Acute cardiac dysfunction and rapid descending aortic expansion following surgery for acute Stanford type A aortic dissection: a case report.

Background: Severe true lumen stenosis of the aorta can increase left ventricular afterload and impair cardiac function. We report a rare case of significant true lumen stenosis and cardiac dysfunction after undergoing total arch replacement for acute type A aortic dissection. Case summary: A 39-year-old man with acute Stanford type A aortic dissection and intimal tear in the ascending aorta underwent the Bentall procedure and total arch replacement with a frozen elephant trunk (FET). He was readmitted 1 month after discharge with progressive cardiac dysfunction. Myocardial scintigraphy excluded ischaemia, and computed tomography revealed severe true lumen stenosis at the distal FET, resulting in an elevated left ventricular afterload. Thoracic endovascular aortic repair (EVAR) to expand the true lumen resulted in gradual improvement in cardiac function. However, there was progressive dilation of the descending and thoracoabdominal aorta: 26 mm at onset and 32 and 46 mm at 2 and 6 months postoperatively, respectively. To close distal re-entries, EVAR was performed after 2 months. His brain natriuretic peptide level decreased from 2901 to 142 pg/ml over 8 months; open abdominal aortic replacement was performed 9 months after the onset, after sufficient cardiac function recovery (ejection fraction = 40%). Discussion: True lumen stenosis is a substantial reversible cause of cardiac dysfunction after type A dissection surgery. Thoracic EVAR effectively reduces the afterload and restores cardiac function; long-term imaging and staged intervention are essential to address distal aortic remodelling.