About Dr. Mei Ju
Dr. Mei Ju is a senior cardiac surgeon at Zhongshan Hospital, Fudan University — one of China's foremost academic centres for cardiovascular surgery. She specialises in aortic dissection repair, heart valve replacement, and minimally invasive cardiac surgery, with particular expertise in complex, high-risk cases involving combined aortic root pathology and valvular disease. Dr. Mei's practice is defined by the philosophy that even the most life-threatening aortic emergencies can be managed with precision, individualised surgical planning, and minimally invasive technique — achieving both survival and quality of life. She is a recognised leader in the application of deep hypothermic circulatory arrest, selective cerebral perfusion, and hybrid aortic arch strategies for acute Stanford Type A dissection. Her team at Zhongshan Hospital has accumulated one of the largest single-centre experiences in minimally invasive aortic root reconstruction in China.
Case Overview
Mr. David Harrington, a 52-year-old British corporate executive based in Shanghai, presented with sudden-onset tearing chest and back pain with profuse diaphoresis of four hours' duration. Emergency CT aortography confirmed Stanford Type A aortic dissection (DeBakey Type I) with the primary intimal tear at the proximal ascending aorta, extending to the iliac bifurcation. The ascending aorta was aneurysmally dilated to 5.8 cm, with moderate pericardial effusion, right coronary ostial involvement, and an incidental finding of bicuspid aortic valve (BAV) with severe regurgitation. EuroSCORE II was 12.5%. Dr. Mei Ju elected a minimally invasive upper hemi-sternotomy approach with biological root replacement (Bio-Bentall), partial arch repair with frozen elephant trunk, and selective cerebral perfusion under deep hypothermic circulatory arrest — avoiding full sternotomy and total arch replacement to minimise operative trauma and cerebral ischaemia time. Cardiopulmonary bypass time was 185 minutes; circulatory arrest time 22 minutes. The patient was extubated at six hours post-operatively, discharged on day ten, and returned to full-time work at three months with a patent conduit and normally functioning bioprosthetic valve on surveillance CT.
Patient Background
- Name / Nationality: Mr. David Harrington (pseudonym) — British; corporate executive based in Shanghai
- Age / Sex: 52-year-old male
- Chief Complaint: Sudden tearing chest and back pain with profuse diaphoresis — onset 4 hours prior to presentation
- Cardiovascular History: Hypertension for 10 years, poorly controlled, irregular medication adherence; no diabetes or coronary artery disease; non-smoker
- Family History: Father with aortic dissection — raising suspicion for heritable aortopathy
- Examination: BP 165/95 mmHg (left arm), 140/80 mmHg (right arm); HR 110 bpm; diastolic murmur grade 3/6 at right sternal border (aortic regurgitation); bilateral dorsalis pedis pulses present but weak
- Risk Scores: EuroSCORE II 12.5%; STS Score 8.2% — high surgical risk
Imaging and Laboratory Workup
Emergency CT Aortography
- Diagnosis: Stanford Type A dissection (DeBakey Type I) — primary intimal tear at proximal ascending aorta
- Extent: Dissection from ascending aorta through arch and descending aorta to iliac bifurcation
- Ascending aorta: Aneurysmal dilatation to 5.8 cm diameter
- Complications: Moderate pericardial effusion (tamponade risk); right coronary ostial involvement (suspected avulsion)
- Valve: Bicuspid aortic valve (BAV) — left-right coronary cusp fusion; severe regurgitation
Transoesophageal Echocardiography (TEE)
- LVEF: 55% — compensatory left ventricular hypertrophy
- Aortic valve: Severe regurgitation; leaflet prolapse confirmed
- Ascending aorta: False lumen thrombus identified
Laboratory
- D-Dimer >10 mg/L; Troponin 0.5 ng/mL (mild elevation); Creatinine 110 μmol/L (mild renal impairment)
Clinical Decision Making
Three compounding challenges defined the surgical strategy: a Stanford Type A dissection with fragile, acutely inflamed aortic tissue requiring root replacement; a bicuspid aortic valve with severe regurgitation demanding definitive valve management in the same operative field; and the patient's age and professional lifestyle creating a strong preference to avoid lifelong anticoagulation.
The conventional approach — full median sternotomy with Bentall procedure and total arch replacement with elephant trunk — would have addressed all pathology but at the cost of maximal operative trauma, prolonged cardiopulmonary bypass, and extended circulatory arrest with elevated stroke risk.
Dr. Mei Ju's surgical strategy: This patient has three problems that share one solution: the bicuspid aortic valve is the underlying aortopathy that caused the dissection, the root dilatation, and the regurgitation. We address all three through a single root reconstruction. The question is not what to do — it is how to do it with the least harm. The upper hemi-sternotomy gives us full access to the root and proximal arch without dividing the entire sternum. The frozen elephant trunk handles the distal disease and preserves the option for a second-stage endovascular procedure if the descending aorta requires treatment. We do not need to do everything today. We need to save this patient today and leave the future options open.
Operative Procedure
Phase 1 — Access and Cardiopulmonary Bypass
Incision: Upper hemi-sternotomy — J-shaped incision to the fourth intercostal space, preserving the lower sternum. This approach provides full exposure of the ascending aorta, aortic root, and proximal arch while maintaining thoracic wall integrity and reducing post-operative pain and bleeding.
Cardiopulmonary bypass: Right axillary artery and right atrial cannulation — axillary arterial cannulation selected to perfuse the true lumen and avoid the false lumen, and to provide antegrade cerebral perfusion during circulatory arrest without additional cannulation steps.
Cooling: Deep hypothermic circulatory arrest (DHCA) — nasopharyngeal temperature target 20°C. Bilateral near-infrared spectroscopy (NIRS) cerebral oximetry monitoring throughout.
Dr. Mei's operative note: The axillary artery is our preferred arterial cannulation site in Type A dissection. It guarantees true lumen perfusion — we have confirmed this on the pre-operative CT. And when we arrest the circulation for the arch work, the axillary cannula becomes our selective antegrade cerebral perfusion line without repositioning. Every minute of circulatory arrest carries neurological risk. We eliminate unnecessary steps.
Phase 2 — Aortic Root Reconstruction (Bio-Bentall)
Root inspection: Ascending aorta opened; primary intimal tear identified above the right coronary sinus. Aortic valve leaflets assessed — quality insufficient for repair in the acute inflammatory setting; valve-sparing root replacement (David procedure) abandoned in favour of biological root replacement.
Bio-Bentall procedure: Composite biological root replacement with a stented bioprosthetic valve and Dacron conduit. Coronary ostia reimplanted using the button technique — both coronary buttons mobilised with adequate tissue margins and anastomosed to the conduit without tension.
Dr. Mei's operative note: In acute Type A dissection with a bicuspid valve, attempting valve repair is a high-risk decision. The tissue is acutely inflamed and friable. A failed repair in this setting means a second pump run — and in a patient who is already haemodynamically stressed, that is a risk we cannot accept. The biological root replacement is the definitive, durable solution. No anticoagulation. No structural valve deterioration for fifteen to twenty years. And for a 52-year-old executive who travels internationally, that matters enormously.
Phase 3 — Arch Repair and Frozen Elephant Trunk
Circulatory arrest: Selective antegrade cerebral perfusion (SACP) via right axillary artery at 10 mL/kg/min; left carotid artery perfused via direct cannulation. Circulatory arrest time 22 minutes — within the safe window for neurological protection at 20°C.
Arch strategy: Partial arch replacement at Zone 2 (left subclavian artery origin) — the arch vessels proximal to the left subclavian were incorporated into the arch graft. Total arch replacement was deliberately avoided to limit circulatory arrest time and reduce the risk of post-operative neurocognitive dysfunction.
Frozen elephant trunk: A hybrid stent-graft (Frozenix) deployed into the proximal descending aorta (Zone 3–4) under direct vision during circulatory arrest — providing distal true lumen stenting, promoting false lumen thrombosis in the descending aorta, and creating a landing zone for potential future endovascular completion if the descending aorta requires treatment.
Dr. Mei's operative note: We do not need to replace the entire aorta today. The descending aorta is dissected but the true lumen is perfusing all visceral vessels. The frozen elephant trunk stabilises the proximal descending aorta and gives us a platform for a second-stage TEVAR if surveillance imaging shows progressive false lumen expansion. One operation today. One option preserved for tomorrow. That is the hybrid strategy.
Phase 4 — De-airing and Rewarming
Meticulous TEE-guided de-airing prior to aortic cross-clamp release — preventing air embolism to the coronary and cerebral circulations. Rewarming to 36.5°C before weaning from cardiopulmonary bypass.
Operative data: Cardiopulmonary bypass 185 minutes; aortic cross-clamp 110 minutes; circulatory arrest 22 minutes; intraoperative blood loss approximately 400 mL.
Post-operative Course and Follow-up
- Extubation: 6 hours post-operatively — fast-track extubation protocol
- Haemodynamics: Stable; minimal vasopressor support; no re-exploration for bleeding
- Neurology: Alert and oriented on awakening; full limb movement; no stroke or neurocognitive deficit — attributed to precise cerebral perfusion strategy and limited circulatory arrest time
- Renal function: Creatinine peaked at 130 μmol/L on day 2; normalised by day 4 — no renal replacement therapy required
- Arrhythmia: Transient atrial fibrillation — pharmacologically cardioverted; sinus rhythm maintained at discharge
- Wound: Primary healing; no infection; hemi-sternotomy incision well-tolerated
- Discharge: Day 10 post-operatively
- 3-month surveillance CT: Conduit patent; bioprosthetic valve functioning normally; no paravalvular leak; frozen elephant trunk in satisfactory position; false lumen thrombosis progressing in proximal descending aorta
- 3-month clinical: Returned to full-time work; ECOG 0; no angina or dyspnoea
Expert Commentary — Dr. Mei Ju
1. Minimally Invasive Access for Acute Type A Dissection: Redefining the Standard
The conventional teaching that acute Type A aortic dissection mandates full median sternotomy is being challenged by accumulating evidence from high-volume centres. The upper hemi-sternotomy provides equivalent exposure of the ascending aorta and proximal arch while preserving lower sternal integrity, reducing post-operative pain, decreasing chest wall bleeding, and accelerating recovery. In a patient with normal BMI and no prior sternotomy, the hemi-sternotomy is not a compromise — it is the superior approach. The key technical prerequisite is surgeon familiarity with the exposure and confidence in managing unexpected intraoperative findings through the limited access. At Zhongshan Hospital, we have standardised this approach for selected Type A dissection cases, and our outcomes data support its safety and efficacy.
2. Bicuspid Aortic Valve in Acute Dissection: Repair or Replace?
Bicuspid aortic valve is present in approximately 5% of the general population but accounts for a disproportionate share of Type A aortic dissections — the abnormal aortic wall biology associated with BAV creates a substrate for progressive dilatation and dissection independent of haemodynamic stress. When BAV is encountered in acute Type A dissection, the surgeon faces a critical decision: valve-sparing root replacement (David procedure) or composite root replacement (Bentall). The David procedure preserves the native valve and avoids prosthetic valve complications — but it requires technically demanding reconstruction of acutely inflamed, friable tissue, and failure rates are higher in the emergency setting than in elective cases. Our decision framework: if the leaflet quality is good and the root geometry is favourable, we attempt valve-sparing. If the tissue is compromised — as in this case — biological root replacement is the correct choice. A bioprosthetic valve in a 52-year-old patient provides fifteen to twenty years of durable function without anticoagulation, and re-intervention at age 65–70 can be planned electively under controlled conditions.
3. Cerebral Protection: The Determinant of Neurological Outcome
Stroke and neurocognitive dysfunction are the most feared complications of aortic arch surgery — and they are largely preventable with disciplined cerebral protection strategy. Our protocol at Zhongshan Hospital combines three elements: deep hypothermia to 20°C, which reduces cerebral metabolic rate by approximately 80% and provides a safe circulatory arrest window of 20–25 minutes; selective antegrade cerebral perfusion via the axillary artery, which maintains cerebral blood flow during arrest and extends the safe operating window; and continuous NIRS monitoring, which provides real-time cerebral oxygenation data and allows immediate detection of perfusion asymmetry. The decision not to perform total arch replacement in this case was driven by the circulatory arrest time calculation: total arch replacement would have required 35–45 minutes of arrest — beyond our preferred safety threshold. Partial arch with frozen elephant trunk achieved the necessary distal control in 22 minutes. The neurological outcome — no deficit, full cognitive recovery — validates that decision.
4. The Hybrid Strategy: One Operation, Two Stages
The frozen elephant trunk represents the evolution of aortic surgery from a single-stage total replacement philosophy to a staged hybrid approach. In acute Type A dissection with extensive descending aortic involvement, attempting total aortic replacement in a single emergency operation carries prohibitive mortality. The frozen elephant trunk addresses the proximal descending aorta under direct vision during the primary operation — promoting false lumen thrombosis and true lumen expansion — while creating a precise landing zone for future endovascular completion. In this patient, the descending aorta is dissected but haemodynamically stable. We will monitor with annual CT surveillance. If the false lumen expands beyond 55 mm or the true lumen compromises visceral perfusion, a second-stage thoracic endovascular aortic repair (TEVAR) can be performed percutaneously — a two-hour procedure under local anaesthesia, not a second open operation. The hybrid strategy converts a potentially fatal single-stage emergency into a planned, staged programme of care.
How CMCS Shanghai Coordinated This Case
CMCS Shanghai supported Mr. Harrington from emergency presentation through three-month post-operative surveillance, including: emergency triage and immediate referral to Dr. Mei Ju's team at Zhongshan Hospital upon CT confirmation of Type A dissection; pre-operative family communication and bilingual interpretation for informed consent under time pressure; coordination of emergency TEE, laboratory, and anaesthesia teams; real-time surgical progress updates to the patient's family in English; post-operative ICU communication with daily bilingual updates to family members in the United Kingdom; discharge planning including medication reconciliation, wound care instructions, and follow-up scheduling in English; three-month surveillance CT coordination with results translation and direct communication to the patient's cardiologist in London; and long-term surveillance protocol establishment with annual CT aortography scheduling and direct liaison between Dr. Mei Ju's team and the patient's overseas physicians.
For international patients facing aortic emergencies in Shanghai, the speed and precision of CMCS coordination can be the difference between timely expert intervention and delayed care. Dr. Mei Ju's team at Zhongshan Hospital represents cardiac surgical expertise at the international frontier — and CMCS ensures that expertise is accessible to every international patient, in their language, from the first moment of crisis through long-term recovery.
This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.
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