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Ann Thorac Surg 2004;77:707-708
© 2004 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
Accepted for publication April 9, 2003.
* Address reprint requests to Dr Kincaid, Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA
e-mail: tkincaid{at}wfubmc.edu
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Abstract |
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Introduction |
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A 39-year-old man was admitted to our institution with chest and interscapular back pain. His history was significant for a bicuspid aortic valve and having undergone a Ross procedure in 1996 for severe aortic insufficiency. This operation was performed using a total root replacement technique. He was followed with annual echocardiograms that demonstrated good valvular function before a missed appointment in 2001. Echocardiography at the time of the current admission in 2002 revealed mild to moderate aortic insufficiency (AI), marked dilation of the ascending aorta to 5.5 cm, and mild pulmonary insufficiency with no gradient across the allograft pulmonic valve. In the operating room at the time of redo sternotomy, the ascending aorta was densely adherent to the underside of the sternum. For this reason, cardiopulmonary bypass (CPB) was initiated using femoral cannulation. After completion of the sternotomy, a significant amount of dense inflammatory tissue was appreciated around the ascending aorta and root. The patient was cooled to a core temperature of 20°C, and the circulation was arrested. Upon opening the aorta, there was an obvious flap in the ascending aorta that extended distally to the arch and proximally into the autograft at the level of the right coronary sinus (Fig 1). The right coronary artery was separated from the root by the dissection. There were intimal tears in both the native aorta and autograft. The left and noncoronary sinuses, along with the autograft leaflets, were normal in appearance. The repair was started by suturing a 24-mm knitted Dacron graft to the underside of the aortic arch. Cardiopulmonary bypass was reinstituted after an 11-minute period of circulatory arrest. Because the autograft was normal except for the right coronary sinus, only this portion of the root was removed. The ostium of the right coronary artery was mobilized on a button of normal aortic tissue that remained from the previous operation. A 24-mm Dacron tube graft was fashioned to have one sinus of Valsalva extending from the graft. This conduit was anastomosed to the sinotubular junction in the regions of the left and noncoronary sinuses, and the entire right sinus was replaced by suturing the Dacron sinus limb to the annulus. The right coronary ostium was then reimplanted into a separate opening in the Dacron sinus (Fig 2). Transesophageal echocardiography after termination of CPB revealed trace aortic insufficiency, and the patient's postoperative course was unremarkable. Histologic examination of the native aortic wall revealed focal myxoid degeneration. He remained asymptomatic in follow-up, and transthoracic echocardiography 4 months after discharge revealed mild aortic insufficiency, an aortic valve area of 3.3 cm2, and a mean gradient of 4 mm Hg.
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Repair of late pathology within the autograft using valve-sparing techniques has been described [6] and is feasible because the autograft leaflets usually remain pliable and potentially competent, even in the presence of degenerative changes in the sinuses or sinotubular junction. In this patient, a modified root remodeling technique was used because the tissue in two of the three sinuses appeared normal, and the annulus had remained fixed from the initial operation. Valve reimplantation could also have been performed, but would have required more extensive mobilization, an additional coronary reimplantation, and removal of unaffected root tissue.
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