Acute aortic dissection is one of the most common life-threatening disease which affects aortic vessel. We present a case of acute Stanford type A aortic dissection in a patient with covid-19 under treatment of ACE inhibitors. A 68-year-old female complaining of acute chest pain and dyspnea admitted to the emergency clinic of our hospital on May 6, 2020. She had history of diabetes and hypertension. This is one of the first acute aortic surgery case among patients with COVID-19.
COVID-19 has proven to be one of the worst pandemic in modern times in terms of both mortality and morbidity after being detected in the Republic of China on December 8, 2019. After the first confirmed case in Turkey was detected on March 11, 2020; the number of confirmed cases has increased so far [1] .
Although there are an increasing number of reports regarding the effects of Coronavirus on cardiovascular system, acute dissection of the aorta among patients with COVID-19 has not been presented.
A 68-year-old female referred to our institution with a chest pain and shortness of breath. The patient's family reported a history of hypertension and diabetes. Upon admission, the physical examination showed pulseless right femoral artery, an arterial pressure of 165/90 mmHg, and a pulse rate of 80 beats/min. Pulmonary rales were audible at the bases of both lungs, and an aortic diastolic murmur was detected during cardiac auscultation. Electrocardiography revealed pulmonary hypertension.
Transthoracic echocardiography showed mild aortic insufficiency with 55% of ejection fraction. Computed tomography revealed Type A aortic dissection flap extending through right common iliac artery, and ground-glass opacities in both lungs with nodular infiltration in right apex (Figure 1 ).
At surgery, because of the dissection that extended to right femoral artery, we decided to establish cardiopulmonary bypass through the left femoral artery. Transesophageal echocardiography was performed, which revealed intact aortic valves without insufficiency. A midline sternotomy was performed and a cross-clamp was placed on the intact aorta to ensure cardiac arrest with the administration of del Nido cardioplegia solution through coronary ostiums after aortotomy, which exposed marked thickening of the aortic wall. Proximally, the aorta was completely transected at a level just above the aortic commissures and distally, just before the innominate artery. A 28mm Dacron graft (Intervascular SA, La Ciotat Cedex, France) was placed.
Individual Teflon pledgeted sutures were used for distal anastomosis in order to affix the dissection flap to the aortic wall.
The crossclamp was removed and deairing maneuvers were applied.
Cardiopulmonary bypass (CPB) was concluded without any complication, and the femoral cannula was removed after protamine administration. (CPB time was 85 min, aortic crossclamp time was 55 min). Despite repairs and protamine administration, the bleeding through distal anastomosis line did not cease. Therefore, BioGlue ® surgical adhesive (CryoLife International, Inc.;Kennesaw, Ga) was applied to the bleeding zones.
The patient had an excellent pulse in her right femoral artery after the operation. and/or dissections when compared with patients having non-AIDS chronic cardiovascular diseases as arterial hypertension [2] . Reports are presented to evaluate the possibility of "similarity" of virulence as well as its' therapy of HIV and SARS-CoV-2 and their infections [3] . During aortotomy, in our case, we evaluated the aorta, which revealed pronounced thickening of the wall (as seen in inflammatory aortopathies [4] ) when compared with our experience in previous aortic dissection published [5] and/or unpublished cases.
Another challenge in surgery for inflammatory aortopathy remains in the suture line where, in acute phase, bleeding might be occur (as seen in our present case) and/or in chronic phase, formation of aneurysm may be seen. This inflammation may be due to SARS-CoV-2 viremia. Preoperative measurement of C-reactive protein and erythrocyte sedimentation rate were high in our patient and immunosuppressive therapy was started just after surgery.
Another important point in our case was the use of ACE inhibitory drugs for the treatment hypertension. SARS-CoV binds to the angiotensin-converting enzyme (ACE)2 which is also present on endothelial cells and ACE inhibitory drugs are presented to have beneficial effects on the COVID-19 process [6] . Despite the hypothetical concerns on the use of RAAS inhibitors which alter ACE2 expression, the maintenance of hypertension treatment by RAAS inhibitors is recommended due its beneficial effect on RAAS activation, however, our present case did not show any beneficial performance despite usage of RAAS inhibitors for 4 years, which may be due to RAAS activation may not efficiently achieved without local/systemic mast cell stabilizers as pro-inflammatory and pro-fibrotic cytokines as well as proteases as renin are highly released by local mast cells [7, 8] .
Additionally, one of the important issue in patients with Covid-19 is the elevated risk of thrombosis which necessitates anti-coagulation therapy during hospitalization. Low molecular weight heparin was used for anticoagulation in our patient during hospital stay, and clopidogrel was preferred for profilactic antiaggregant agent during followup.