Aortic root aneurysm after - off-pump reduction aortoplasty

Serdar Akgun, MD, Nazan Atalan, MD,

Osman Fazliog˘ullari, MD, Atike Tekeli Kunt, MD, Cem Basaran, MD, and Sinan Arsan, MD

Departments of Cardiovascular Surgery and Anesthesiology and Intensive Care, Medicana Bahcelievler Hospital, Department of Cardiovascular Surgery, Uskudar State Hospital, and Department of Cardiovascular Surgery, School of Medicine, Marmara University, Istanbul, Turkey

We present a patient with aortic root aneurysm and severe aortic regurgitation who had a previous off-pump reduction ascending aortoplasty and external wrapping with concomitant coronary bypass grafting. Preliminary aortic dissection and erosion of the aortic intima were detected during the operation. This complication war-rants the re-evaluation of the indications for reduction ascending aortoplasty and emphasizes the necessity for close follow-up.

Reduction ascending aortoplasty (RAA) is one of the techniques  in  the  surgical  spectrum  of  surgical treatments for ascending aortic aneurysmal dilatation. The procedure continues to be controversial since it was introduced by Robicsek and colleagues [1]. Some sur-geons favored the technique due to its low mortality and morbidity compared with that of conventional surgical options.  The  debate  of  the  use  of  external  support, tailoring, anchoring, different techniques, and rates of complications has been previously reported, including reports by our group [2–5]. We reported the results of RAA and external wrapping with “sandwiched tech-nique” in on- pump and off-pump cases with external wrapping and anchoring without tailoring the aorta on the  basis  of  concomitant  operations  [5,  6].  Here  we present a case of an aortic root aneurysm and prelimi-nary dissection below the segment of the wrapped and reduced aorta.

A 71-year-old woman was admitted to our hospital for severe aortic regurgitation. The patient had undergone an off-pump RAA with external wrapping and concomi-tant coronary artery bypass grafting due to a history of gastrointestinal bleeding. Our group had performed this surgery 7 years prior. During her admission, coronary angiography revealed two patent grafts to the left ante-rior descending coronary artery (left internal mammary artery) and the first diagonal branch (saphenous vein). Aortography revealed severe aortic regurgitation and marked aneurysm of the aortic root with a diameter of 5.8 cm. Zone A (Fig 1) demonstrates the reduced segment of the aorta with external Dacron (Maquet Vascular Inter-ventions, La Ciotat, France) support and lines B and C show the marked dilatation of the aortic root.

The reoperation was planned for the aortic root replacement. Inspection of the aortic wall during the pro-cedure revealed preliminary dissection lines near the border of the Dacron graft (Maquet Vascular Interven-tions) and the native aorta. The entire aortic wall in-cluded within the graft has been eroded by the graft.

Intraoperatively, the Dacron graft was clearly observed just beneath the intimal layer. These views are demon-strated in Figure 2. At that time the Cabrol modification was performed to the aortic root and the valve with additional diagonal vein graft anastomosis to the Dacron graft. The patient had an uneventful postoperative course and was discharged on the postoperative day 6.

Comment

Until 2004, we had performed 72 RAAs with external wrapping [2]. However, since 2004 we have only operated on 12 patients with this same technique. Two of these patients in our original report were reoperated on for a secondary aortic dissection. The patient presented here is now the third to undergo reoperation for this same complication. This raises the question on the safety of this technique regarding the continued dilatation of the aorta, despite external wrapping. To avoid further poten-tial complications, we have narrowed the indications and only used this technique with high-risk patients.

We believe that aortic dilatation is a progressive dis-ease. The mural stress acting on the aortic wall can not be solved by RAA, regardless of which technique is used. It is clear to us that the border between the wrapped segment and the native aortic wall might be under high pressure, resulting in dissection and erosion of the native intima as was observed in our patient. Some surgeons may argue that RAA does not completely preserve the integrity and physiologic properties of the aorta. How-ever, we believe this topic should be further discussed, as well as an investigation of the impact on the aortic root and regurgitation due to the disturbed aortic wall structure.

Reduction  ascending  aortoplasty  is  a  conservative technique that can still be used with the appropriate indications, especially in high-risk patients. However, careful evaluation and close follow-up is essential for patients with ascending aortic dilatation exceeding 6 cm in diameter, enlargement of the sinotubular junction, and concomitant aortic regurgitation.