Ann Thorac Surg 2007;83:2224-2226
© 2007 The Society of Thoracic Surgeons
Case Reports
Valve-Sparing Operation for Aortic Root Aneurysm Late After Mustard Procedure
Masamichi Ono, MDa,*,
Heidi Goerler, MDa,
Dietmar Boethig, MDb,
Mechthild Westhoff-Bleck, MDc,
Dagmar Hartung, MDd,
Thomas Breymann, MDa
a Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany
b Division of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
c Division of Cardiology, Hannover Medical School, Hannover, Germany
d Division of Radiology, Hannover Medical School, Hannover, Germany
Accepted for publication December 27, 2006.
* Address correspondence to Dr Ono, Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Carl Neubergstrasse 1, Hannover, 30625, Germany (Email: ono.masamichi{at}mh-hannover.de).
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Abstract
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The aortic valve reimplantation technique leads to excellent clinical outcome in patients with aortic valve incompetence and aneurysms of the ascending aorta. This technique is now applied for aneurysms of ascending aorta, aortic dissection type A, and even dilatation of pulmonary autograft after the Ross operation. We report a case of aortic root dilatation late after a Mustard operation for transposition of the great arteries that was successfully managed by valve-sparing aortic root reimplantation.
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Introduction
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Since 1964, the Mustard operation has been performed for surgical correction of transposition of the great arteries (TGA) [1]. Although the arterial switch has now supplanted atrial redirection as the procedure of choice, most adults with TGA have had intraatrial repairs. Late complications include arrhythmia, venous pathway obstruction, and systemic right ventricular dysfunction. Although aortic root dilatation after the Mustard operation has not been recognized, histologic abnormalities of the ascending aortic wall in patients with TGA, as well as tetralogy of Fallot and truncus arteriosus, have been reported [2]. Progressive dilatation of the aortic root more than a decade after the surgical repair of tetralogy of Fallot has been now recognized in small cohort of adult patients [3], and some of them have been surgically managed by aortic valve replacement or aortic root replacement with a composite graft containing a mechanical valve [4].
The aortic valve-sparing operation, first described by David and Feindel [5] more than a decade ago in patients with aortic valve incompetence and aneurysm of the ascending aorta, now demonstrates favorable long-term results in patients with Marfan syndrome [6] and acute aortic dissection type A [7]. These results encouraged us to extend the indications for this technique. We report the use of a valve-sparing operation in a patient with aortic root dilatation late after a Mustard operation for TGA.
A 30-year-old man who had undergone a Mustard operation for TGA at the age of 2 years presented a moderate insufficiency of the aortic valve. Follow-up echocardiography revealed signs of progressive volume overload of the functional left ventricle and a slightly impaired ejection fraction (0.50). The aortic root had a diameter of 45 mm. Clinically, the patient was in New York Heart Association functional class II. Because of his young age, a valve-sparing operation was considered, and an elective operation was done.
After establishment of cardiopulmonary bypass through femoral access, rethoracotomy was carefully performed. Another venous cannula was inserted into the superior vena cava and a vent cannula was placed into the functional left atrium. Because there was much collateral flow returning into the left atrium, the operation was performed under deep hypothermia (22°C rectal temperature). After aortic cross-clamping, we found a dilatation of the aortic root but normal leaflets.
A valve-sparing procedure (reimplantation technique David I) was performed with a 28-mm Dacron (Boston Scientific, Natric, MA) polyester fabric graft. There was no technical difference owing to the anatomy of aortic root arising from right ventricle.
The patient’s postoperative course was uneventful, and he was discharged on postoperative day 6. At the first follow-up at 2 months, the patient was free of symptoms (New York Heart Association functional class I). Magnetic resonance imaging showed a functional left ventricular end-diastolic volume index of 93 mL/m2 (normal, 80 mL/m2), a functional left ventricular end-systolic volume index of 47 mL/m2 (normal, 32 mL/m2), and an ejection fraction of 0.50. The valve was completely competent, with a mean gradient of 9 mm Hg (Fig 1). At the last communication at the eighth postoperative month, the patient remained in good condition.
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Fig 1. Postoperative two-dimensional steady-state free precession cine magnetic resonance image of functional left ventricular outflow tract and proximal ascending aorta at 7 months’ follow-up. (A) Systolic phase shows laminar flow of the ascending aorta arising from morphologic right ventricle. (B) Diastolic phase shows well coapted aortic valve leaflets without dilatation of aortic annulus.
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Comment
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We have reported a successful repair of an aneurysm of the ascending aorta and insufficient aortic valve by aortic root reimplantation technique late after a Mustard operation. Although the frequency of root aneurysms after the atrial switch operation is low, Niwa and colleagues [2] reported histologic abnormalities of the medial wall of the ascending aorta in patients with TGA and suggested the possibility of late aneurysmal change of the ascending aorta. Because of the increasing number of adult patients after surgical correction of complex congenital heart disease, the number of patients requiring reoperation for aortic root dilatation will also increase. Then, we believe that a significant number of these patients with an adult congenital heart anomaly will meet the criteria for repair by means of a valve-sparing technique.
Because valve-sparing operations were originally performed for adult patients with aortic valve incompetence and aneurysm of the ascending aorta [5], indication for this technique has been extended to that of Marfan syndrome [6], acute aortic dissection type A [7], and dilatation of pulmonary autografts after the Ross operation [8]. Although larger number of patients and additional data from extended follow-up studies are required for a final judgment on this surgical approach, this patient showed an excellent short-term result. We hope that this report will help to initiate a new tool for the surgical management of aortic root dilatation after the correction of various kinds of complex congenital heart anomalies.
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References
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- Mustard WT. Successful two stage correction of transposition of the great vessels Surgery 1964;55:469-472.[Medline]
- Niwa K, Perloff JK, Bhuta SM, et al. Structural abnormalities of great arterial walls in congenital heart disease: light and electron microscopic analyses Circulation 2001;103:393-400.[Abstract/Free Full Text]
- Niwa K, Siu SC, Gray SM, Webb GD, Gatzoulis MA. Progressive aortic root dilatation in adults late after repair of tetralogy of Fallot Circulation 2002;106:1374-1378.[Abstract/Free Full Text]
- Dodds III GA, Warnes CA, Danielson GK. Aortic valve replacement after repair of pulmonary atresia and ventricular septal defect or tetralogy of Fallot J Thoracic Cardiovasc Surg 1997;113:736-741.[Abstract/Free Full Text]
- David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta J Thoracic Cardiovasc Surg 1992;103:617-622.[Abstract]
- Karck M, Kallenbach K, Hagl C, Rhein C, Leyh R, Haverich A. Aortic root surgery in Marfan syndrome: comparison of aortic valve-sparing reimplantation versus composite grafting J Thoracic Cardiovasc Surg 2004;127:391-398.[Abstract/Free Full Text]
- Kallenbach K, Oelze T, Salcher R, et al. Evolving strategies for treatment of acute aortic dissection type A Circulation 2004;110(suppl II)II243–9.
- Ishizaka T, Devaney EJ, Ramsburgh SR, Suzuki T, Ohye RG, Bove EL. Valve sparing aortic root replacement for dilatation of the pulmonary autograft and aortic regurgitation after the Ross procedure Ann Thorac Surg 2003;75:1518-1522.[Abstract/Free Full Text]
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Abstract
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