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Cangut B, Greason KL, Todd A, Arghami A, Krishnan P, Crestanello JA, Stulak JM, Dearani JA, Schaff HV. Aortic root replacement in the setting of a mildly dilated nonsyndromic ascending aorta. J Thorac Cardiovasc Surg 2023; 166:983-993. [PMID: 35863966 DOI: 10.1016/j.jtcvs.2022.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 03/18/2022] [Accepted: 03/29/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE There is controversy on how to address mild aortic root dilation during concomitant aortic valve replacement: composite aortic valve conduit replacement or separate ascending aorta and aortic valve replacement. We reviewed our experience to address the issue. METHODS We retrospectively reviewed 778 adult nonsyndromic patients with aortic root diameter 55 mm or less who received replacement of the ascending aorta and aortic valve from January 1994 to June 2017. Patients were divided into 2 groups based on the type of aortic root intervention: composite aortic valve conduit replacement in 406 patients (52%) and separate ascending aorta and aortic valve replacement in 372 patients (48%). Propensity matching was used to mitigate differences in baseline patient characteristics and produced 188 matched pairs. RESULTS Sinus of Valsalva diameter was 43 mm (39-47). Operative mortality occurred in 3 patients (2%) in the composite aortic valve conduit replacement group and in 5 patients (3%) in the separate ascending aorta and aortic valve replacement group (P = .470). Median follow-up was 9.6 years (8.4-10.1). Long-term mortality was similar in the 2 groups (P = .083). Repeat operation was performed in 13 patients (7%) in the composite aortic valve conduit replacement group and in 19 patients (10%) in the separate ascending aorta and aortic valve replacement group (P = .365). Sinus of Valsalva diameter decreased 2 mm (-4-0; median follow-up 41 months) in the propensity-matched separate ascending aorta and aortic valve replacement group. CONCLUSIONS In patients with mild aortic root dilation, separate ascending aorta and aortic valve replacement results in a similar risk of repeat operation and mortality in comparison with composite aortic valve replacement. Separate ascending aorta and aortic valve replacement is not associated with subsequent aortic root dilation on medium-term echocardiography follow-up.
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Affiliation(s)
- Busra Cangut
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
| | - Austin Todd
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minn
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Prasad Krishnan
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
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Higashino A, Taketani T, Suzuki H, Miura S, Ohno T. A Giant Left Coronary Button Aneurysm After Aortic Root Remodeling Procedure in a Patient With Marfan Syndrome: A Case Report. Cureus 2022; 14:e26031. [PMID: 35865442 PMCID: PMC9293275 DOI: 10.7759/cureus.26031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2022] [Indexed: 11/05/2022] Open
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3
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Jo JJ, Kim YS, Kim GJ, Kim JH. True Aneurysm of the Common Coronary Button in a Marfan Patient with an Anomalous Right Coronary Artery after a Bentall Procedure: A Case Report. J Chest Surg 2022; 55:243-245. [PMID: 35638121 PMCID: PMC9178298 DOI: 10.5090/jcs.22.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/14/2022] [Accepted: 04/10/2022] [Indexed: 11/16/2022] Open
Abstract
True aneurysms of the coronary artery after aortic root replacement in Marfan syndrome patients are very rare. An anomalous origin of the right coronary artery (RCA) from the left sinus of Valsalva adds complexity during aortic root surgery. We present a case of a 37-year-old male patient with Marfan syndrome who had an RCA anomaly and a 4.5-cm true aneurysm of the common coronary button 14 years after a previous Bentall procedure. A redo Bentall operation and hemi-arch replacement were successfully performed. The anomalous origin of the RCA from the left sinus of Valsalva was safely divided and anastomosed as separate coronary buttons to the prosthetic composite valve graft. To prevent coronary button aneurysms after aortic root surgery in Marfan patients, the coronary buttons and the corresponding side holes on the prosthetic graft must be reduced to the maximum possible extent.
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Affiliation(s)
- Jeong Jun Jo
- Department of Thoracic and Cardiovascular Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Yun Seok Kim
- Department of Thoracic and Cardiovascular Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Gun-Jik Kim
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jae Hyun Kim
- Department of Thoracic and Cardiovascular Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
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Rodriguez Guerra MA, Urena Neme AP, Victoria M, Roa Gomez G, Acosta G. Left Main Coronary Artery Fusiform Aneurysm. Cureus 2022; 14:e24790. [PMID: 35673313 PMCID: PMC9165914 DOI: 10.7759/cureus.24790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2022] [Indexed: 12/03/2022] Open
Abstract
Aneurysm of the coronary artery is an uncommon condition that is usually found incidentally. The left coronary aneurysm is the least common. We report the case of a young patient with a history of vasculitis who was found to have a left fusiform coronary aneurysm. This is a 20-year-old female who has a history of polyarteritis nodosa and who came due to shortness of breath associated with chest discomfort. The physical exam was only relevant for multiple joint pains and tenderness. An echocardiogram showed a possible coronary aneurysm that was confirmed on the angio-tomography. The patient was discharged without complications. The left main coronary artery aneurysm is a rare condition and the least common of the coronary aneurysms. There is no established guideline for screening and therapy of these aneurysms, but invasive methods are not a preferred method for follow-up on this condition.
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Varela Barca L, Calderón Romero P, Sánchez-Aquino R, Donado Miñambres A, Hernández-Estefanía R, Sanz Mayordomo P, Aldámiz-Echevarría G. Coronary pseudoaneurysm after Bentall-Bono intervention: A novel treatment to a rare surgery complication. J Cardiol Cases 2022; 26:157-160. [DOI: 10.1016/j.jccase.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 04/01/2022] [Accepted: 04/17/2022] [Indexed: 11/26/2022] Open
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6
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Kostopoulou A, Fountas E, Karapanagiotou O, Kyrzopoulos S. Inappropriate shocks from a transvenous implantable defibrillator caused by atrial fibrillation and a missed atrial septal defect in a patient with a modified Bentall procedure. Eur Heart J Case Rep 2021; 5:ytab412. [PMID: 34870086 PMCID: PMC8637801 DOI: 10.1093/ehjcr/ytab412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/19/2021] [Accepted: 10/05/2021] [Indexed: 11/13/2022]
Abstract
Abstract
Background
Inappropriate shocks have been reported in ∼1/3 of patients with implantable cardiac defibrillators (ICDs). We report an unusual case of inappropriate ICD shocks due to atrial fibrillation (AF) caused by a missed atrial septal defect (ASD) in a patient with a modified Bentall procedure.
Case summary
A 67-year-old Caucasian male, with an ICD and a history of a modified Bentall procedure 24 years ago, reported to our outpatient clinic with recurrent inappropriate ICD shocks due to episodes of fast AF. The transthoracic echocardiographic exam revealed two large aneurysms at the ostia of the coronary arteries. We performed further evaluation with transoesophageal echocardiogram and computed tomography (CT) angiography. The aneurysms measured on CT were 3.14 cm × 2.29 cm on the right ostium and 1.9 cm × 0.99 cm on the left. A large secundum type ASD of 1.5 cm, missed in all previous echocardiographic studies, was revealed. The therapeutic options of surgical closure of the ASD and repair of the aneurysms or a more conservative approach with percutaneous closure of the ASD and closer follow-up were discussed with the patient. The patient declined the surgical option due to high complication risk, and closure of the ASD with an Amplatzer device was performed 3 months later. A 3-year follow-up was uneventful.
Conclusion
It is of major importance to comprehensively and thoroughly assess patients before and after a surgical intervention to not miss other treatable conditions preoperatively and complications in the postoperative period.
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Affiliation(s)
- Anna Kostopoulou
- Department of Electrophysiology and Pacing, Onassis Cardiac Surgery Center, Syngrou 356, 17674 Kallithea, Greece
| | - Epameinontas Fountas
- Laboratory of Echocardiography, Onassis Cardiac Surgery Center, Syngrou 356, 17674 Kallithea, Greece
| | - Olga Karapanagiotou
- Laboratory of Imaging, Onassis Cardiac Surgery Center, Syngrou 356, 17674 Kallithea, Greece
| | - Stamatis Kyrzopoulos
- Laboratory of Echocardiography, Onassis Cardiac Surgery Center, Syngrou 356, 17674 Kallithea, Greece
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7
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Coronary artery complications related to aortic root replacement in Marfan syndrome. J Cardiovasc Comput Tomogr 2021; 16:e5-e7. [PMID: 34629301 DOI: 10.1016/j.jcct.2021.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 09/24/2021] [Indexed: 11/21/2022]
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8
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Saku K, Takagi K, Fukuda T, Tayama E, Tanaka H. Short-segment coronary artery bypass grafting using radial artery to repair bilateral coronary ostial aneurysms after aortic root replacement in a patient with Marfan syndrome. J Card Surg 2021; 36:3399-3401. [PMID: 34053120 DOI: 10.1111/jocs.15684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 05/04/2021] [Accepted: 05/10/2021] [Indexed: 11/30/2022]
Abstract
Coronary ostial aneurysm is a complication of aortic root replacement, particularly in Marfan syndrome. Reconstructing the coronary artery is an important problem during reoperation. Herein, we report a case of coronary artery bypass grafting using radial artery to repair bilateral coronary ostial aneurysms after aortic root replacement in a patient with Marfan syndrome.
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Affiliation(s)
- Kosuke Saku
- Department of Surgery, School of Medicine, Kurume University, Kurume, Japan
| | - Kazuyoshi Takagi
- Department of Surgery, School of Medicine, Kurume University, Kurume, Japan
| | - Tomofumi Fukuda
- Department of Surgery, School of Medicine, Kurume University, Kurume, Japan
| | - Eiki Tayama
- Department of Surgery, School of Medicine, Kurume University, Kurume, Japan
| | - Hiroyuki Tanaka
- Department of Surgery, School of Medicine, Kurume University, Kurume, Japan
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Pradegan N, Azzolina D, Gregori D, Randazzo G, Frasson S, Gerosa G. Residual root fate after aortic surgery in bicuspid aortic valve with right-to-left fusion: A comparative risk analysis. J Card Surg 2021; 36:2628-2635. [PMID: 33960500 PMCID: PMC8359844 DOI: 10.1111/jocs.15585] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/04/2021] [Accepted: 04/08/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIM Although bicuspid aortic valve (BAV) anatomy might influence aortic aneurysm development, BAV-related root involvement still lacks standardized surgical management. We aimed to evaluate late clinical outcomes and risk factors for root dilation after proximal aortic replacement in patients with BAV and right-left fusion (RL-BAV). METHODS Clinical and echocardiographic data of all patients with intraoperative RL-BAV who underwent ascending aortic replacement with or without noncoronary sinus (NCS) replacement (Groups 1 and 2, respectively) between 1999 and 2017, were retrospectively revised. A multivariable analysis assessed hazard factors for root dilation during follow-up (FU). RESULTS Of 206 surgeries performed (M 81%; age: 57 ± 13 years, EuroSCORE II: 2.7 ± 1.9%), 79 (38%) required NCS replacement. One hundred fifty-seven patients (76%) underwent aortic valve replacement (with aortic regurgitation predominating in Group 1, p = .04). The preoperative aortic root was larger in patients requiring NCS replacement (43.3 ± 5.1 vs. 39.2 ± 4.8 mm, p < .001). At a median FU time of 7 years (interquartile range: 4-10), no residual root dissections occurred, and only two patients (belonging to Group 2) required redo root surgery. Preoperative mild aortic regurgitation and aortic root diameter >35 mm at discharge were risk factors for root dilation >40 mm at FU (p = .02). Aortic root did not dilate over time, irrespective of NCS replacement (p = .06). CONCLUSIONS Aortic root in patients with RL-BAV undergoing ascending aortic replacement (±NCS replacement) does not significantly dilate over time, even if patients with preoperative aortic regurgitation and postoperative root more than 35 mm might require more surveillance.
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Affiliation(s)
- Nicola Pradegan
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University Hospital, Padova, Italy
| | - Danila Azzolina
- Biostatistics Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Dario Gregori
- Biostatistics Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Gianmarco Randazzo
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University Hospital, Padova, Italy
| | - Sara Frasson
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University Hospital, Padova, Italy
| | - Gino Gerosa
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University Hospital, Padova, Italy
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10
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A rare case of a giant circumflex coronary artery aneurysm 10 years after bentall surgery. Radiol Case Rep 2021; 16:1749-1753. [PMID: 34007396 PMCID: PMC8111465 DOI: 10.1016/j.radcr.2021.03.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 03/28/2021] [Accepted: 03/28/2021] [Indexed: 11/21/2022] Open
Abstract
In this paper, we describe a rare case of coronary artery aneurysms occasionally found on a pre interventional Coronary Computed Tomography Angiography performed on a 67-year-old man with a history of aneurysm of the ascending aorta previously treated with Bentall surgery, who arrived at our hospital to have a percutaneous valve-in-valve implantation procedure. Even though the patient was considered not eligible for the procedure, due to his many comorbidities, and conservatively managed, at 1-year followup his angiographic condition remained stable.
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11
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Coronary Artery Aneurysms in Patients With Marfan Syndrome: Frequent, Progressive, and Relevant. Can J Cardiol 2021; 37:1225-1231. [PMID: 33711475 DOI: 10.1016/j.cjca.2021.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/15/2021] [Accepted: 03/02/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND There are few data on the prevalence and clinical consequences of coronary artery aneurysms (CAAs) in adult patients with Marfan syndrome (MFS). METHODS We performed a retrospective cohort study of 109 patients with pathogenic variants in the FBN1 gene. Diameters of the left main coronary artery (LMCA) and right- coronary artery (RCA) were measured by computed tomography angiography. RESULTS The overall prevalence of CAA was 46%. The prevalence rates of CAA were 18% and 68% in patients with a native aortic root (group 1) and patients with previous aortic-root replacement (group 2), respectively. Previous aortic dissection or aortic intervention, longer time from aortic-root replacement, higher systemic score, significant mitral valve involvement, and diffuse aortic disease were correlated with CAA. During a mean follow-up of 8.5 ± 7.6 years, 4 patients developed pseudoaneurysms of the coronary anastomoses, requiring surgery. CONCLUSIONS CAAs are common in adult patients with MFS and are associated with a more severe aortic phenotype and a longer follow-up after aortic-root replacement. Our study demonstrates that coronary artery size should be regularly followed, mostly after aortic-root replacement and in patients with severe aortic phenotypes. Large multicentre studies are warranted to elucidate the most appropriate surveillance plan.
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12
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Raju SN, Shaw M, Pandey NN, Sharma A, Kumar S. Imaging evaluation using computed tomography after ascending aortic graft repair. Asian Cardiovasc Thorac Ann 2020; 29:132-142. [PMID: 32957798 DOI: 10.1177/0218492320960331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Prosthetic aortic graft repair is employed in the management of various conditions such as annuloaortic ectasia, ascending aortic aneurysm, type A aortic dissection, and aortic root abscess. Correct interpretation of post-surgical prosthetic graft complications requires familiarity with the expected normal cross-sectional imaging appearance as well knowledge of additional surgical materials used in the repair, which could influence the imaging appearance. Multiple life-threatening complications of a prosthetic ascending aortic graft can be seen in the aorta and vicinity of the operative field. Complications can arise from involvement of the prosthetic aortic graft per se or secondary involvement of the coronary arteries, mediastinum, and sternotomy site. The optimal imaging protocol using multidetector computed tomography allows accurate interpretation of the expected benign postoperative changes as well as complications associated with the prosthetic graft, and differentiation of true complications from their mimickers. This review focuses on the normal imaging appearance of a prosthetic aortic graft on multidetector computed tomography, and imaging evaluation of multiple post-surgical complications that could arise after repair of the ascending aorta and the aortic valve.
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Affiliation(s)
- Sreenivasa Narayana Raju
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Manish Shaw
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Niraj Nirmal Pandey
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Arun Sharma
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Kumar
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
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Krishna H, Ginde S, Katzmark L, Mitchell M, Woods R, Hraska V, Earing MG. Coronary ostial aneurysms following aortic root replacement in patients with familial aortic aneurysm are common and support the need for long-term surveillance. PROGRESS IN PEDIATRIC CARDIOLOGY 2019. [DOI: 10.1016/j.ppedcard.2019.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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14
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Green DB, Vargas D, Reece TB, Raptis CA, Johnson WR, Truong QA. Mimics of Complications in the Postsurgical Aorta at CT. Radiol Cardiothorac Imaging 2019; 1:e190080. [PMID: 33778523 DOI: 10.1148/ryct.2019190080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/15/2019] [Accepted: 07/26/2019] [Indexed: 01/09/2023]
Abstract
Various surgical techniques of the aorta result in expected imaging appearances on CT images that resemble complications such as pseudoaneurysm, perigraft abscess, and dissection. Awareness of these techniques, understanding the clinical situation in which they are performed, and familiarity with the typical appearances and locations of these mimics are essential for accurate interpretation. CT imaging techniques such as electrocardiographic gating and inclusion of a precontrast series can help distinguish an expected postsurgical finding from a complication. Information in the medical record, particularly the operative note, can clarify challenging cases with unusual imaging features. This review article provides examples of expected postsurgical findings at CT mimicking complications. © RSNA, 2019.
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Affiliation(s)
- Daniel B Green
- Departments of Radiology (D.B.G., D.B.V.) and Surgery (T.B.R.), University of Colorado School of Medicine, 12401 E 17th St, Mailstop L954, Aurora, CO 80045; Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (C.A.R.); Premier Radiology, Tupelo, Miss (W.R.J.); and Department of Radiology, Weill Cornell Medicine, New York, NY (Q.A.T.)
| | - Daniel Vargas
- Departments of Radiology (D.B.G., D.B.V.) and Surgery (T.B.R.), University of Colorado School of Medicine, 12401 E 17th St, Mailstop L954, Aurora, CO 80045; Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (C.A.R.); Premier Radiology, Tupelo, Miss (W.R.J.); and Department of Radiology, Weill Cornell Medicine, New York, NY (Q.A.T.)
| | - T Brett Reece
- Departments of Radiology (D.B.G., D.B.V.) and Surgery (T.B.R.), University of Colorado School of Medicine, 12401 E 17th St, Mailstop L954, Aurora, CO 80045; Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (C.A.R.); Premier Radiology, Tupelo, Miss (W.R.J.); and Department of Radiology, Weill Cornell Medicine, New York, NY (Q.A.T.)
| | - Constantine A Raptis
- Departments of Radiology (D.B.G., D.B.V.) and Surgery (T.B.R.), University of Colorado School of Medicine, 12401 E 17th St, Mailstop L954, Aurora, CO 80045; Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (C.A.R.); Premier Radiology, Tupelo, Miss (W.R.J.); and Department of Radiology, Weill Cornell Medicine, New York, NY (Q.A.T.)
| | - W Russell Johnson
- Departments of Radiology (D.B.G., D.B.V.) and Surgery (T.B.R.), University of Colorado School of Medicine, 12401 E 17th St, Mailstop L954, Aurora, CO 80045; Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (C.A.R.); Premier Radiology, Tupelo, Miss (W.R.J.); and Department of Radiology, Weill Cornell Medicine, New York, NY (Q.A.T.)
| | - Quynh A Truong
- Departments of Radiology (D.B.G., D.B.V.) and Surgery (T.B.R.), University of Colorado School of Medicine, 12401 E 17th St, Mailstop L954, Aurora, CO 80045; Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (C.A.R.); Premier Radiology, Tupelo, Miss (W.R.J.); and Department of Radiology, Weill Cornell Medicine, New York, NY (Q.A.T.)
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Wagner AH, Zaradzki M, Arif R, Remes A, Müller OJ, Kallenbach K. Marfan syndrome: A therapeutic challenge for long-term care. Biochem Pharmacol 2019; 164:53-63. [PMID: 30926475 DOI: 10.1016/j.bcp.2019.03.034] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/25/2019] [Indexed: 12/14/2022]
Abstract
Marfan syndrome (MFS) is an autosomal dominant genetic disorder caused by mutations in the fibrillin-1 gene. Acute aortic dissection is the leading cause of death in patients suffering from MFS and consequence of medial degeneration and aneurysm formation. In addition to its structural function in the formation of elastic fibers, fibrillin has a major role in keeping maintaining transforming growth factor β (TGF-β) in an inactive form. Dysfunctional fibrillin increases TGF-β bioavailability and concentration in the extracellular matrix, leading to activation of proinflammatory transcription factors. In turn, these events cause increased expression of matrix metalloproteinases and cytokines that control the migration and infiltration of inflammatory cells into the aorta. Moreover, TGF-β causes accumulation of reactive oxygen species leading to further degradation of elastin fibers. All these processes result in medial elastolysis, which increases the risk of vascular complications. Although MFS is a hereditary disease, symptoms and traits are usually not noticeable at birth. During childhood or adolescence affected individuals present with severe tissue weaknesses, especially in the aorta, heart, eyes, and skeleton. Considering this, even young patients should avoid activities that exert additional stress and pressure on the aorta and the cardiovascular system. Thus, if the diagnosis is made and prophylactic treatment is initiated in a timely fashion, MFS and its preliminary pathophysiologic vascular remodeling can be successfully ameliorated reducing the risk of life-threatening complications. This commentary focuses on new research opportunities and molecular findings on MFS, discusses future challenges and possible long-term therapies.
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Affiliation(s)
- A H Wagner
- Institute of Physiology and Pathophysiology, Division of Cardiovascular Physiology, Heidelberg University, Germany.
| | - M Zaradzki
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - R Arif
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - A Remes
- Department of Internal Medicine III, University Hospital Kiel, Kiel, Germany
| | - O J Müller
- Department of Internal Medicine III, University Hospital Kiel, Kiel, Germany
| | - K Kallenbach
- INCCI HaerzZenter, Department of Cardiac Surgery, Luxembourg, Luxembourg
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16
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Prevalence and Natural History of Coronary Ostial Aneurysms in Marfan Patients. J Comput Assist Tomogr 2019; 43:115-118. [DOI: 10.1097/rct.0000000000000799] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Karangelis D, Tzertzemelis D, Demis AA, Economidou S, Panagiotou M. Eighteen years of clinical experience with a modification of the Bentall button technique for total root replacement. J Thorac Dis 2018; 10:6733-6741. [PMID: 30746218 DOI: 10.21037/jtd.2018.11.61] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background We retrospectively reviewed our experience with the modified Bentall procedure and evaluated the short- and long-term results over a period of 18 years. Methods Between 1999 and 2017, 89 patients with a mean age of 57.3±13.9 years underwent the modified Bentall operation with a slight modification for the correction of aortic root disease. Results The operative mortality was 1.1% while the overall early mortality rate, defined as death within 30 days of initial hospitalization, was 2.2% (2/89). Logistic regression analysis revealed that increased Euroscore and aortic cross-clamp times were associated with greater likelihood for complications. The overall survival rates for the 89 patients (including deaths occurred at the initial hospitalization) were 93.0% (SE =3.0%) at 6 months, 93.0% (SE =3.0%) at 1 year, 89% (SE =5.0%) at 5 years and 73.0% (SE =5.0%) at 10, 15 and 18 years. Multiple Cox regression analysis for survival identified that increased aortic cross-clamp time, increased age, having a concomitant cardiac procedure and increased NYHA Class were associated with greater hazard. Left ventricular remodeling was assessed by means of echocardiography preoperatively and 1, 3, 6 and 12 months postoperatively. Conclusions According to our experience, the Bentall procedure is a safe procedure, provides optimal long-term survival and can still be regarded as the gold standard procedure for aortic root replacement.
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Affiliation(s)
- Dimos Karangelis
- Cardiac Surgery Department, Athens Medical Center, Distomou 5, Amaroussio 151 25, Greece
| | - Dimitrios Tzertzemelis
- Cardiac Surgery Department, Athens Medical Center, Distomou 5, Amaroussio 151 25, Greece
| | - Alexandros A Demis
- Cardiac Surgery Department, Athens Medical Center, Distomou 5, Amaroussio 151 25, Greece
| | - Stella Economidou
- Cardiac Surgery Department, Athens Medical Center, Distomou 5, Amaroussio 151 25, Greece
| | - Matthew Panagiotou
- Cardiac Surgery Department, Athens Medical Center, Distomou 5, Amaroussio 151 25, Greece
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Jeudy J, White CS, Kligerman SJ, Killam JL, Burke AP, Sechrist JW, Shah AB, Hossain R, Frazier AA. Spectrum of Coronary Artery Aneurysms: From the Radiologic Pathology Archives. Radiographics 2018; 38:11-36. [DOI: 10.1148/rg.2018170175] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Mahesh B, Deville C, Nashef S. Proposed modification for valve-sparing aortic root replacement. Ann Thorac Surg 2014; 97:1811-3. [PMID: 24792282 DOI: 10.1016/j.athoracsur.2013.08.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 07/18/2013] [Accepted: 08/28/2013] [Indexed: 11/19/2022]
Abstract
Valve-sparing aortic root replacement (ARR) is the procedure of choice in young patients with aortic root aneurysm and preserved aortic valve leaflets; however, coronary ostial anastomoses remain an issue. Troublesome bleeding sometimes occurs during surgery, and in the long term, there is a risk of aneurysmal formation in the residual aortic wall of the ostial "button." We describe a technique of valve-sparing ARR wherein each coronary button along with its flange of aortic tissue is implanted within the prosthetic graft used for ARR, thereby eliminating the risk of both immediate surgical bleeding and late coronary button aneurysms.
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Giant Coronary Aneurysms: A Rare Complication Following Bentall Procedure. Heart Lung Circ 2013. [DOI: 10.1016/j.hlc.2013.03.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Ng ACC, Hanzek D, Kritharides L, Yiannikas J. A novel parasternal transthoracic echocardiographic window for detecting coronary ostial dilation after modified Bentall surgery. Cardiovasc Ultrasound 2013; 11:14. [PMID: 23688292 PMCID: PMC3665738 DOI: 10.1186/1476-7120-11-14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 05/16/2013] [Indexed: 11/10/2022] Open
Abstract
Background During the modified Bentall surgery (aortic root replacement), a cuff of native aorta is implanted, together with the coronary ostium, into the aortic graft. Multi-detector computed tomography (MDCT) imaging can accurately assess the coronary ostial anastomosis site post-surgery. In this study, we assessed the feasibility of imaging the coronary ostial anastomosis site using transthoracic echocardiography (TTE). Methods Patients (n = 14, mean age 65 ± 12 years, 79% males) with previous Bentall surgery underwent TTE study, with MDCT (64-slice) as the reference standard. TTE used conventional and novel acoustic windows to interrogate the coronary ostia. Results All coronary ostia (n = 28) were well-visualized with MDCT. The optimum TTE acoustic window for visualizing the coronary ostia was a superiorly positioned parasternal short-axis view with the probe tilted towards the left shoulder, medially angulated for the right coronary artery ostia (RCAos) and laterally angulated for the left main coronary artery (LMAos). In this off-axis position, 10 (71%) LMAos and 13 (93%) RCAos could be visualized. In the conventional parasternal views, only 5 (36%) RCAos and no LMAos could be visualized. TTE underestimated the diameter of the LMAos (10.0 ± 2.4 mm TTE vs. 13.4 ± 2.7 mm MDCT, p = 0.007), but was similar to MDCT for the RCAos (9.8 ± 3.1 mm TTE vs. 11.1 ± 3.2 mm MDCT, p = 0.10). Conclusions We report a novel TTE acoustic window to image the coronary ostia of post-Bentall surgery patients. Although TTE underestimates the left coronary ostium size, recognition of the ostial dilation with TTE appears feasible in most patients. Those that cannot be imaged will require alternative imaging modality such as MDCT.
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Affiliation(s)
- Austin Chin Chwan Ng
- Cardiology Department, Concord Hospital, The University of Sydney, Hospital Road, Concord 2139, NSW, Australia.
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Park CB, Greason KL, Suri RM, Michelena HI, Schaff HV, Sundt TM. Fate of nonreplaced sinuses of Valsalva in bicuspid aortic valve disease. J Thorac Cardiovasc Surg 2011; 142:278-84. [DOI: 10.1016/j.jtcvs.2010.08.055] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Revised: 08/07/2010] [Accepted: 08/29/2010] [Indexed: 01/27/2023]
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Bonnichsen CR, Sundt TM, Anavekar NS, Foley TA, Morris MF, Martinez MW, Williamson EE, Glockner JF, Araoz PA. Aneurysms of the ascending aorta and arch: the role of imaging in diagnosis and surgical management. Expert Rev Cardiovasc Ther 2011; 9:45-61. [PMID: 21166528 DOI: 10.1586/erc.10.168] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Thoracic aortic aneurysms tend to be asymptomatic and were previously often diagnosed only after a complication such as dissection or rupture occurred. Better imaging techniques and an increase in the use of cross-sectional imaging has led to an increase in the diagnosis of aortic aneurysms, which has allowed for elective treatment prior to the development of a complication. The location, size and etiology of an aneurysm all impact the clinical outcomes and these factors are used to determine the appropriate timing of surgical replacement. Surgeons often rely on the information obtained from preoperative imaging to determine when to intervene and what type of procedure will be necessary, making it important for the radiologist to understand these issues in order to provide the necessary information. Postoperative imaging after surgical replacement of the aorta is also important, as there are some common findings that occur in this patient population that can impact how they are treated. The purpose of this article is to review the etiology and associated findings of aneurysms of the ascending aorta and arch, with a focus on how computed tomography angiography and magnetic resonance angiography findings are used to determine the appropriate timing for elective replacement and the type of surgical procedure, as well as the role of follow-up imaging. This will include a review of the most commonly performed types of surgical procedures, to provide an understanding of how the findings of preoperative imaging studies impact what the surgeon does in the operating room, as well as the expected findings of postoperative imaging studies.
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Affiliation(s)
- Crystal R Bonnichsen
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic and Mayo Foundation, 200 1st Street SW, Rochester, MN 55905, USA
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Aortic root replacement in young adults: disease characteristics and early outcome. Indian J Thorac Cardiovasc Surg 2011. [DOI: 10.1007/s12055-010-0068-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Chwan Ng AC, Yiannikas J, Chiang Yong AS, Ridley L, Wilson MK, Kritharides L. Coronary ostial morphology after modified Bentall operation assessed with dual-source multidetector computed tomography. J Cardiovasc Comput Tomogr 2010; 4:206-12. [PMID: 20413365 DOI: 10.1016/j.jcct.2010.03.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Revised: 01/03/2010] [Accepted: 03/09/2010] [Indexed: 11/15/2022]
Abstract
During the modified Bentall operation (aortic root replacement), a cuff of native aorta is commonly implanted together with the coronary ostium into the aortic graft. We describe the radiologic appearance on computed tomography of coronary-aortic and aorto-aortic graft anastomoses over long-term follow-up in 21 consecutive asymptomatic patients (mean age, 67 +/- 12 years) with previous Bentall operation. Multidetector (64-slice, dual-source) computed tomography was performed at a median of 76 months after surgery. One patient had asymptomatic aortic dissection that extended into the carotid artery. Seven patients had aortic dilation > or =40 mm distal to the graft. All patients had dilation at the postsurgical coronary ostia-aortic attachment: mean coronary ostial diameter was 12.8 +/- 3.6 mm, which was on average 1.7-fold greater than the adjacent proximal coronary vessel diameter. All patients had at least one ostium > or =10 mm in diameter. In 16 patients, both coronary ostia were > or =10 mm. There was no relationship between time after surgery and the ostial diameter. In patients with accessible presurgery angiograms, no relationship was observed between ostial diameters before and after surgery. Dilation of the coronary ostia anastomosis site is typical after the modified Bentall operation. Asymptomatic aortic pathology is also evident in this population.
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Affiliation(s)
- Austin Chin Chwan Ng
- Cardiology Department, Concord Hospital, The University of Sydney, Hospital Road, Concord 2139, NSW, Australia
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Caynak B, Sagbas E, Onan B, Onan IS, Sen O, Bayramoglu Z, Kabakci B, Sanisoglu I, Akpinar B. Comparison of three different surgical methods in aortic root aneurysms: long-term results. J Card Surg 2009; 24:710-5. [PMID: 19754676 DOI: 10.1111/j.1540-8191.2009.00928.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Degenerative ascending aortic aneurysms frequently present with aortic valve pathology. If only the noncoronary sinus of Valsalva is dilated, replacement of the noncoronary sinus by tailoring the supracoronary graft with or without aortic valve replacement (AVR) can be a simple operation strategy. We sought to describe our experiences in this kind of operation, and compare them with a relatively homogeneous group of patients who underwent the classical Bentall operation. METHODS Between January 1997 and June 2007, 99 patients who had dilated ascending aortas with root dilatation and aortic valve pathology underwent operation. Patients were divided into three groups according to the surgical procedure. Classical Bentall operation was applied in 54 patients with dilated sinuses (Group 1). The other patients with dilated noncoronary sinus underwent either ascending aortic replacement with noncoronary sinus replacement (NSR, n = 27) (Group 2), or separate AVR and ascending aortic replacement with NSR (AVR + NSR, n = 18) (Group 3). RESULTS There were significant reduction of aortic root in Group 2 (Z =-4.560, p < 0.001), and Group 3 (Z =-3.758, p < 0.001). Degree of aortic regurgitation was decreased from 1.56 +/- 0.5 to 0.67 +/- 0.5 postoperatively in Group 2 (Z =-3.874, p < 0.001). Hospital mortality was six (6.1%) (three in Group 1; three in Group 2). Late mortality rate was 6.1% (three in Group 1, three in Group 2). The type of operation was not found to be an independent predictor of overall mortality. No patients in the NSR and AVR-NSR groups had aortic root aneurysm, and there were no reoperations or verified deaths caused by aortic root aneurysm in these patients. CONCLUSIONS Noncoronary cusp replacement for aortic root remodeling in patients with ascending aortic aneurysm is a technically simple and durable operation. Short- and mid-term results of this method were favorable compared to the Bentall procedure.
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Affiliation(s)
- Baris Caynak
- Department of Cardiovascular Surgery, Istanbul Bilim University, Florence Nightingale Hospital, Istanbul, Turkey.
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Okamoto K, Casselman FP, De Geest R, Vanermen H. Giant left coronary ostial aneurysm after modified Bentall procedure in a Marfan patient. Interact Cardiovasc Thorac Surg 2008; 7:1164-6. [DOI: 10.1510/icvts.2008.183103] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Cebi N, Frömke J, Ozcelik K, Walterbusch G. Perioperative results of the aortic root replacement in strict graft inclusion technique. J Card Surg 2008; 23:505-10. [PMID: 18928488 DOI: 10.1111/j.1540-8191.2008.00650.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM Bleeding may sometimes be a serious problem after the termination of the aortic root replacement. Therefore, the strict graft inclusion technique has been developed to avoid major complications. We present the early results after aortic root replacement in strict graft inclusion technique. MATERIALS AND METHODS The strict graft inclusion technique was performed in 28 patients between April 2001 and June 2006 in St-Johannes-Hospital-Dortmund, Dortmund, Germany. There were nine female and 19 male patients. The mean age was 57.78 +/- 12.01 years (28 to 77 years). A type A aortic dissection and an ascending aortic aneurysm with aortic valve lesion were the indication to operation in patients. RESULTS There were no early mortality and postoperative rethoracotomy. The mean postoperative bleeding over mediastinal drains was 565 +/- 310 mL. (100-2250 mL). In exception of the patients with preoperative double thrombocyte aggregation inhibitors therapy and postoperative consumption coagulopathy, the mean postoperative bleeding over mediastinal drain was 443.04 +/- 171.59 mL (100-1100) in the first 24 hours, the transfusion rate was minimal, mean 0.39 +/- 0.64 packed red blood cells (RBC) (0-4) and mean 0.14 +/- 0.27 packed fresh frozen plasma (FFP) (0-4), whereas only in 18 patients (78.26%) out of 23 patients was a transfusion not necessary. The intraoperative and postoperative requirement for substitution of erythrocyte concentrate was mean 1 +/- 1.28 packed RBC (0-5) and FFP concentrate was mean 1.21 +/- 1.90 packed FFP (0-12). CONCLUSIONS The strict graft inclusion technique for aortic root replacement represents a safe and feasible method to avoid bleeding from coronary ostial anastomoses, from aortic annular suture lines, and annular leak.
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Affiliation(s)
- Niyazi Cebi
- Department of Thoracic and Cardiovascular Surgery, St.-Johannes-Hospital-Dortmund, Dortmund, Germany.
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Nezic D, Cirkovic M, Knezevic A, Jovic M. Modified Bentall procedure - 'a collar technique' to control bleeding from coronary ostia anastomoses. Interact Cardiovasc Thorac Surg 2008; 7:709-11. [PMID: 18477601 DOI: 10.1510/icvts.2008.180745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Composite conduit aortic root replacement has become widely accepted as the preferred treatment for ascending aorta aneurysm and dissection. We present a patient in whom creation of 'buttons' was impossible due to fragility of the ascending aorta wall. The distal anastomosis was made to the transected aorta. The remnant of the proximal ascending aortic wall was fully transected 8-9 mm above the upper edge of coronary ostia anastomoses (incorporated into conduit using inclusion technique), thus forming a 'collar' around the proximal part of the conduit. At the end of the procedure the 'collar' was anchored to the conduit to control persistent bleeding from coronary ostia anastomoses.
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Affiliation(s)
- Dusko Nezic
- Dedinje Cardiovascular Institute, Belgrade, Serbia.
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Kaemmerer H, Oechslin E, Seidel H, Neuhann T, Neuhann IM, Mayer HM, Hess J. Marfan syndrome: what internists and pediatric or adult cardiologists need to know. Expert Rev Cardiovasc Ther 2006; 3:891-909. [PMID: 16181034 DOI: 10.1586/14779072.3.5.891] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Marfan syndrome (MFS) is one of the most frequent connective tissue disorders, showing striking pleiotropism and clinical variability. There is autosomal dominant inheritance with complete penetrance but variable expression. Approximately 25% of MFS patients have no family history of the syndrome and represent sporadic cases due to new mutations. This hazardous condition is often associated with premature cardiovascular death unless surveillance and management are optimized. The fibrillin gene (FBN1) encodes the structure of the connective tissue protein fibrillin. MFS is caused by mutations in the fibrillin gene, located on chromosome 15 at locus 15q21. Fibrillin abnormalities reduce the structural integrity of different body systems, primarily involving the heart valves, blood vessels, lungs, bones, tendons, ligaments, cartilages, eyes, skin, spinal dura and the CNS. Patients with MFS are likely to have too little fibrillin within these structures, resulting in clinically relevant problems. For example, in the aortic wall, deficient fibrillin may trigger progressive aortic ectasia and may result in aortic dissection.
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Affiliation(s)
- Harald Kaemmerer
- Klinik für Kinderkardiologie und angeborene Herzfehler, Deutsches Herzzentrum München, Klinik an der Technischen UniversiteatLazarettstr. 36D-80636 Munich, Germany.
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Turkoz R, Gulcan O. Composite Graft Replacement in Acute Aortic Dissection: Technique for Anastomosing the Right Coronary Artery without an Aortic Button. Heart Surg Forum 2004; 7:E574-6. [PMID: 15769690 DOI: 10.1532/hsf98.20041131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Acute aortic dissection that involves the ostium of the right coronary artery is a rare occurrence, but treatment by composite graft replacement of the aortic root is a technically difficult procedure, usually involving implantation of an aortic button. We describe 2 patients with ostium of the right coronary artery severely damaged by acute aortic dissection. In both cases we used a technique that mobilized the right coronary artery sufficiently so that it could be implanted without including an aortic button.
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Affiliation(s)
- Riza Turkoz
- Baskent University, Cardiovascular Surgery Department, Adana, Turkey.
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Abstract
The Marfan syndrome is an autosomal dominant disorder of connective tissue, caused by mutations in the FBN1 gene on chromosome 15. More than 500 mutations have been identified and almost all are unique to an affected individual or family. Genotype--phenotype correlations in the Marfan syndrome have been complicated by the large number of unique mutations reported, as well as by clinical heterogeneity among individuals with the same mutation. A relatively unknown cardiovascular manifestation of Marfan syndrome is dilatation of the main pulmonary artery. Of 50 patients with Marfan syndrome, MR imaging showed in 74% patients an enlarged pulmonary artery root above the upper limit of normal. Aortic elasticity determined by measurement of local distensibility and flow wave velocity with MR imaging is decreased in non-operated patients with Marfan syndrome. Aortic distensibility of the thoracic descending aorta appeared to be the strongest predictor for descending aortic complications. Over the past 30 years improvement of diagnostic modalities and aggressive medical and surgical therapy, have resulted in considerable improvement of life expectancy of patients with Marfan syndrome. Further studies are needed to investigate the role of modulating genes and genotype--phenotype correlations. Long-term follow-up studies may reveal the prognostic significance of aortic elasticity and may identify patients at risk of aortic complications.
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Affiliation(s)
- G J Nollen
- Department of Cardiology, Academic Medical Center, Room B2-240, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands
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Sioris T, David TE, Ivanov J, Armstrong S, Feindel CM. Clinical outcomes after separate and composite replacement of the aortic valve and ascending aorta. J Thorac Cardiovasc Surg 2004; 128:260-5. [PMID: 15282463 DOI: 10.1016/j.jtcvs.2003.11.011] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES We sought to compare the clinical profile and outcomes of operations for aortic valve disease and ascending aortic aneurysm in patients treated with aortic valve replacement and supracoronary replacement of the ascending aorta or composite replacement of the aortic valve and ascending aorta (Bentall operation). METHODS From 1990 through 2001, 133 patients had aortic valve replacement and supracoronary replacement of the ascending aorta, and 452 patients had Bentall operations. Aortic valve replacement and supracoronary replacement of the ascending aorta was performed in patients who had aortic valve disease and dilation of the ascending aorta, whereas the Bentall operation was performed in patients with aortic root abnormality and ascending aortic aneurysm. Mean follow-up was 4.6 +/- 3.1 years and was 100% complete. RESULTS Patients who had aortic valve replacement and supracoronary replacement of the ascending aorta were older (61 +/- 13 vs 52 +/- 16 years, P <.001) and more likely to have aortic stenosis, coronary artery disease, and mitral valve disease than those who had Bentall operations. The use of mechanical valves was equal in both groups (42% for aortic valve replacement and supracoronary replacement of the ascending aorta and 43% for the Bentall operation). Operative mortality was 5% for patients undergoing aortic valve replacement and supracoronary replacement of the ascending aorta and 4% for patients undergoing the Bentall operation (P =.45). Survival at 10 years was 57% +/- 8% for patients undergoing aortic valve replacement and supracoronary replacement of the ascending aorta and 74% +/- 4% for patients undergoing the Bentall operation (P =.04), but the type of operation had no effect on survival. Older age, moderate or severe left ventricular dysfunction, active endocarditis, previous cardiac surgery, and coronary artery disease were independent predictors of death. The freedom from reoperation at 10 years was 95% +/- 5% for patients undergoing aortic valve replacement and supracoronary replacement of the ascending aorta and 94% +/- 3% for patients undergoing the Bentall operation (P =.18). Reoperations were mostly because of tissue valve failure or endocarditis. The risk of valve-related complications was the same in both groups. No patient required reoperation for aortic root aneurysm after having aortic valve replacement and supracoronary replacement of the ascending aorta. CONCLUSIONS Aortic valve replacement and supracoronary replacement of the ascending aorta and the Bentall operation provide comparable long-term results. The Bentall operation is more appropriate for patients with aortic root abnormality and a dilated ascending aorta, whereas aortic valve replacement and supracoronary replacement of the ascending aorta is a perfectly acceptable operation for patients with aortic valve disease, normal or mildly dilated aortic sinuses, and a dilated ascending aorta.
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Affiliation(s)
- Thanos Sioris
- Division of Cardiovascular Surgery, Toronto General Hospital and the University of Toronto, 200 Elizabeth Street, Toronto, Ontario, Canada M5G 2C4
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Milano AD, Pratali S, Mecozzi G, Boraschi P, Braccini G, Magagnini E, Bortolotti U. Fate of coronary ostial anastomoses after the modified Bentall procedure. Ann Thorac Surg 2003; 75:1797-801; discussion 1802. [PMID: 12822618 DOI: 10.1016/s0003-4975(03)00015-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Introduction of the modified Bentall procedure with the button technique has reduced but not eliminated anastomotic complications in patients receiving a composite aortic conduit. Particularly the true incidence of coronary ostial complications such as stenosis, kinking or pseudoaneurysm formation needs to be assessed. METHODS We reviewed 71 patients receiving a composite aortic conduit from November 1993 to November 1999 for chronic aneurysms (n = 51) or aortic dissection (n = 20), 12 of whom had Marfan syndrome. Patients were divided into two groups according to variations in the surgical technique. In group 1 (30 patients; 42%) the classic modified Bentall operation with the button technique was employed whereas in group 2 (41 patients; 58%) some technical modifications were added mainly consisting of a reinforcement suture joining the cut edge of the aortic wall and the prosthetic sewing ring and suture of the coronary buttons with an "endo-button" technique. To detect potential procedure-related complications particularly at the coronary ostia anastomoses follow-up included transthoracic two-dimensional echocardiography every 6 months and computerized tomographic angiography at 12 months or whenever indicated; in 20 patients a magnetic resonance imaging angiography and standard aortography with selective coronary angiography were also added. RESULTS At a mean follow-up of 49 +/- 19 months anastomotic complications occurred in 4 patients (6%): in 2 a pseudoaneurysm developed at the distal aortic suture line and in 1 a pseudoaneurysm developed at the right coronary ostium after repair of acute aortic dissection; in 1 Marfan patient an aneurysm of the left coronary ostium developed. Such complications were unrelated to the two surgical techniques used in this series for reimplantaion of the coronary ostia. CONCLUSIONS The modified Bentall operation is associated with an extremely low incidence of anastomotic complications particularly at the coronary ostia. More extensive use of new imaging techniques is desirable to assess the true incidence of such complications in patients receiving a composite aortic conduit.
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Affiliation(s)
- Aldo D Milano
- Division of Cardiac Surgery, Cardio-Thoracic Department, University of Pisa Medical School, Pisa, Italy
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Nollen GJ, Groenink M, van der Wall EE, Mulder BJM. Current insights in diagnosis and management of the cardiovascular complications of Marfan's syndrome. Cardiol Young 2002; 12:320-7. [PMID: 12206553 DOI: 10.1017/s1047951100012907] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Marfan's syndrome is an inherited disorder of connective tissue, caused by mutations in the fibrillin-1 gene located on chromosome 15. Diagnosis is still based on a combination of major and minor clinical features. Prognosis is mainly determined by the cardiovascular complications. Advances in surgical and medical treatment for these complications have dramatically improved the prognosis of the syndrome.
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Affiliation(s)
- Gijs J Nollen
- Department of Cardiology, Academic Medical Center Amsterdam, The Netherlands
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