Abstract 4367862: When to Pull the Trigger: The Critical Role of Early VA-ECMO for Neuroprotection in the Frozen Elephant Trunk Era of Acute Type A Aortic Dissection

Introduction: Acute Type A aortic dissection (ATAAD) carries a substantial risk of perioperative cerebral injury, especially during complex aortic arch reconstructions employing the Frozen Elephant Trunk (FET) technique. Extended circulatory arrest and prolonged cardiopulmonary bypass can compromise cerebral perfusion. Early initiation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) may provide targeted neuroprotection during this vulnerable intraoperative window. We present a case exemplifying the neuroprotective potential of early ECMO support in extensive aortic surgery. Case Description: A 42-year-old woman with hypertension and chronic kidney disease presented with acute chest and neck pain. Imaging confirmed a DeBakey type I dissection extending into the descending thoracic aorta. Surgical intervention included valve-sparing root and total arch replacement with FET, under deep hypothermic circulatory arrest at 24°C and bilateral antegrade cerebral perfusion. During rewarming, she developed severe left ventricular dysfunction, worsening acidosis, and cerebral hypoperfusion evidenced by near-infrared spectroscopy. VA-ECMO was promptly initiated via femoral cannulation prior to weaning from bypass, with the explicit aim of preserving cerebral perfusion. Results: ECMO resulted in immediate hemodynamic stabilization and correction of metabolic derangements. Cerebral oximetry confirmed continuous, symmetric perfusion without evidence of ischemia. Progressive myocardial recovery allowed ECMO discontinuation on postoperative day five. The patient was extubated on day six, neurologically intact. At three months, both cardiac and neurologic functions were preserved. Discussion: This case underscores the value of early VA-ECMO not merely as circulatory support, but as an active neuroprotective intervention. Intraoperative cerebral monitoring was essential in identifying perfusion deficits and guiding timely escalation. When deployed proactively, ECMO can mitigate ischemic risk during critical phases of complex ATAAD repair. Conclusion: In ATAAD requiring FET, early VA-ECMO should be considered a core component of neuroprotective strategy. Integrating ECMO into institutional protocols, guided by real-time cerebral monitoring, may optimize neurologic outcomes and should be adopted in high-risk surgical algorithms.