One surgery saved three lives: Bentall procedure in a woman with aortic dissection and preterm twin pregnancy

A multidisciplinary team (MDT) at Prince Wales Hospital (PWH) and the Chinese University of Hong Kong (CUHK) successfully performed an emergency Bentall procedure in a pregnant woman with acute type A aortic dissection and preterm twins. The patient survived and her healthy twins were delivered 6 weeks later.

Rare, life-threatening case

In June 2024, a 36-year-old woman with twin pregnancy at 25 weeks of gestation was admitted to PWH with chest pain radiating to the back. Physical examination was unremarkable, and the patient was haemodynamically stable. Bedside echocardiography showed a 5 cm dilated aortic root with severe regurgitation, and a suspicious flap over the ascending aorta. Urgent aortography showed Stanford type A aortic dissection. [Ann Thorac Surg 2025;120:604-607]

Aortic dissection is characterized by tearing of the aortic wall, creating a false lumen that can compromise blood flow to vital organs. Pregnancy is a predisposing factor for aortic dissection as pregnancy-related physiological changes, including increased blood volume, fluctuating blood pressure during labour, and hormonal changes, may lead to large vessel remodelling. [Case Rep Womens Health 2024:45:e00678]

Aortic dissection during pregnancy is a rare and life-threatening complication, occurring in 0.0004 percent of pregnancies and associated with very high maternal and foetal mortality. [Clin Case Rep 2025;13:e70090; Ann Cardiothorac Surg 2016;5:256]

Aortic dissection is classified as type A or type B. Type A aortic dissection is more dangerous due to its proximity to the heart. It is therefore considered as a ticking time bomb, with mortality rate reaching 50 percent within 48 hours of symptom onset if not treated surgically. [Surg Clin North Am 2009;89:869-893; J Thorac Dis 2020;129:4598-4601]

Formulating a surgical plan with MDT

“The operation was not just about one patient. It involved a mother of twins,” said Dr Man-Ling Lai, Deputy Chief of Staff of the Department of Anaesthesia, Pain and Perioperative Medicine at PWH. “The team had to consider safety for all three of them when designing the procedures, including plans for anaesthesia and vital measurements.”

“[This] is an extremely complex and challenging case. Therefore, it is of utmost importance that an experienced MDT [involving cardiac surgeons, obstetricians, cardiac anesthesiologists, and intensivists] work together to ensure the best possible outcomes,” said Professor Liona Chiu-Yee Poon of the Department of Obstetrics and Gynaecology, CUHK.

“The surgical approach depends on gestational age, balancing risks of foetal malperfusion during cardiopulmonary bypass and premature birth,” noted Poon.

The 2022 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines suggest a “deliver-then-repair” strategy for gestational age of ≥26 weeks. However, given the very low foetal survival rate for pregnancies <26 weeks, as in this case, the team decided to perform a Bentall procedure with cardiopulmonary bypass and in-utero protection after counselling with the patient and her family. [J Am Coll Cardiol 2022;80:e223-e393; Ann Thorac Surg 2025;120:604-607]

“Cardiopulmonary bypass temporarily replaces the patient’s heart and lung function during a Bentall procedure. The traditional procedure involves systemic cooling to protect against ischaemia-induced injury and reduce metabolic demand,” said Professor Randolph Hung-Leung Wong, Head of the Division of Cardiothoracic Surgery at PWH. “However, previous evidence showed that deep hypothermia and cardiac arrest are independent predictors of higher foetal mortality. Therefore, the team decided to perform the surgery without systemic cooling or circulatory arrest, and to monitor the foetal heart intermittently with ultrasound.”

“The patient was positioned in a left lateral tilt to avoid inferior vena cava compression, and was put under general anaesthesia. We continuously monitored her heart condition with echocardiography before and after the cardiopulmonary bypass,” noted Lai. “The team also needed to calculate anaesthetic dosages precisely to maintain the patient’s blood pressure at a higher level and to control her coagulation indices accurately.”

Three lives saved in one surgery

“The entire surgery was time-sensitive,” pointed out Wong. “We chose to use a mixed biological heart valve and synthetic graft for aortic root replacement instead of traditional large vessel segmental suturing, successfully saving more than 15 minutes of cardiac arrest time, thereby lowering the risk of complications.”

The Bentall surgery was completed in 4 hours and 35 minutes, with bypass time of 2 hours and 53 minutes, and cardiac ischaemic time of 1 hour and 58 minutes. Both mother and foetuses survived. [Ann Thorac Surg 2025;120:604-607]

“Postoperative care must also be considered to ensure the patient’s recovery and successful subsequent delivery,” pointed out Wong.

The patient was extubated 8 hours after the surgery. She developed fever on postoperative day 1, and received a 10-day course of empirical antibiotics for suspected pneumonia. She was discharged from the intensive care unit on day 4 and from the high-dependency unit on day 8, and discharged from the hospital on day 17.

The patient had an uneventful recovery and sustained her pregnancy for 6 weeks, eventually delivering healthy twins at 31 weeks of gestation through an emergency caesarean section.

“It is extremely rare to save three lives in one single surgery,” highlighted Wong.

This case illustrates key factors enabling a successful emergency Bentall procedure for acute type A aortic dissection during the second trimester of pregnancy with twins in utero. “This was a highly successful procedure that demonstrates the importance of quickly assembling an MDT when dealing with highly complex surgery,” Wong added.