Angina, an Unusual and Late Complication of the Cabrol Procedure: A Case Report and Review of the Literature

Cabrol procedure and its modifications: a systematic review and meta-analysis

BACKGROUND

The Cabrol procedure has undergone various modifications and developments since its invention. However, there is a notable gap in the literature regarding meta-analyses assessing it.

METHODS

A systematic review and meta-analysis was conducted to evaluate the effectiveness and long-term outcomes of the Cabrol procedure and its modifications. Pooling was conducted using random effects model. Outcome events were reported as linearized occurrence rates (percentage per patient-year) with 95% confidence intervals.

RESULTS

A total of 14 studies involving 833 patients (mean age: 50.8 years; 68.0% male) were included in this meta-analysis. The pooled all-cause early mortality was 9.0% (66 patients), and the combined rate of reoperation due to bleeding was 4.9% (17 patients). During the average 4.4-year follow-up (3,727.3 patient-years), the annual occurrence rates (linearized) for complications were as follows: 3.63% (2.79-4.73) for late mortality, 0.64% (0.35-1.16) for aortic root reoperation, 0.57% (0.25-1.31) for hemorrhage events, 0.66% (0.16-2.74) for thromboembolism, 0.60% (0.29-1.26) for endocarditis, 2.32% (1.04-5.16) for major valve-related adverse events, and 0.58% (0.34-1.00) for Cabrol-related coronary graft complications.

CONCLUSION

This systematic review provides evidence that the outcomes of the Cabrol procedure and its modifications are acceptable in terms of mortality, reoperation, anticoagulation, and valve-related complications, especially in Cabrol-related coronary graft complications. Notably, the majority of Cabrol procedures were performed in reoperations and complex cases. Furthermore, the design and anastomosis of the Dacron interposition graft for coronary reimplantation, considering natural anatomy and physiological hemodynamics, may promise future advancements in this field.

Percutaneous intervention for an occluded left Cabrol graft

Percutaneous intervention for surgical reconstruction of a coronary artery is a challenging and complex procedure for interventional cardiologists. Particularly in settings of acute coronary syndrome, urgent revascularization may be critical for the prognosis of patients. Therefore, it is important that physicians have knowledge of various surgical techniques for coronary reconstruction. The Cabrol procedure is one of the surgical techniques after aortic root replacement, but it is rarely used at present. Here we describe a case of successful percutaneous revascularization for an occluded left Cabrol graft in acute ST-elevation myocardial infarction with cardiogenic shock. <Learning objective: Percutaneous intervention for surgical reconstruction of coronary artery is challenging. In coronary artery reconstruction, computed tomography angiography might be extremely useful. We describe a case of successful percutaneous revascularization for the occluded left Cabrol graft.>.

Long-Term Postoperative Complication of the Cabrol Procedure Presenting as Recurrent Anterior ST-Segment Elevation Myocardial Infarction

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Development of fistulae between the aneurysm sac and aortic graft can be a potential source of thrombi in patients treated with surgical aortic root replacement.

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Transesophageal echocardiography is an effective tool to assess post-operative complications of the Cabrol procedure.

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Post-operative complications of the Cabrol procedure can have a very delayed initial presentation.

An acutely occluded Cabrol graft presenting as an acute coronary syndrome

The Cabrol technique employs a synthetic graft to connect the coronary arteries to an aortic graft in patients with complex disease of the ascending aorta. Acute Cabrol graft thrombosis is a life-threatening situation that presents as acute coronary syndrome, as it leads to acute coronary hypoperfusion. We present a patient with unstable anginal symptoms who had undergone aortic surgery 6 months prior to presentation. Cardiac catheterisation was concerning for aortic dissection yet was later revealed to be acute occlusion of a Cabrol graft. The patient ultimately died of cardiogenic shock. We review the Cabrol technique, complications and management of acute graft thrombosis.

Aortic Root Reconstruction with a New Dacron Graft Featuring Prefabricated Coronary Side Branches: Lessons Learned from the Cabrol Procedure

BACKGROUND

Coronary button reimplantation can represent a technical challenge of aortic root reconstruction that can be associated with significant morbidity and mortality. With the goal of simplifying coronary reimplantation and reducing the incidence of related complications, we designed a new Dacron graft with prefabricated coronary branches to minimize coronary artery mobilization and prevent the potential mechanical complications of reattachment to the body of the graft.

METHODS

Between June 2010 and May 2012, we implanted the graft in eight patients (six males, two females) ranging in age from 42-68 years (mean, 54 years). Six procedures were modified Bentall reconstructions, and two procedures were valve-sparing root replacements using the reimplantation technique.

RESULTS

There were no complications and no morbidity or mortality related to coronary reattachment. All patients were alive and doing well at a mean follow-up of 26 months (range, 17-38 months). At an extended mean follow-up of 42 months (range, 25-56 months), one patient died of stroke-related complications. No radiologic or clinical evidence of impairment of coronary perfusion was identified in any patient.

CONCLUSIONS

The use of this new graft model may simplify the technique of root reconstruction and potentially lower the incidence of mechanical complications related to coronary button reimplantation.

Composite valve graft implantation for the treatment of aortic valve and root disease: Results in 1045 patients

OBJECTIVES

Aortic root replacement using a composite graft is the treatment of choice for a large variety of aortic root conditions with a diseased aortic valve. The objective of the current study was to evaluate the long-term results of this procedure.

METHODS

Between 1978 and 2010, 1045 patients aged 58.7 ± 13.6 years underwent aortic root composite graft replacement using the following techniques: 95 Bentall operation; 926 the "button technique;" 24 the Cabrol technique. A mechanical composite valve graft was implanted in 69.6% of the patients. Six-hundred and thirty-five patients (62.3%) had annuloaortic ectasia and 162 (15.5%) had aortic dissection.

RESULTS

Early mortality was 5.3% (55/1045). Independent risk factors for early mortality at logistic regression analysis were age ≥70 years (P = .051; odds ratio [OR], 2.97), New York Heart Association III-IV (P = .052; OR, 1.88), reoperation (P = .021; OR, 2.36), urgency/emergency (P = .003; OR, 3.09), mitral valve replacement (P = .001; OR, 6.01), or coronary artery bypass grafting (CABG) (P < .001; OR, 4.39); while bicuspid aortic valve (BAV) (P = .013; OR, 0.21), and time of operation 2001-2011 (P = .025; OR, 0.60) were protective predictors for early mortality. Overall survival at 5, 10, and 20 years was 84.1% ± 1.3%, 65.5% ± 2.6%, and 40.7% ± 4.6%, respectively. Multivariate analysis revealed chronic renal insufficiency (P = .001; hazard ratio [HR], 3.48), chronic obstructive pulmonary disease (P = .027; HR, 1.94), aortic dissection (P = .001; HR, 2.63), Cabrol technique (P = .009; HR, 15.34), and CABG (P = .016; HR, 2.02) to be significant predictors of late death, and BAV (P = .010; HR, 0.43) to be a significant protective predictor. Freedom from thromboembolism, bleeding complications, and endocarditis was 93.7% ± 2.6%, 90.3% ± 3.1%, and 98.4% ± 1% at 20 years, respectively. Freedom from aortic reoperation was 91.8% ± 2.1% at 20 years and was significantly lower in patients with aortic dissection.

CONCLUSIONS

Within the limitations of this retrospective study, we can conclude that aortic root replacement for aortic root aneurysms can be performed with low morbidity and mortality and with satisfactory long-term results. Few late serious complications were related to the need for long-term anticoagulation or a prosthetic valve. Reoperation on the proximal or in the distal aorta was most commonly performed in patients with aortic dissection.

Midterm experience with modified Cabrol procedure: safe and durable for complex aortic root replacement

OBJECTIVE

To evaluate the early and late outcomes of the modified Cabrol technique as a method of coronary reimplantation during complex composite graft replacement of the ascending aorta.

METHODS

Between 1995 and 2012, 348 patients (mean age, 56 ± 14 years; 283 males and 65 females) underwent composite graft replacement of the ascending aorta, 40 of whom (mean age, 60 ± 12 years; 35 males and 5 females) had one or both coronary ostia reimplanted using a modified Cabrol technique with an 8- to 10-mm Dacron interposition graft. The mean clinical and radiologic (computed tomographic scan) postoperative follow-up was 39 months (range, 1-171 months), via our aortic database, patient interviews, and Social Security Death Index.

RESULTS

Cabrol reimplantation was necessitated by reoperations with anatomically fixed coronary ostia (n = 16, 40%), severely displaced coronary arteries (n = 15, 37.5%), button calcification (n = 4, 10%), coronary anomalies (n = 3, 7.5%), and coronary aneurysm (n = 2, 5%). Of the operations, 20% (8 patients) were urgent interventions. Early mortality was 3 (7.5%) of 40, none related to the Dacron interposition graft. Total late mortality was 16.2%, also not related to the coronary graft. Actuarial survivals were 0.88 ± 0.05, 0.79 ± 0.07, and 0.73 ± 0.08 at 1, 3, and 6 years, respectively. Radiologic follow-up was available for 31 (83.8%) of the surviving patients and revealed that the interposition graft was widely patent in all.

CONCLUSIONS

The modified Cabrol technique using a Dacron interposition graft showed good survival rates and excellent durability over time, confirmed radiographically. These data confirm that it is appropriate to use the Cabrol technique when technical complexity prevents bringing coronary buttons to the main aortic graft.

Long-term follow-up, computed tomography, and computational fluid dynamics of the Cabrol procedure

OBJECTIVES

The Cabrol procedure is characterized by insertion of an ascending aortic composite graft with reimplantation of the coronary arteries by the interposition of a graft tube. Our purpose is to report the clinical long-term follow-up and computed tomographic findings in patients having undergone the Cabrol procedure and to determine blood flow in the Cabrol graft using computational fluid dynamics.

METHODS

Clinical follow-up (76.6 +/- 16.6 months) and dual-source computed tomographic angiography data of 7 patients (all men, mean age 54.9 +/- 9.6 years) with 12 Cabrol grafts (left main coronary artery, n = 7; right coronary artery, n = 5) were reviewed. In 2 patients, the right coronary artery was directly reattached to the aortic graft. Computational fluid dynamics were calculated using computed tomographic data of a patient with the Cabrol procedure and compared with those in a Valsalva graft and a healthy aortic root.

RESULTS

Computed tomography showed Cabrol graft occlusions to 1 of 7 (14%) left main and of 2 of 5 (40%) right coronary arteries. Six grafts to the left main and 3 to the right coronary artery were fully patent, similar to the 2 directly reattached right coronary arteries to the aortic graft. Computational fluid dynamics results show similar blood flow parameters into the coronaries for the healthy aortic root and Valsalva graft. In the Cabrol graft, a spiraling flow pattern with low flow into the right coronary artery was found (right coronary artery = 1 mL/min at both systole and diastole).

CONCLUSIONS

Our study indicates low flow rates particularly in the right Cabrol graft correlating with a higher incidence of occlusions of the right as compared with the left Cabrol graft at long-term follow-up.