Management
The patient was tachycardic and was started on low dose esmolol drip. Midline sternotomy was performed which revealed that the heart and mediastinum were encased in clot and bulging pericardium which was removed with pericardiotomy. Direct visual examination revealed an intact aortic arch with rupture at the sino-tubular ridge extending to the left coronary ostium. The entire posterior aspect of the ascending aorta was transected with complete separation of the adventitia, media and intima with dissecting aneurysm and contained periaortic hematoma formation. Left coronary ostium was repaired, 23 mm valved St. Jude conduit was placed, ascending aorta was repaired and both coronary arteries were re-implanted. Intraoperative TEE post-Bentall procedure revealed a competent aortic valve and good flow in the coronary arteries. The patient was discharged home with uneventful postoperative stay.