoring revealed frequent atrial premature contractions, ventricular premature contractions, paroxysmal atrial tachycardia, and brief bursts of ventricular tachycardia. Consequently, esmolol was administered via infusion pump for antiarrhythmic therapy. Subsequently, an emergency thoracic aortic computed tomography angiography (CTA) and ultrasonography were conducted, revealing an aortic dissection of DeBakey Type I. The dissection originated from the root of the ascending aorta and extended through the ascending aorta, descending aorta, and abdominal aorta within the scanning range. Notably, the true lumen was relatively small, whereas the false lumen was enlarged. The tear was approximately located above the root of the ascending aorta. The brachiocephalic trunk, left common carotid artery, left subclavian artery, and the celiac artery within the scanning range arose from the true lumen (as depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. After discussing the patient's condition with their family members, it was emphasized that the patient was suffering from aortic dissection complicated by acute myocardial infarction and cardiac dilation. This posed a significant risk of aortic dissection rupture, cardiac arrest, malignant arrhythmias, cardiogenic shock, multiple organ failure, and sudden death at any given moment. Therefore, the patient was promptly transferred to our department for scheduled surgical intervention.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe surgery was performed within a median sternotomy incision, involving a longitudinal incision of the pericardium to suspend the heart for external exploration. The innominate artery, left common carotid artery, and left subclavian artery were isolated and ligated. After intracardiac heparinization, cannulation was sequentially inserted into the right femoral artery, right subclavian artery, superior and inferior vena cava, and ligation was performed. Cardiopulmonary bypass was initiated, the aorta was occluded, and the right atrium was opened. A left heart drainage tube was inserted through the root of the right superior pulmonary vein. The aortic root was then incised, and retrograde perfusion of cardioplegia solution was administered through the coronary veins. During the exploration, significant dilation of the ascending aorta, severe edema of the vascular wall, and extensive tearing of the intima and adventitia were observed, with only the adventitia remaining intact. A tear in the dissection was identified, located approximately 2 cm above the non-coronary sinus, with a diameter of about 2 cm. Notably, the dissection did not involve the brachiocephalic trunk, left common carotid artery, left subclavian artery, or the left and right coronary arteries. The aortic valve leaflets were assessed to be of good quality, without evidence of rheumatic or calcific lesions. Repeated water testing confirmed satisfactory closure, thus obviating the need for aortic valve replacement. The proximal resection extended from the diseased non-coronary sinus to the aortic valve annulus, while the distal resection terminated at the proximal branch of the innominate artery. the affected aortic valve junction was suspended to the corresponding position of the aortic wall using a 2\u0026thinsp;\u0026minus;\u0026thinsp;0 imported valve replacement suture. An artificial biological patch, approximately shaped like the non-coronary sinus, was first cut and a 5\u0026thinsp;\u0026minus;\u0026thinsp;0 sliding suture was employed to perform a sandwich reinforcement suture on the proximal autologous vascular intima\u0026thinsp;+\u0026thinsp;adventitia\u0026thinsp;+\u0026thinsp;artificial biological patch of the aorta. Additionally, a 5\u0026thinsp;\u0026minus;\u0026thinsp;0 sliding suture was utilized for the replacement of the non-coronary sinus with an artificial biological patch. A 26 artificial blood vessel was selected for end-to-end suture with the proximal incision of the ascending aorta using a 4\u0026thinsp;\u0026minus;\u0026thinsp;0 sliding suture, ensuring the suture was tightly sealed. A 4\u0026thinsp;\u0026minus;\u0026thinsp;0 sliding suture was then used to perform a sandwich-style end-to-end anastomosis between the distal end of the artificial blood vessel and the normal vascular wall of the distal aorta. After the anastomosis was completed, an exhaust needle was placed. The aortic cross-clamping was released to initiate circulation, and the heart automatically resumed beating. Temporary pacing leads were sutured on the epicardium and subcutaneously, connected to a temporary pacemaker, and pacing parameters were set. After the circulation stabilized, the inferior vena cava cannula was removed, and the internal environment was adjusted. The flow was gradually reduced and the machine was turned off. However, the heart rate and blood pressure could not be maintained after the machine was turned off, so cardiopulmonary bypass assistance was reinitiated. Despite repeated cardiopulmonary bypass assistance, the machine could not be successfully turned off. After communicating with the patient's family about the condition, intraoperative extracorporeal membrane oxygenation (ECMO) was installed, and a left femoral venous cannula was placed. The femoral artery and venous cannulas were connected to the ECMO connection tube, and ECMO assistance was initiated while stopping the cardiopulmonary bypass machine. The axillary arterial cannula was removed, and the blood vessels and incisions were sutured. Careful hemostasis was performed on the chest due to extensive wound bleeding. Intraoperative blood recovery was initiated, and hemostatic gauze and sterile bandages were applied to the bleeding sites. A pericardial longitudinal drainage tube was placed, and due to osteoporosis of the sternum, a sternal retractor and steel wire were used for layered interrupted suturing to close the chest. The surgery was successful with no omissions during the procedure. Due to intraoperative bleeding amounting to 1000ml, significant destruction of blood cells by extracorporeal circulation, and insufficient cardiac filling during the priming of the extracorporeal circuit, we administered 4.5 units of red blood cells and 600ml of plasma for supportive treatment. There were no adverse reactions, such as anaphylactic rash, observed in the patient either during or after the transfusion. The time of selective cerebral perfusion was 44 minutes, the total circulatory arrest time was 45 minutes, and the CPB time was 229 minutes. When the patient was taken to the ICU, the BP was 90/70mmHg and CVP was 11cm H\u003csub\u003e2\u003c/sub\u003eO. Three hours later, the patient recovered consciousness. The patient was extubated in 8 hours post-operation. We regularly monitored the changes of cardiac function through bedside transthoracic echocardiogram (TTE) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The movement of the right ventricular wall gradually improved. On day 3 post-operative, ECMO was removed. The final postoperative TTE revealed that the left ventricular ejection fraction was 55% and the right ventricular wall moved normally. The patient recovered uneventfully.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAcute type A AD was the most critical complication of cardiovascular surgery. The mortality rate of acute type A AD increases by 1% every hour within 48 h of onset. Conservative treatment has a high mortality rate of 50% within 2 days [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Surgery was the preferred treatment for acute type A AD. The most prevalent causes of mortality in aortic dissection cases were rupture of the dissection, incompetent aortic valve closure, and ischemia and necrosis of vital organs resulting from occlusion of blood supply to aortic branches. The primary factor contributing to insufficient perfusion in branch vessels was the absorption of a significant portion of blood by the false lumen arising from the intimal tear in the branch vessel. Consequently, this leaded to dilation of the false lumen and compression of the true lumen, ultimately causing insufficient blood supply to organs [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. When aortic dissection involves organs or other crucial branch arteries, the surgical treatment strategy remained controversial. For instance, aortic dissections typically required the urgent repair of ruptured or impending ruptures in the aortic wall to avert fatal hemorrhages and subsequent sudden death. Conversely, acute myocardial infarctions necessitate the prompt restoration of blood flow to obstructed coronary arteries in order to salvage myocardial mitigate further damage [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatients with acute Type A aortic dissections and myocardial infarctions commonly exhibited persistent chest and back pain as the primary clinical manifestation [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Consequently, during the acute phase of coronary artery syndromes, relying solely on chest pain symptoms for diagnosis can easily lead to misdiagnosis. This was because acute aortic dissections were not limited to simple coronary artery pathologies. Acute myocardial infarctions may also represent the initial manifestation of acute aortic dissections [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Therefore, for the rapid diagnosis of such diseases, cardiac ultrasound examinations are particularly crucial, and when necessary, aortic computed tomography angiography (CTA) may be required for further confirmation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Additionally, Pace Maker Originated Cardiac Ultrasound (POCUS) can rapidly diagnose Type A aortic dissections, allowing for the adjustment of treatment strategies for patients with ST segment elevation myocardial infarctions [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere existed significant conflicts and limitations between the therapeutic approaches for these two diseases. Specifically, at the level of pharmacological intervention, myocardial infarction and aortic dissection require different anticoagulation protocols. In terms of blood pressure management, patients with myocardial infarction needed to maintain relatively higher blood pressure levels to ensure adequate perfusion of the coronary arteries; whereas patients with aortic dissection necessitate a rapid reduction in blood pressure to significantly minimize the risk of aortic rupture. As for the selection of treatment strategies, thrombolytic therapy may be required in emergency situations for myocardial infarction to reopen the obstructed coronary artery. However, thrombolytic therapy is absolutely contraindicated for patients with aortic dissection [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Therefore, in the field of clinical medicine, it is crucial to identify a treatment regimen that can simultaneously address both diseases.\u003c/p\u003e \u003cp\u003eExtracorporeal Membrane Oxygenation (ECMO) was primarily utilized to provide continuous extracorporeal respiratory and circulatory support for patients with severe cardiopulmonary insufficiency [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. It played a pivotal role in the treatment of critical illnesses such as cardiogenic shock resulting from acute myocardial infarction [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], fulminant myocarditis [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], and severe respiratory failure [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In the management of aortic dissection combined with myocardial infarction, ECMO can partially or fully substitute for the cardiac pump function, alleviating the workload of the heart and affording it ample rest and recovery [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Multiple studies have demonstrated that ECMO significantly improved the prognosis of patients with aortic dissection complicated by myocardial infarction [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. It holded considerable value not only in supporting right heart function but also in ensuring the stability of aortic dissections involving the coronary artery and facilitating myocardial recovery [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCareful postoperative management was also vital for ensuring the survival of patients who have undergone extracorporeal membrane oxygenation (ECMO). In our case, the femoral artery served as the arterial cannulation site for the ECMO cannula. When the patient presented with unstable hemodynamic conditions, femoral cannulation was found to be a more facile and expeditious procedure, and fortunately, the patient did not manifest any symptoms of calf ischemia [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. As the same time, in most medical centers, patients receiving ECMO support were typically maintained on mechanical ventilation and sedation [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Conversely, our ECMO patients were actively encouraged to undergo early extubation, which offered three distinct advantages. Firstly, prompt extubation aids in reducing the incidence of ventilator-associated complications [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Secondly, patients experienced a significant boost in confidence following extubation. Lastly, oral feeding stimulated appetite, thereby facilitating the administration of nutritional supplements. Additionally, we regularly monitored activated clotting time and platelet counts to ensure hemostasis. Bleeding remained a significant complication associated with ECMO support. However, fortunately, our case had not experienced fatal bleeding complications. Therefore, rigorous postoperative management was paramount for achieving optimal outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConsent for publication\u003c/h2\u003e \u003cp\u003e Informed Consent for the publication of this case has been obtained from the patient.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eFinancial support\u003c/h2\u003e \u003cp\u003eNational Natural Science Foundation of China (82102506), Sichuan leading carder health care research project (2023\u0026thinsp;\u0026minus;\u0026thinsp;1301) and Sichuan Science and Technology Program (2023NSFSC1477).\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHonghao Huang contributed substantially to the conception, design, analysis, and interpretation of data for the work; and drafted and revised the work. Mei Xin contributed substantially to the acquisition, analysis, interpretation of data, and revising the intellectual content. Ke Y made substantial contributions to the interpretation of data and revising the intellectual content. Jinbao Z made substantial contributions to the interpretation of data and revising the intellectual content. Xiaohong W and Feng Gao made substantial contributions to the interpretation of data and revising the intellectual content. Shunbi L and Li J made substantial contributions to bedside transthoracic echocardiogram (TTE). Ke Yang and Mei Xin contributed substantially to the conception, design, acquisition, analysis, and interpretation of data for the work; and drafted and revised the work. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThe authors are grateful to a patient who has allowed us to conduct this case report in proper shape.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZhu Y, Lingala B, Baiocchi M, Tao JJ, Toro Arana V, Khoo JW, Williams KM, Traboulsi AA, Hammond HC, Lee AM, Hiesinger W, Boyd J, Oyer PE, Stinson EB, Reitz BA, Mitchell RS, Miller DC, Fischbein MP, Woo YJ. Type A Aortic Dissection-Experience Over 5 Decades: JACC Historical Breakthroughs in Perspective. J Am Coll Cardiol. 2020;76(14):1703\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Martino A, Morganti R, Falcetta G, Scioti G, Milano AD, Pucci A, Bortolotti U. Acute aortic dissection and pregnancy: Review and meta-analysis of incidence, presentation, and pathologic substrates. 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Liver Transpl. 2021;27(5):627\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBonicolini E, Martucci G, Simons J, Raffa GM, Spina C, Lo Coco V, Arcadipane A, Pilato M, Lorusso R. Limb ischemia in peripheral veno-arterial extracorporeal membrane oxygenation: a narrative review of incidence, prevention, monitoring, and treatment. Crit Care. 2019;23(1):266.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDoll N, Kiaii B, Borger M, et al. Five-year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock. Ann Thorac Surg. 2004;77:151\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsai MT, Hsu CH, Luo CY, Hu YN, Roan JN. Bridge-to recovery strategy using extracorporeal membrane oxygenation for critical pulmonary hypertension complicated with cardiogenic shock. Interact Cardiovasc Thorac Surg. 2015;21:55\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFior G, Colon ZFV, Peek GJ, Fraser JF. Mechanical Ventilation during ECMO: Lessons from Clinical Trials and Future Prospects. Semin Respir Crit Care Med. 2022;43(3):417\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"case report, aortic dissection, acute myocardial infarction, extracorporeal membrane oxygenation","lastPublishedDoi":"10.21203/rs.3.rs-4945556/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4945556/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAortic dissection, a critical cardiovascular condition, poses a significantly high risk of mortality. The clinical manifestations associated with myocardial infarction can complicate the diagnosis of aortic dissection, thereby hindering timely and comprehensive treatment administration and aggravating patient prognosis. However, the administration of ECMO therapy postoperatively for aortic dissection has been shown to effectively enhance patient outcomes.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003eA 45-year-old male patient presented to our hospital's emergency department complaining of back pain. Upon urgent electrocardiogram examination, he was diagnosed with acute inferior ST-segment elevation myocardial infarction complicated by third-degree atrioventricular block. Promptly, the patient underwent treatment for acute myocardial infarction and was urgently transferred to the interventional catheterization laboratory. Coronary angiography revealed a 60% stenosis in the distal portion of the circumflex artery, attributed to plaque accumulation. Despite the subsequent performance of balloon angioplasty and thrombectomy, the patient's precordial pain persisted. Subsequently, an emergency thoracic aortic computed tomography angiography (CTA) and echocardiography were conducted, revealing the presence of a DeBakey Type I aortic dissection. Prompt action was taken, and the patient was immediately transferred to the cardiac surgery department. There, he underwent an emergency surgical procedure involving cardiopulmonary bypass (CPB) for the replacement of the ascending aorta and aortic sinus. Postoperatively, he was supported with extracorporeal membrane oxygenation (ECMO) and gradually regained consciousness under the intensive care unit's vigilant supervision. Once hemodynamic stability was achieved, ECMO support was discontinued. The patient ultimately recovered and was successfully discharged from the hospital.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis case underscores that precordial pain is not exclusively confined to myocardial infarction, but may also coexist with aortic dissection. The implementation of ECMO therapy postoperatively can effectively mitigate adverse prognoses stemming from myocardial infarction, cardiopulmonary bypass procedures, prolonged cardiac arrest, and myocardial ischemia-reperfusion injury. Furthermore, individualized treatment holds utmost significance in managing complex aortic dissections.\u003c/p\u003e","manuscriptTitle":"Post-Cardiopulmonary Bypass Surgery with Sequential ECMO Therapy for the Management of Aortic Dissection Complicated with Myocardial Infarction: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-16 06:13:10","doi":"10.21203/rs.3.rs-4945556/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c1fd7d5e-6c50-49cc-9c6c-fd2ba707451d","owner":[],"postedDate":"October 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-30T10:38:30+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-16 06:13:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4945556","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4945556","identity":"rs-4945556","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}