Ann Vasc Dis Vol. 6, No. 3; 2013; pp 666–669 ©2013 Annals of Vascular Diseases
Online September 5, 2013 doi:10.3400/avd.cr.13-00023
Case Report
Partial Root Remodeling on the Two Sinuses for Acute Type A Aortic Dissection with Right Coronary Arterial Dissection Akira Katayama, MD,1 Naomichi Uchida, MD,2 Miwa Sutoh, MD,1 and Taijiro Sueda, MD2
We reported simple partial root remodeling using a graft trimmed twin ”U” shape for extensive dissection into the right/non-coronary sinuses with acute type A aortic dissection with cardiac tamponade, acute myocardial infarction on the right coronary artery and aortic regurgitation. After total arch replacement with frozen elephant trunk technique for distal dissection, partial root remodeling on the non and right coronary sinuses was performed. Postoperative computed tomography (CT) showed well shaped Valsalva sinuses and aortic regurgitation completely disappeared. This technique might become an alternative procedure for aortic dissection severely involving Valsalva sinuses without dilatation on the aortic root. Keywords: aortic root remodeling, type A aortic dissection, right coronary arterial dissection
Introduction
A
ortic root replacement has been widely performed for aortic dissection with extensive dissection into the Valsalva sinuses.1) Recently valve sparing operation has been sometimes selected instead of root replacement because of avoiding prosthesis valve replacement.2) However they have technical difficulties, in special hemostasis on the anastomosis site. We report simple partial root remodeling using the graft trimmed twin “U” shape for intensive dissection into the right/non- coronary sinuses without dilatation on the aortic root.
Case Report A 59-year-old woman was emergently admitted to our Department of Cardiovascular Surgery, Hiroshima City Asa Hospital, Hiroshima, Hiroshima, Japan 2Department of Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Hiroshima, Japan 1
Received: March 12, 2013; Accepted: July 31, 2013 Corresponding author: Akira Katayama, MD. Department of Cardiovascular Surgery, Hiroshima City Asa Hospital, 2-1-1 Kabeminami, Asakitaku, Hiroshima, Hiroshima 731-0293, Japan Tel: +81-82-815-5211, Fax: +81-82-814-1791 E-mail: [email protected]
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hospital with chest pain. Her heart rate decreased to 50/min and systolic pressure decreased to 90 mmHg. Cardiac echo in emergent room presented moderate pericardial effusion, moderate aortic regurgitation, and poor wall motion on the inferior left ventricle. Electrocardiogram reported ST-elevation on the II, III, and aVF. Computed tomography revealed De-Bakey type I aortic dissection with severe stenosis on the right coronary artery because of right Valsalva sinus dissection (Fig. 1). Primary entry was located on the distal aortic arch. We performed emergent operation for acute type A aortic dissection with cardiac tamponade, aortic regurgitation and acute coronary syndrome on the right coronary artery. We scheduled total arch replacement with frozen elephant trunk for intimal tear on the distal arch and partial root remodeling for the dissection on the right coronary artery. After median sternotomy was performed, cardiopulmonary bypass was established by arterial perfusion from graft anastomosed on the right axillary artery. During moderate hypothermia at a rectal temperature of 28°C, selective cerebral perfusion was established under the monitor by regional cerebral oxygen saturation (rSO2) and bilateral radial arterial pressure, and the aortic arch was transected. After performing the frozen elephant trunk technique using a stent graft to close initial
Annals of Vascular Diseases Vol. 6, No. 3 (2013)
666
2013/09/11
15:33:07
Partial Root Remodeling for Aortic Dissection
Fig. 1 P reoperative computed tomography (CT). CT revealed De-Bakey type I aortic dissection with severe stenosis on the right coronary artery because of right Valsalva aortic dissection (white arrows).
Fig. 2 Operative schema. The partial aortic root remodeling was performed by using a tube graft trimmed as a twin “U” shapes on the non- and right coronary sinuses. CABG: coronary artery bypass grafting
Finally a right coronary bypass using the saphenous vein graft was performed after two grafts (inserted proximal graft and distal 4 branched graft) were anastomosed endto-end with a 4-0 running suture. The anastomosis level of two grafts was 3 cm above STJ. Surgical, cardiopulmonary, and selective cerebral perfusion times were 370, 195, and 70 minutes, respectively. The postoperative course was considerably good, and the patient was discharged 21 days after the operation without complication. Postoperative CT revealed well shaped Valsalva and complete thrombosis of false lumen on the thoracic aorta (Fig. 4). Aortic regurgitation completely disappeared according to postoperative cardiac echogram.
Discussion tear, we underwent proximal anastomosis on the aortic root. The partial aortic root remodeling was performed by using a tube graft trimmed as a twin “U” shapes on the non- and right coronary sinuses (Fig. 2). A graft with a diameter 1 or 2 mm smaller compared with the direct measurement of the sinotubular junction (STJ). A twin “U” shaped graft of 4 cm part inserted into the STJ was fixed to each of the 3 commissures that were suspended using a 4/0 polypropylene with a felt strip. Subsequently, the graft was fixed to the left STJ and to the right/ non-aortic valve annulus by using 4-0 horizontal mattress sutures (Fig. 3). We performed 24 “U” stitches for fixation and did not use any glue in the false lumen.
Annals of Vascular Diseases Vol. 6, No. 3 (2013)
AVD-CR 13-00023 Katayama_P.indd
667
Although early operative outcomes of acute type A aortic dissection have recently improved,3) the incidence of reoperation on the proximal aorta remains high during long-term follow-up.4) Therefore, there are still controversies concerning the appropriate approach. The valve sparing operation on the proximal site has been proposed as an alternative for the repair of aortic dissections based on the principle of total resection of the aortic root.5,6) However, since dilatation of the aortic root is very often absent, total aortic root replacement, regardless of valve preservation, is difficult to justify because of a potentially higher surgical risk for acute aortic dissection;
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Katayama A, et al.
Fig. 3 O perative finding. Right coronary artery was dissected and torn (white arrow). Partial root remodeling was performed on the right/non sinuses except left coronary sinus. LCC = left coronary cusp; NCC = noncoronary cusp; RCC = right coronary cusp
Fig. 4 P ostoperative computed tomography (CT). Postoperative CT revealed well shaped Valsalva and complete thrombosis of false lumen on the thoracic aorta.
therefore, root replacement is not always performed.7) The decision to treat only the dissected sinuses and to avoid either a complete root replacement or root remodeling/reimplantation procedure reduces operative complexity, which is an important factor in life-threatening situations. In addition, the need for proximal reoperation is related to both patient pathology as well as operative technique.4,7) Niederhäuser, et al.,8) reported that gelatin
668
AVD-CR 13-00023 Katayama_P.indd
resorcin formalin (GRF) glue reconstruction resulted in an increased freedom from reoperation on the aortic root compared with suture resuspension (92% vs. 70%). However, the use of GRF glue has been incriminated in a higher incidence of false aneurysms or redissection, particularly in the proximal part of the aorta.9) Graft insertion to the sinus Valsalva can avoid the pressure load to the dissected sinus wall. Because of dissected Valsalva wall is free from pressure load, there is no need of fixation of dissected lumen and can avoid the side effect of GRF glue. On the basis of these concepts, partial root remodeling on the two sinuses for acute type A aortic dissection with right coronary arterial dissection was performed in the absence of root dilatation greater than 35 mm. This technique can be preserved needless coronary reconstruction of left coronary artery. The aim of graft insertion to the sinus Valsalva is avoid the pressure load to the dissected sinus wall. The proximal anastomosis is at the level of 2–3 cm upper the STJ. Because of no resection of Valsalva sinus wall and no anastomosis at this level, we can reduce the risk of bleeding from aortic root. Post bleeding from the basal aorta has been well controlled and Valsalva sinuses have been well remodeled. In conclusion, partial root remodeling of two coronary sinuses without left side should be an alternative technique for acute aortic dissection severely involving right coronary artery without dilatation on the aortic root instead of root replacement or valve sparing method.
Annals of Vascular Diseases Vol. 6, No. 3 (2013)
668
2013/09/11
15:33:07
Partial Root Remodeling for Aortic Dissection
Disclosure Statement The authors have declared that no conflict of interest exists.
References 1) Halstead JC, Meier M, Etz C, et al. The fate of the distal aorta after repair of acute type A aortic dissection. J Thorac Cardiovasc Surg 2007; 133: 127-35. 2) Erasmi AW, Stierle U, Bechtel JF, et al. Up to 7 years’ experience with valve-sparing aortic root remodeling/ reimplantation for acute type A dissection. Ann Thorac Surg 2003; 76: 99-104. 3) Golledge J, Eagle KA. Acute aortic dissection. Lancet 2008; 372: 55-66. 4) Malvindi PG, van Putte BP, Sonker U, et al. Reoperation after acute type a aortic dissection repair: a series of 104 patients. Ann Thorac Surg 2013; 95: 922-7.
Annals of Vascular Diseases Vol. 6, No. 3 (2013)
AVD-CR 13-00023 Katayama_P.indd
669
5) Aicher D, Langer F, Lausberg H, et al. Aortic root remodeling: ten-year experience with 274 patients. J Thorac Cardiovasc Surg 2007; 134: 909-15. 6) Charitos EI, Stierle U, Sievers HH, et al. Valve-sparing aortic root remodeling with partial preservation of the intact native aortic sinuses. Eur J Cardiothorac Surg 2009; 36: 589-91. 7) Farhat F, Durand M, Boussel L, et al. Should a reimplantation valve sparing procedure be done systematically in type A aortic dissection? Eur J Cardiothorac Surg 2007; 31: 36-41. 8) Niederhäuser U, Künzli A, Seifert B, Schmidli J, Lachat M, Zünd G, et al. Conservative treatment of the aortic root in acute type A dissection. Eur J Cardiothorac Surg 1999; 15: 557-63. 9) Hata H, Takano H, Matsumiya G, et al. Late complications of gelatin-resorcin-formalin glue in the repair of acute type A aortic dissection. Ann Thorac Surg 2007; 83: 1621-6.
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Online September 5, 2013 doi:10.3400/avd.cr.13-00023
Case Report
Partial Root Remodeling on the Two Sinuses for Acute Type A Aortic Dissection with Right Coronary Arterial Dissection Akira Katayama, MD,1 Naomichi Uchida, MD,2 Miwa Sutoh, MD,1 and Taijiro Sueda, MD2
We reported simple partial root remodeling using a graft trimmed twin ”U” shape for extensive dissection into the right/non-coronary sinuses with acute type A aortic dissection with cardiac tamponade, acute myocardial infarction on the right coronary artery and aortic regurgitation. After total arch replacement with frozen elephant trunk technique for distal dissection, partial root remodeling on the non and right coronary sinuses was performed. Postoperative computed tomography (CT) showed well shaped Valsalva sinuses and aortic regurgitation completely disappeared. This technique might become an alternative procedure for aortic dissection severely involving Valsalva sinuses without dilatation on the aortic root. Keywords: aortic root remodeling, type A aortic dissection, right coronary arterial dissection
Introduction
A
ortic root replacement has been widely performed for aortic dissection with extensive dissection into the Valsalva sinuses.1) Recently valve sparing operation has been sometimes selected instead of root replacement because of avoiding prosthesis valve replacement.2) However they have technical difficulties, in special hemostasis on the anastomosis site. We report simple partial root remodeling using the graft trimmed twin “U” shape for intensive dissection into the right/non- coronary sinuses without dilatation on the aortic root.
Case Report A 59-year-old woman was emergently admitted to our Department of Cardiovascular Surgery, Hiroshima City Asa Hospital, Hiroshima, Hiroshima, Japan 2Department of Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Hiroshima, Japan 1
Received: March 12, 2013; Accepted: July 31, 2013 Corresponding author: Akira Katayama, MD. Department of Cardiovascular Surgery, Hiroshima City Asa Hospital, 2-1-1 Kabeminami, Asakitaku, Hiroshima, Hiroshima 731-0293, Japan Tel: +81-82-815-5211, Fax: +81-82-814-1791 E-mail: [email protected]
666
AVD-CR 13-00023 Katayama_P.indd
hospital with chest pain. Her heart rate decreased to 50/min and systolic pressure decreased to 90 mmHg. Cardiac echo in emergent room presented moderate pericardial effusion, moderate aortic regurgitation, and poor wall motion on the inferior left ventricle. Electrocardiogram reported ST-elevation on the II, III, and aVF. Computed tomography revealed De-Bakey type I aortic dissection with severe stenosis on the right coronary artery because of right Valsalva sinus dissection (Fig. 1). Primary entry was located on the distal aortic arch. We performed emergent operation for acute type A aortic dissection with cardiac tamponade, aortic regurgitation and acute coronary syndrome on the right coronary artery. We scheduled total arch replacement with frozen elephant trunk for intimal tear on the distal arch and partial root remodeling for the dissection on the right coronary artery. After median sternotomy was performed, cardiopulmonary bypass was established by arterial perfusion from graft anastomosed on the right axillary artery. During moderate hypothermia at a rectal temperature of 28°C, selective cerebral perfusion was established under the monitor by regional cerebral oxygen saturation (rSO2) and bilateral radial arterial pressure, and the aortic arch was transected. After performing the frozen elephant trunk technique using a stent graft to close initial
Annals of Vascular Diseases Vol. 6, No. 3 (2013)
666
2013/09/11
15:33:07
Partial Root Remodeling for Aortic Dissection
Fig. 1 P reoperative computed tomography (CT). CT revealed De-Bakey type I aortic dissection with severe stenosis on the right coronary artery because of right Valsalva aortic dissection (white arrows).
Fig. 2 Operative schema. The partial aortic root remodeling was performed by using a tube graft trimmed as a twin “U” shapes on the non- and right coronary sinuses. CABG: coronary artery bypass grafting
Finally a right coronary bypass using the saphenous vein graft was performed after two grafts (inserted proximal graft and distal 4 branched graft) were anastomosed endto-end with a 4-0 running suture. The anastomosis level of two grafts was 3 cm above STJ. Surgical, cardiopulmonary, and selective cerebral perfusion times were 370, 195, and 70 minutes, respectively. The postoperative course was considerably good, and the patient was discharged 21 days after the operation without complication. Postoperative CT revealed well shaped Valsalva and complete thrombosis of false lumen on the thoracic aorta (Fig. 4). Aortic regurgitation completely disappeared according to postoperative cardiac echogram.
Discussion tear, we underwent proximal anastomosis on the aortic root. The partial aortic root remodeling was performed by using a tube graft trimmed as a twin “U” shapes on the non- and right coronary sinuses (Fig. 2). A graft with a diameter 1 or 2 mm smaller compared with the direct measurement of the sinotubular junction (STJ). A twin “U” shaped graft of 4 cm part inserted into the STJ was fixed to each of the 3 commissures that were suspended using a 4/0 polypropylene with a felt strip. Subsequently, the graft was fixed to the left STJ and to the right/ non-aortic valve annulus by using 4-0 horizontal mattress sutures (Fig. 3). We performed 24 “U” stitches for fixation and did not use any glue in the false lumen.
Annals of Vascular Diseases Vol. 6, No. 3 (2013)
AVD-CR 13-00023 Katayama_P.indd
667
Although early operative outcomes of acute type A aortic dissection have recently improved,3) the incidence of reoperation on the proximal aorta remains high during long-term follow-up.4) Therefore, there are still controversies concerning the appropriate approach. The valve sparing operation on the proximal site has been proposed as an alternative for the repair of aortic dissections based on the principle of total resection of the aortic root.5,6) However, since dilatation of the aortic root is very often absent, total aortic root replacement, regardless of valve preservation, is difficult to justify because of a potentially higher surgical risk for acute aortic dissection;
667
2013/09/11
15:33:07
Katayama A, et al.
Fig. 3 O perative finding. Right coronary artery was dissected and torn (white arrow). Partial root remodeling was performed on the right/non sinuses except left coronary sinus. LCC = left coronary cusp; NCC = noncoronary cusp; RCC = right coronary cusp
Fig. 4 P ostoperative computed tomography (CT). Postoperative CT revealed well shaped Valsalva and complete thrombosis of false lumen on the thoracic aorta.
therefore, root replacement is not always performed.7) The decision to treat only the dissected sinuses and to avoid either a complete root replacement or root remodeling/reimplantation procedure reduces operative complexity, which is an important factor in life-threatening situations. In addition, the need for proximal reoperation is related to both patient pathology as well as operative technique.4,7) Niederhäuser, et al.,8) reported that gelatin
668
AVD-CR 13-00023 Katayama_P.indd
resorcin formalin (GRF) glue reconstruction resulted in an increased freedom from reoperation on the aortic root compared with suture resuspension (92% vs. 70%). However, the use of GRF glue has been incriminated in a higher incidence of false aneurysms or redissection, particularly in the proximal part of the aorta.9) Graft insertion to the sinus Valsalva can avoid the pressure load to the dissected sinus wall. Because of dissected Valsalva wall is free from pressure load, there is no need of fixation of dissected lumen and can avoid the side effect of GRF glue. On the basis of these concepts, partial root remodeling on the two sinuses for acute type A aortic dissection with right coronary arterial dissection was performed in the absence of root dilatation greater than 35 mm. This technique can be preserved needless coronary reconstruction of left coronary artery. The aim of graft insertion to the sinus Valsalva is avoid the pressure load to the dissected sinus wall. The proximal anastomosis is at the level of 2–3 cm upper the STJ. Because of no resection of Valsalva sinus wall and no anastomosis at this level, we can reduce the risk of bleeding from aortic root. Post bleeding from the basal aorta has been well controlled and Valsalva sinuses have been well remodeled. In conclusion, partial root remodeling of two coronary sinuses without left side should be an alternative technique for acute aortic dissection severely involving right coronary artery without dilatation on the aortic root instead of root replacement or valve sparing method.
Annals of Vascular Diseases Vol. 6, No. 3 (2013)
668
2013/09/11
15:33:07
Partial Root Remodeling for Aortic Dissection
Disclosure Statement The authors have declared that no conflict of interest exists.
References 1) Halstead JC, Meier M, Etz C, et al. The fate of the distal aorta after repair of acute type A aortic dissection. J Thorac Cardiovasc Surg 2007; 133: 127-35. 2) Erasmi AW, Stierle U, Bechtel JF, et al. Up to 7 years’ experience with valve-sparing aortic root remodeling/ reimplantation for acute type A dissection. Ann Thorac Surg 2003; 76: 99-104. 3) Golledge J, Eagle KA. Acute aortic dissection. Lancet 2008; 372: 55-66. 4) Malvindi PG, van Putte BP, Sonker U, et al. Reoperation after acute type a aortic dissection repair: a series of 104 patients. Ann Thorac Surg 2013; 95: 922-7.
Annals of Vascular Diseases Vol. 6, No. 3 (2013)
AVD-CR 13-00023 Katayama_P.indd
669
5) Aicher D, Langer F, Lausberg H, et al. Aortic root remodeling: ten-year experience with 274 patients. J Thorac Cardiovasc Surg 2007; 134: 909-15. 6) Charitos EI, Stierle U, Sievers HH, et al. Valve-sparing aortic root remodeling with partial preservation of the intact native aortic sinuses. Eur J Cardiothorac Surg 2009; 36: 589-91. 7) Farhat F, Durand M, Boussel L, et al. Should a reimplantation valve sparing procedure be done systematically in type A aortic dissection? Eur J Cardiothorac Surg 2007; 31: 36-41. 8) Niederhäuser U, Künzli A, Seifert B, Schmidli J, Lachat M, Zünd G, et al. Conservative treatment of the aortic root in acute type A dissection. Eur J Cardiothorac Surg 1999; 15: 557-63. 9) Hata H, Takano H, Matsumiya G, et al. Late complications of gelatin-resorcin-formalin glue in the repair of acute type A aortic dissection. Ann Thorac Surg 2007; 83: 1621-6.
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