Abstract 4367714: Bridge to Recovery: Successful Integration of Frozen Elephant Trunk and VA-ECMO in Acute Type A Dissection with Cardiogenic Shock

Abstract

Introduction: Acute type A aortic dissection (ATAAD) is a life-threatening emergency requiring urgent surgical repair. The Frozen Elephant Trunk (FET) technique enables single-stage treatment of extensive aortic disease but carries risk of postcardiotomy shock due to prolonged ischemia and surgical complexity. Early initiation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as a bridge to recovery in this context. We report a case of ATAAD complicated by severe biventricular failure successfully managed with intraoperative VA-ECMO following FET. Case Report / Methods: A 36-year-old previously healthy male presented with acute chest and back pain. CT angiography demonstrated DeBakey type I dissection extending to the descending aorta. Emergent surgery was performed via median sternotomy with cardiopulmonary bypass through axillary and right atrial cannulation. Circulatory arrest was induced at 24°C with selective antegrade cerebral perfusion. Total arch replacement with branched graft and deployment of a 26 mm FET stent graft were completed, alongside valve-sparing root replacement. Severe biventricular dysfunction persisted on attempted weaning from bypass despite inotropic support. Early VA-ECMO was initiated via femoral cannulation, stabilizing hemodynamics. Results: Within 48 hours, lactate levels normalized and echocardiography demonstrated progressive ventricular recovery. ECMO was successfully weaned on postoperative day 4. The patient was extubated on day 5 and discharged from ICU on day 8 without neurological deficits. At 30-day follow-up, cardiac function was fully restored and aortic repair remained stable. Discussion: Post-FET postcardiotomy shock is a recognized complication in extensive aortic repairs. Early VA-ECMO preserves end-organ perfusion, facilitates myocardial recovery, and prevents multiorgan failure. This case illustrates the critical role of timely intraoperative ECMO in reversing cardiogenic shock. Neuroprotection strategies were maintained, with no neurological sequelae. The absence of prior cardiac disease and rapid escalation of mechanical support likely contributed to the favorable outcome. Conclusion: Early integration of VA-ECMO with FET repair in ATAAD complicated by cardiogenic shock is feasible and lifesaving in selected high-risk patients. Prompt recognition, multidisciplinary coordination, and strict adherence to neuroprotective protocols are essential to optimize recovery.