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Ann Thorac Surg 2003;75:583-584
© 2003 The Society of Thoracic Surgeons

Case report

Dislocated wrap after previous reduction aortoplasty causes erosion of the ascending aorta

Matthias Bauer, MDa*, Onnen Grauhan, MD, PhDa, Roland Hetzer, MD, PhDa

a Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany

Accepted for publication August 22, 2002.

* Address reprint requests to Dr Bauer, Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
e-mail: mbauer{at}dhzb.de


   Abstract
Top
 Abstract
Introduction
 Comment
 Acknowledgments
 References
 
We report a patient with bicuspid aortic valve and dilatation of the ascending aorta who had previous aortic valve replacement and reduction aortoplasty with wrapping. After 4 years, reoperation because of coronary artery disease and paravalvular leakage revealed an erosion of the aortic wall due to dislocation of the wrap. This complication confirms the need for secure anchoring and good fitting of the Dacron wrap to avoid alterations of the underlying aortic wall.


   Introduction
Top
 Abstract
 Introduction
Comment
 Acknowledgments
 References
 
Reduction aortoplasty with or without external prosthetic support is one of the operative techniques currently used to treat patients with ascending aorta dilatation and aneurysms [1, 2]. The surgical method shows good long-term results [3]. Complications such as development of false aortic aneurysms or aortic rupture are extremely rare [4, 5]. We present the intraoperative finding of an ascending aorta erosion caused by a dislocated Dacron (C.R. Bard, Haverhill, PA) wrap in a patient who had undergone aortic valve replacement and reduction aortoplasty with external support 4 years before.

The patient underwent surgery in July 1997 at the age of 50 years in another institution, involving aortic valve replacement, reduction aortoplasty, and external Dacron wrapping of the ascending aorta because of combined aortic valve disease and dilatation of the ascending aorta. He had a bicuspid aortic valve and the diameter of the ascending aorta was 6.0 cm. The operation and the perioperative course were uneventful. In June 2001 he had an acute myocardial infarction.

Coronary artery angiography showed a 75% stenosis of the left main trunk and angiography of the ascending aorta revealed an indentation of the vessel in the region of the inner curve (Fig 1). Echocardiography examination showed reduced left ventricular function, a paravalvular leakage at the aortic valve prosthesis, and a normal diameter of the ascending aorta.



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  		Fig 1. Angiography of the ascending aorta in left anterior oblique projection shows an indentation of the vessel in the region of the inner curve (arrow).

 
Reoperation was planned for aortic valve prosthesis replacement, coronary artery revascularization, and inspection of the ascending aorta for the cause of the indentation. Intraoperatively it became evident that the Dacron wrapping had moved to the distal part of the ascending aorta, creating a sharp fold at the inner curve of the vessel. Inspection of the inner surface of the ascending aorta revealed extreme rarefaction of the aortic wall in the region of the fold of the Dacron wrap. The tissue of the Dacron material was clearly visible though the remnants of the aortic wall (Fig 2). Because of the impending danger of rupture of the ascending aorta in this region, we replaced the ascending aorta with a vascular prosthesis using graft-inclusion technique, in addition to undertaking coronary artery bypass grafting and aortic valve replacement. The patient left hospital on the seventh postoperative day after an uneventful course.



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  		Fig 2. Intraoperative inspection of the inner surface of the ascending aorta reveals an extreme rarefaction of the aortic wall in the region of the fold of the Dacron wrap (arrows).

 

   Comment
Top
 Abstract
 Introduction
 Comment
Acknowledgments
 References
 
Surgeons can choose from a large spectrum of surgical techniques to handle ascending aortic pathology. Dilatation and aneurysms of the ascending aorta combined with aortic valve disease can be treated by separate replacement of the aortic valve and ascending aorta, as well as by composite graft implantation, valve-sparing ascending aorta replacement, or the Ross procedure [6].

An alternative method is reduction aortoplasty with or without external prosthetic support as proposed by Robicsek [1]. The procedure consists of replacing the aortic valve, reducing the aortic diameter by excision of an oval segment of the aortic wall, placing a well-tailored Dacron vascular graft around the ascending aorta, and anchoring the graft with previously placed sutures driven through the sewing ring of the valve prosthesis and through the aortic wall.

The technique is suitable for patients with fusiform aneurysms and poststenotic dilatation of the ascending aorta [1, 2]. In patients with bicuspid aortic valve and dilatation of the ascending aorta Robicsek’s technique also shows good long-term results, when an optimal reduction in diameter (to less than 35 mm) is achieved perioperatively [3].

To prevent late complications, especially redilatation of the ascending aorta due to dislocation of the wrap, secure anchoring of the prosthetic wrap to the aorta is mandatory. This is achieved in the Robicsek technique in the above-mentioned fashion. Carrel sets the anchoring stitches in the noncoronary sinus and at the three commissures.

Complications during the long-term course in patients with aortoplasty and external wrapping are extremely rare. Neri and colleagues [4] reported on 2 patients who developed false aneurysm of the ascending aorta after 7 and 11 years, respectively. Histologic examination of the aortic wall underlying the reinforcement cuff revealed extensive wall degeneration. Dhillon and associates [5] observed late ruptures after wrapping of descending aorta aneurysms. In all 3 cases the aortic wall had been eroded.

On reoperation after aortic valve replacement and reduction aortoplasty with wrapping, we found in 1 patient that the Dacron wrapping had become dislocated by moving to the distal part of the ascending aorta, creating a sharp fold at the inner curve of the vessel. In this region we noted extreme rarefaction of the aortic wall with impending rupture.

Or observation confirms the need for secure anchoring of the Dacron wrap when carrying out reduction aortoplasty with external support. To avoid alterations of the aortic wall, the prosthetic wrapping has to be well fitted to prevent the creation of folds, which become areas of high mechanical stress.


   Acknowledgments
Top
 Abstract
 Introduction
 Comment
 Acknowledgments
References
 
We are grateful for editorial assistance from Anne Gale.


   References
Top
 Abstract
 Introduction
 Comment
 Acknowledgments
 References
 

  1. Robicsek F. A new method to treat fusiform aneurysms of the ascending aorta associated with aortic valve disease: an alternative to radical resection. Ann Thorac Surg 1982;34:92-94.[Abstract/Free Full Text]
  2. Carrel T., von Segesser L., Jenni R., et al. Dealing with dilated ascending aorta during aortic valve replacement: advantages of conservative surgical approach. Eur J Cardiothorac Surg 1991;5:137-143.[Abstract/Free Full Text]
  3. Bauer M., Pasic M., Schaffarzyk R., et al. Reduction aortoplasty for dilatation of the ascending aorta in patients with bicuspid aortic valve. Ann Thorac Surg 2002;73:720-724.[Abstract/Free Full Text]
  4. Neri E., Massetti M., Tanganelli P., et al. Is it only a mechanical matter? Histologic modifications of the aorta underlying external banding. J Thorac Cardiovasc Surg 1999;118:1116-1118.[Free Full Text]
  5. Dhillon J.S., Randhawa G.K., Straeley C.J., McNamara J.J. Late rupture after Dacron wrapping of aortic aneurysm. Circulation 1986;74(Suppl 1):11-14.
  6. Ergin M.A., Spielvogel D., Apaydin A., et al. Surgical treatment of the dilated ascending aorta: when and how?. Ann Thorac Surg 1999;67:1834-1839.[Abstract/Free Full Text]



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Roland Hetzer
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