Successful Bentall Surgery in a Moyamoya Disease Patient with Intraoperative Brain Protection via IABP-Induced Pulsatile Flow and CO2 Management during Cardiopulmonary Bypass.

INTRODUCTION

Moyamoya disease is an occlusive cerebrovascular disorder in which maintaining cerebral blood flow during cardiac surgery is challenging. No reports have described Bentall surgery in such patients. We present a successful case using an integrated brain protection strategy combining intra-aortic balloon pumping (IABP)-induced pulsatile flow, carbon dioxide management, and moderate hypothermia.

CASE PRESENTATION: A 51-year-old male with symptomatic moyamoya disease was referred for severe aortic regurgitation due to left coronary cusp leaflet shortening and a sinus of Valsalva aneurysm (50.7 mm) with cardiac dysfunction and left ventricular enlargement. Selective carotid angiography revealed poor visualization of the circle of Willis, including the anterior and middle cerebral arteries, along with the presence of moyamoya vessels. Oxygen PET imaging revealed Powers Stage II, indicating a high risk of cerebral infarction and intracranial hemorrhage. To maintain cerebral blood flow during cardiopulmonary bypass (CPB), intra-aortic balloon pumping was used to induce pulsatile flow, with moderate hypothermia for brain protection. Continuous monitoring of the partial pressure of carbon dioxide in the oxygenator exhaust gas allowed timely management of the arterial carbon dioxide during CPB, and cerebral oxygen saturation was used to optimize cerebral blood flow. Under this comprehensive brain flow management strategy, Bentall surgery was successfully performed. Postoperative MRI revealed no evidence of brain hemorrhage or infarction, and the patient was discharged without any neurological symptoms.

CONCLUSIONS

This case demonstrates that IABP-induced pulsatile flow, PexCO2-guided CO2 management, and moderate hypothermia can effectively preserve cerebral circulation during CPB. This integrated approach enabled the safe and successful completion of Bentall surgery in a patient with moyamoya disease.