1. Concomitant valve sparing root remodeling with extra aortic ring annuloplasty and e-vita stented elephant trunk implantation
Igor Rudez, Marko Kusurin, Mislav Planinc, Josip Varvodic, Davor Baric, Daniel Unic, Ante Bosnjak, Robert Blazekovic, Zeljko Sutlic
Dpt. Of Cardiac and Transplant Surgery, University Hospital Dubrava, Zagreb, Croatia
Relevant History: A 49-year-old male, with chronic Stanford B dissection presented to hospital due to paroxysmal atrial fibrillation and concomitant chest pain. Transthoracic echocardiography revealed bicuspid aortic valve with AR 2+, enlarged aortic root up to 40 mm, and aorta sizeing 42 mm at the level of ST junction. No dilatation of heart cavities was observed with preserved EF of 74%. MSCT revealed enlarged ascending aorta with maximum diameter of 42 mm, and 37 mm at the beginning of Stanford type B aortic dissection at the origin of the left subclavian artery. Dissection spread through the descending aorta down to the level of Th8, with true lumen diameter 10x28 mm, and false lumen diameter 29x36 mm at level of pulmonary bifurcation.
Preoperative Plan: Valve sparing root remodeling with external subvalvular ring annuloplasty technique is a newly implemented procedure at our department. It represents excellent alternative to patients with aortic insufficiency and concomitant root and ascending aortic dilatation who were previously treated with modified Bentall procedure. E-vita stented elephant trunk is a good modality for treatment of complex cases of aortic pathology which were previously treated with frozen elephant trunk requiring a second procedure with thoracotomy. In this case we wanted to preserve native aortic valve and stabilize dissected thoracic aorta without need for secondary intervention.
Discussion of what was actually done and the challenges, deaths and complications encountered: Right axillary cannulation over the 8 mm side graft and right atrium three-stage cannula was used for initiation of cardiopulmonary bypass, patient was cooled to 25 ˚C and the aorta was cross-clamped. After aortic root was dissected 6 subvalvular U stiches were placed, cusp free edges were aligned and root remodeling was preformed. Cusps resuspension was done after remodeling, and subvalvular extra aortic Coroneo ring was placed, and coronary ostia were reimplanted according to the usual technique. Circulatory arrest with bilateral antegrade cerebral perfusion was established for 43 minutes during which the stent was deployed and the graft sutured to the distal aorta with separate reimplantation of the supraaoritc branches starting from the left subclavian artery to the brachiocephalic trunk respectively. Total cross-clamp time was 106 minutes and CPB time was 172 min. Patient recovered uneventfully and early transthoracic echocardiography findings show no aortic insufficiency.
MSCT showed exclusion of the false lumen. The patient was discharged from hospital nine days after surgery with no complications and 6 months after surgery is doing well.
ECHO showing bicuspid aortic valve with AR 2+
Postoperative MSCT showing complete obliteration of false lumen (left and above) and ECHO showing competent aortic valve with no residual regurgitation
MSCT showing Stanford B dissection with small true lumen and large false lumen