Ann Thorac Surg 2002;74:1246-1248
© 2002 The Society of Thoracic Surgeons
Case report
Repair of recurrent aneurysm after aortic valve and ascending aortic replacement
Per H. Wickstrom, MD*a
a Department of Thoracic and Cardiovascular Surgery, St. Mary’s/Duluth Clinic Health System, Duluth, Minnesota, USA
Accepted for publication May 30, 2002.
* Address reprint requests to Dr Wickstrom, Department of Thoracic and Cardiovascular Surgery, St. Mary’s/Duluth Clinic Health System, 400 East Third St, Duluth, MN 55805 USA
e-mail: pwickstrom{at}smdc.org
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Abstract
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The standard approach for recurrent aortic root problems has been a composite graft placement. This is a description of a case where a simplified technique was used. The new aortic graft was sutured to the sewing ring of a previously placed, well-seated aortic prosthesis. Coronary buttons were then implanted into that graft.
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Introduction
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Redo aortic root surgery after previous aortic valve replacement may be required when the retained ascending aorta or aortic sinuses become aneurismal, or when the aorta dissects. Usually these have been handled by replacing the aortic prosthesis and ascending aorta with a composite graft [1–3]. We used a different approach.
In 1995, a 66-year-old man underwent replacement of his aortic valve with a 27 St. Jude prosthesis (St. Jude Medical, St. Paul, MN) for symptomatic aortic regurgitation. His 6.2-cm ascending aorta was replaced with a 35-mm Hemashield graft (Boston Scientific/Meadox, Oakland, NJ). The proximal anastomosis was to the sinotubular ridge. A vein graft was placed to the circumflex coronary artery and brought off of the aorta above the dacron graft (Boston Scientific/Meadox, Oakland, NJ).
He was well until March 2001, when he developed angina. At angiography, the graft to the circumflex was noted to be closed, as was the native vessel. A tight stenosis in the right coronary artery was dilated and stented. Aortogram revealed a 9-cm aortic aneurysm between the prosthetic aortic valve and the aortic graft. There was also a small aneurysm at the distal aortic graft to aorta anastomosis site (Figs 1, 2)
A month later, his angina relieved, he underwent replacement of his ascending aorta and a second vein graft was placed to his circumflex. The femoral artery was used for arterial return. The sternum was opened in the midline. After dividing the adhesions, the right atrium was cannulated and the patient placed on bypass and cooled. The aorta was cross-clamped just proximal to the innominate artery and distal to the vein graft and aortic graft. The aneurysm and the dacron graft were divided vertically; where adherent to the atrium and pulmonary artery, these were not excised. Coronary buttons were dissected from the aortic wall. A 32-mm woven Hemashield graft was sutured to the sewing ring of the previously placed St. Jude aortic valve prosthesis with a running 3-0 Prolene (Ethicon Inc, Cincinnati, OH) suture (Fig 3).
The sewing ring had endothelialized, but deep bites just outside of the valve housing provided good purchase through the endothelium and the valve’s dacron sewing ring. The coronary buttons were attached to the graft with running 5-0 Prolene. The anastomosis to the distal aortic cuff was done with the cross-clamp still in place. This was reinforced with an external Teflon (Impra Inc, subsidiary of C. R. Bard, Tempe, AZ) felt strip. A vein graft was again placed to the circumflex and it was brought off of the aorta at the site of the previous vein graft (Fig 4). The anastomosis lines were dry when the cross-clamp was removed.
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Fig 1. Aortogram demonstrating a 9-cm aneurysm between the prosthetic St. Jude valve and the 35-mm ascending aortic graft.
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Fig 2. The coronary arteries arose rather high on the aneurysm. The graft to the circumflex artery had closed.
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Fig 3. The replacement graft was sutured to the sewing ring of the St. Jude prosthesis through the layer of endothelium.
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Fig 4. The completed operation: The Hemashield ascending aortic graft was tightly sutured to the prosthetic valve sewing ring. The coronary buttons were attached to the aortic graft. A new circumflex vein graft has been placed.
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The patient did well postoperatively and was discharged on the 6th postoperative day. He remains well a year later.
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Comment
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Before composite grafts were manufactured, they were constructed by the surgeon at the time of the operation. The prosthetic valve was sutured to the aortic graft, then this was inserted as a composite [4, 5]. The operation described here has similarities to that.
Suturing the aortic graft to a well-seated, previously placed aortic valve prosthesis is simpler and more hemostatic than suturing a composite graft to the irregular annulus that remains after an aortic valve prosthesis has been excised. It is also more secure than suturing a graft to a residual aortic rim at or below the sinotubular ridge, which is the other alternative.
The technique here described should be applicable for any aortic problem that occurs after the aortic valve has been replaced, such as aneurysm or acute and chronic dissection.
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Addendum
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Since the acceptance of this report for publication, this technique has been used a second time with a good result in a 48-year-old man who was 16-years status post-aortic valve replacement with a 27 Medtronic Hall (Medtronic Inc, Minneapolis, MN) prosthesis. His ascending aorta had recently enlarged to 8 cm.
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References
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- Crawford E.S., Crawford J.L., Safi H.J., Coselli J.S. Redo operations for recurrent aneurismal disease of the ascending aorta and transverse aortic arch. Ann Thorac Surg 1985;40:439-455.[Abstract]
- Dougenis D., Daily B.B., Kouchoukos N.T. Reoperations on the aortic root and ascending aorta. Ann Thorac Surg 1997;64:986-992.[Abstract/Free Full Text]
- Dossche K.M., Tan M.E., Schepens M.A., Morshuis W.J., de la Rivière A.B. Twenty-four year experience with reoperations after ascending aortic or aortic root replacement. Eur J Cardiothorac Surg 1999;16:607-612.[Abstract/Free Full Text]
- Bentall H., De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338-339.[Abstract/Free Full Text]
- Mayer J.E., Jr, Lindsay W.G., Wang Y., Jorgensen C.R., Nicoloff D.M. Composite replacement of the aortic valve and ascending aorta. J Thorac Cardiovasc Surg 1978;76:816-823.[Abstract]
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Abstract
Introduction
