- Email: [email protected]
Modified aortic root remodeling for annuloaortic ectasia with abnormal coronary take-off
Ann Thorac Surg 2002;74:1687–9
of time showed increased diameter of the abdominal aneurysm. The tortuous thoracic aorta had an aneurysm measuring 9 cm from its proximal third to 4 to 5 cm proximal to the celiac axis. The aorta between the celiac axis and renal arteries was of normal size. Distal to the renal arteries the aneurysm measured 13 cm extending into both iliac arteries. Because there was a proximal (3-cm diameter of aorta) and distal (2.4-cm diameter of the aorta) neck in the thoracic and distal aorta, we treated this patient with multiple endovascular stents (Fig 1A). In the first step of this intervention and under general anesthesia, the right femoral artery was dissected, and five endovascular stents (9 cm each) were deployed distally to the left subclavian artery. The endovascular stents were intussucepted into each other covering the left subclavian artery and extending to the celiac axis. Follow-up transesophageal echocardiography and computed tomographic scan showed exclusion of the thoracic aneurysm by the endovascular stent. Correction of the abdominal aortic aneurysm was done 2 weeks later. The patient was again anesthetized, and endovascular stents were placed distally to the renal arteries extending into both iliac arteries. Before discharge, computed tomography showed multiple stents (Fig 1B) and total exclusion of the thoracoabdominal aneurysm by the endovascular stents (Fig 2). The endovascular stents were stainless steel covered with polyester (Braile Medical, Sao Jose do Rio Preto, Sao Paulo, Brazil). The cylinders are highly resistant to radial collapse and maintain their ability to return to their original diameter once deployed. The prostheses were compressed and inserted into a 20 F catheter. Length, diameter, and whether the stent was bifurcated was selected according to the extension and size of the diseased segment to be treated.
Comment The surgical treatment of thoracoabdominal aneurysms poses a major challenge to the cardiothoracic surgeon, especially because the patients are usually elderly and have serious comorbidities. The development of endovascular prostheses has greatly improved the treatment of patients with aneuryms or dissection in the thoracic and abdominal aorta [4 – 6]. This is a major achievement in the therapy of these aneurysms, but it necessitates precise diagnostic investigations to determine the proximal and distal necks of the aneurysm, vessels involved in the aneurysm, and location of tears in aortic dissection. One of the major challenges is the risk of paraplegia in patients who undergo surgical treatment of these aneurysms. Short cross-clamp time, distal perfusion, hypothermia, and steroids are few of the strategies aimed at decreasing this risk [7]. The use of endovascular stents potentially could decrease the risk of paraplegia and serious morbidities associated with the surgical approach. Chuter and associates [8] developed a multibranched stent graft for thoracoabdominal aneurysm. The use of endovascular stents will have to undergo clinical investigation to de© 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
CASE REPORT MATSUDA ET AL MODIFIED AORTIC REMODELING
1687
termine whether they decrease the incidence of serious morbidities. Although the patient is doing well at 3 months follow-up, longer follow-up is needed to further delineate the beneficial effects of this new approach to a complex problem.
References 1. Okita Y, Ando M, Minatoya K, Tagusari O, Kitamura S, Nakajima N, Takamoto S. Early and long-term results of surgery for aneurysms of the thoracic aorta in septuagenarians and octogenarians. Eur J Cardiothorac Surg 1999;16:317– 23. 2. Svensson LG, Crawford E, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thorocoabdominal operations. J Vasc Surg 1993;17:357–70. 3. Parodi JC. Endovascular repair of abdominal aortic aneurysms and other arterial lesions. J Vasc Surg 1995;21:549 –57. 4. Dake MD, Kato N, Michell RS. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med 1999;340(20):1546 –52. 5. Nienaber CA, Fattori R, Lund G, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med 1999;340(20):1539 –45. 6. Palma JH, Almeida DR, Carvalho AC, Andrade JCS, Buffolo E. Surgical treatment of acute type B aortic dissection using an endoprosthesis (elephant trunk). Ann Thorac Surg 1997;63: 1081–4. 7. Griepp RB, Ergin MA, Galla JD, et al. Surgery for acquired heart disease. J Thorac Cardiovasc Surg 1996;112:1202–15. 8. Chuter TA, Gordon RL, Reilly LM, Pak LK, Messina LM. Multi-branched stent-graft for type 3 thoracoabdominal aortic aneurysm. J Vasc Interv Radiol 2001;12(3):391–2.
Modified Aortic Root Remodeling for Annuloaortic Ectasia With Abnormal Coronary Take-Off Hikaru Matsuda, MD, PhD, Hajime Ichikawa, MD, Shigemitsu Iwai, MD, and Toshiki Takahashi, MD, PhD Department of Surgery, Osaka University, Osaka, Japan
The abnormality of coronary arterial take-off is a limiting factor for a successful aortic valve sparing procedure. We present a 13-year-old boy, with Marfan syndrome and annuloaortic ectasia, whose coronary take-off was found to be abnormal during surgery. Two adjacent coronary orifices were located in the left coronary sinus and very close to the right–left commissure. A modified aortic remodeling procedure was successfully performed without translocation of the coronary artery. (Ann Thorac Surg 2002;74:1687–9) © 2002 by The Society of Thoracic Surgeons
T
here have been remarkable advancements in aortic valve sparing procedures in surgery of the aortic root including annuoaortic ectasia (AAE). When the Accepted for publication June 20, 2002. Address reprint requests to Dr Matsuda, Department of Surgery, Osaka University, 2-2 Yamada-oka, Suita, Osaka 562-0027, Japan; e-mail: [email protected].
0003-4975/02/$22.00 PII S0003-4975(02)03956-5
1688
CASE REPORT MATSUDA ET AL MODIFIED AORTIC REMODELING
Ann Thorac Surg 2002;74:1687–9
aortic valve can be preserved, there are two main options: the reimplantation technique [1] and aortic remodeling [2]. Both methods have the advantages of leaving the native aortic valve leaflets intact, and reconstructing the sinotubular junction and ascending aorta concomitantly. These methods have been widely practiced [3], and an important consideration appears to be the presence of a coronary arterial abnormality. The abnormality of coronary arterial take-off, in particular, is surely a limiting factor for a successful aortic valve sparing procedure, however, this has previously received little attention. We report a patient with Marfan syndrome and AAE, whose coronary take-off was found to be abnormal during surgery, and successfully who underwent a modified aortic remodeling procedure. A 13-year-old boy was previously diagnosed with Marfan syndrome, with subluxatio lentis and tall stature; his father also has Marfan syndrome with a history of aortic dissection. Aortic dilatation was pointed out when the boy was 5 years old. During follow-up by a pediatric cardiologist, the aortic root was found dilated. When he was 12 years old, aortic regurgitation was also noticed by echocardiography. Because of this progressive dilatation of the aortic root and the aortic regurgitation, surgery was indicated. Physical examination revealed his height as 165.4 cm and abnormal subluxatio lentis. Auscultation revealed a moderate degree of aortic regurgitant murmur. Chest roentgenogram showed a moderate cardiomegaly with a cardiothoracic ratio of 50%. Estimated left ventricular volume showed left ventricular end diastolic volume index 107 ml/m2, left ventricular end systolic volume index 44.9 ml/m2, and left ventricular ejection fraction 0.58. Retrograde aortogram was not performed because the family was reluctant to do such a procedure, considering the aortic dissection. The operation was performed on August 2, 2001. Through median sternotomy and pericardiotomy, the heart was inspected and the typical appearance of AAE was found. Cardiopulmonary bypass was initiated with a single two-staged venous cannula and ascending aortic blood return. The aortic root was dilated (50 mm in diameter) just above the sinotubular junction. The size at the upper ascending aorta was 26 mm. An aortic crossclamp was placed and retrograde cold blood cardioplegia was infused. The ascending aorta was transversely opened just above the sinotubular junction, followed by an antegrade cardioplegic infusion. Myocardial protection was conducted through retrograde fashion every 20 minutes. Aortic valvar incompetence was due to dilatation of the sinotubular junction and the loss of coaptation at its center. The leaflets looked intact in appearance. During direct coronary infusion of cardioplegia, it was found that there was no coronary ostium on the right coronary sinus. The left coronary ostium was located on the left coronary sinus, but it was far deviated toward the commissure between left and right coronary cusps. In addition, the right coronary ostium was found just next to the
Fig 1. The two coronary ostia were located close together in the left coronary cusp, near the commissure between the left and right coronary cusp.
left ostium (Fig 1). It was therefore almost a single ostium. Since this ostium was very close to the commissure, the aortic leaflets could not be saved without damage, if the ostium was removed as a cuff. Because the patient was still young, it was advisable to perform an aortic remodeling procedure instead of a valve replacement. It seemed possible to preserve the valve if the coronary ostium was left untouched. In other words, the cusp wall can be removed from the dilated sinus walls as much as possible, with the coronary orifices left on a minimum space of sinus wall without interfering with the commissure. The sinus was removed from the non- and right coronary sinus as usual. From the left coronary sinus, the removal was limited to the center and left side (Fig 1). A 26-mm Hemashield graft (Boston Scientific Corp, Boston, MA) was tailored to fit the aortic root with Valsalva sinuses removed. The height of the cusps of the graft was adjusted to 25 mm. The tongue for the left coronary sinus was slightly reduced in size to adjust its
Ann Thorac Surg 2002;74:1689 –91
shape. The proximal suture was conducted using continuous 5-0 Prolene (Ethicon, New Brunswick, NJ) suture. The distal aorta was removed as much as possible without removing the aortic clamp, and the distal anastomosis was carried out, adjusting the size difference without difficulties. The aortic cross-clamp was removed and cardiac beat was resumed with sinus rhythm. A transesophageal echocardigram during surgery showed trivial aortic regurgitation and good left ventricular function. The postoperative course was uneventful; the patient was discharged home on the 23rd postoperative day. The aortography before discharge showed no obstruction in the coronary orifices. Aortic regurgitation was trivial in degree. The patient was followed up for 6 months without any symptoms.
CASE REPORT KORKOLIS ET AL BIOPROSTHETIC MITRAL VALVE “PSEUDOSTENOSIS”
1689
References 1. Yacoub MH, Gehle P, Chandrasekaran V, Birks EJ, Child A, Radley-Smith R. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg 1998;115:1080 –90. 2. David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992;103:617–22. 3. David TE, Armstrong S, Ivanov J, Feindel CM, Omran A, Webb G. Results of aortic valve-sparing operations. J Thorac Cardiovasc Surg 2001;122:39 –46. 4. Basso C, Corrado D, Thiene G. Congenital coronary artery anomalies as an important cause of sudden death in the young. Cardiol Rev 2001;9:312–7. 5. Taniguchi K, Nakano S, Matsuda H, et al. Long-term survival and complications after composite graft replacement for ascending aortic aneurysm associated with aortic regurgitation. Circulation 1991;84:(Suppl III)31–9.
Comment In aortic ectasia or other aortic regurgitation due to an abnormal aortic root, the aortic valve sparing operations, such as remodeling or reimplantation, are well accepted as the preferred methods when the aortic leaflets are not deformed and the aortic insufficiency is not severe. Such valve sparing procedures have advantages over Bentall type operations because anticoagulation therapy is not required and the left ventricular function is preserved. Therefore, increasing numbers have been indicated. Regarding the operative procedure, there have been many discussions and controversies about the size selection of the graft and how to make the bottom line suitable. However, the anatomical distribution of the coronary ostia has previously been of little concern. This may be due to the rare instance of a combined anomaly in coronary take-off or intramural coronary arteries in the cohort of the patients who had this operation. The coronary origin from wrong sinus is very rare, particularly the right coronary artery from left sinus. This abnormality usually receives attention as a cause of sudden death in the athlete population [4]. In this report, we presented a modification of the remodeling procedure in a case with abnormal coronary artery ostia disturbing the full removal of the coronary sinuses, without damaging the coronary artery ostia, for the reconstruction with a short-length graft. In this case, both coronary ostia were very close to each other, like a single ostium, and were located just next to the commissure. It was, therefore, impossible to remove the coronary ostium with cuffs. This modification of the remodeling procedure has the benefits of preserving the aortic valve and coronary ostium intact. However, there are some concerns in the late follow-up. Since the sinus wall itself was dilated and weak, as is its nature in AAE, particularly in Marfan patients, there might be some risks of progressive dilatation of the sinus around the coronary ostium [5] where removal of the diseased sinus wall was not complete. Nonetheless, considering the benefits of preserving the native aortic valve in younger patients with Marfan syndrome, who risk aortic dissection in the future, such efforts to preserve the valve even in a situation of abnormal coronary ostia may be important. © 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Early Bioprosthetic Mitral Valve “Pseudostenosis” After Complete Preservation of the Native Mitral Apparatus Dimitris P. Korkolis, MD, PhD, Cary S. Passik, MD, Stephen J. Marshalko, MD, PhD, and George J. Koullias, MD Departments of Cardiothoracic Surgery, Section of Cardiovascular Medicine, Yale–New Haven Hospital, New Haven, Connecticut
An advantage of bioprosthetic mitral valve replacement in patients with normal sinus rhythm is avoidance of the need for long-term anticoagulation. Bioprosthetic valve thrombosis is a rare complication, supporting this approach. This case report represents an example of porcine mitral valve stenosis, likely secondary to thrombosis, in which all of the native mitral valve apparatus was left intact. This was successfully treated with standard anticoagulation therapy. This complication should be considered in patients in whom retention of the mitral valve apparatus has been performed. Such patients may benefit from long-term anticoagulation treatment to obviate this event. (Ann Thorac Surg 2002;74:1689 –91) © 2002 by The Society of Thoracic Surgeons
T
hrombosis of prosthetic valves, in general, affect mechanical prostheses. There have been several case reports of bioprosthetic mitral valve thrombosis that have led to early valve explantation. Resurrection of the technique of retention of the mitral valve apparatus during mitral replacement may lead to an increased incidence of this unusual complication. Accepted for publication May 19, 2002. Address reprint requests to Dr Passik, Cardiothoracic Surgeons of New Haven, P.C., 2 Church St South, Suite 507, New Haven, CT 06519; e-mail: [email protected].
0003-4975/02/$22.00 PII S0003-4975(02)03862-6
of time showed increased diameter of the abdominal aneurysm. The tortuous thoracic aorta had an aneurysm measuring 9 cm from its proximal third to 4 to 5 cm proximal to the celiac axis. The aorta between the celiac axis and renal arteries was of normal size. Distal to the renal arteries the aneurysm measured 13 cm extending into both iliac arteries. Because there was a proximal (3-cm diameter of aorta) and distal (2.4-cm diameter of the aorta) neck in the thoracic and distal aorta, we treated this patient with multiple endovascular stents (Fig 1A). In the first step of this intervention and under general anesthesia, the right femoral artery was dissected, and five endovascular stents (9 cm each) were deployed distally to the left subclavian artery. The endovascular stents were intussucepted into each other covering the left subclavian artery and extending to the celiac axis. Follow-up transesophageal echocardiography and computed tomographic scan showed exclusion of the thoracic aneurysm by the endovascular stent. Correction of the abdominal aortic aneurysm was done 2 weeks later. The patient was again anesthetized, and endovascular stents were placed distally to the renal arteries extending into both iliac arteries. Before discharge, computed tomography showed multiple stents (Fig 1B) and total exclusion of the thoracoabdominal aneurysm by the endovascular stents (Fig 2). The endovascular stents were stainless steel covered with polyester (Braile Medical, Sao Jose do Rio Preto, Sao Paulo, Brazil). The cylinders are highly resistant to radial collapse and maintain their ability to return to their original diameter once deployed. The prostheses were compressed and inserted into a 20 F catheter. Length, diameter, and whether the stent was bifurcated was selected according to the extension and size of the diseased segment to be treated.
Comment The surgical treatment of thoracoabdominal aneurysms poses a major challenge to the cardiothoracic surgeon, especially because the patients are usually elderly and have serious comorbidities. The development of endovascular prostheses has greatly improved the treatment of patients with aneuryms or dissection in the thoracic and abdominal aorta [4 – 6]. This is a major achievement in the therapy of these aneurysms, but it necessitates precise diagnostic investigations to determine the proximal and distal necks of the aneurysm, vessels involved in the aneurysm, and location of tears in aortic dissection. One of the major challenges is the risk of paraplegia in patients who undergo surgical treatment of these aneurysms. Short cross-clamp time, distal perfusion, hypothermia, and steroids are few of the strategies aimed at decreasing this risk [7]. The use of endovascular stents potentially could decrease the risk of paraplegia and serious morbidities associated with the surgical approach. Chuter and associates [8] developed a multibranched stent graft for thoracoabdominal aneurysm. The use of endovascular stents will have to undergo clinical investigation to de© 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
CASE REPORT MATSUDA ET AL MODIFIED AORTIC REMODELING
1687
termine whether they decrease the incidence of serious morbidities. Although the patient is doing well at 3 months follow-up, longer follow-up is needed to further delineate the beneficial effects of this new approach to a complex problem.
References 1. Okita Y, Ando M, Minatoya K, Tagusari O, Kitamura S, Nakajima N, Takamoto S. Early and long-term results of surgery for aneurysms of the thoracic aorta in septuagenarians and octogenarians. Eur J Cardiothorac Surg 1999;16:317– 23. 2. Svensson LG, Crawford E, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thorocoabdominal operations. J Vasc Surg 1993;17:357–70. 3. Parodi JC. Endovascular repair of abdominal aortic aneurysms and other arterial lesions. J Vasc Surg 1995;21:549 –57. 4. Dake MD, Kato N, Michell RS. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med 1999;340(20):1546 –52. 5. Nienaber CA, Fattori R, Lund G, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med 1999;340(20):1539 –45. 6. Palma JH, Almeida DR, Carvalho AC, Andrade JCS, Buffolo E. Surgical treatment of acute type B aortic dissection using an endoprosthesis (elephant trunk). Ann Thorac Surg 1997;63: 1081–4. 7. Griepp RB, Ergin MA, Galla JD, et al. Surgery for acquired heart disease. J Thorac Cardiovasc Surg 1996;112:1202–15. 8. Chuter TA, Gordon RL, Reilly LM, Pak LK, Messina LM. Multi-branched stent-graft for type 3 thoracoabdominal aortic aneurysm. J Vasc Interv Radiol 2001;12(3):391–2.
Modified Aortic Root Remodeling for Annuloaortic Ectasia With Abnormal Coronary Take-Off Hikaru Matsuda, MD, PhD, Hajime Ichikawa, MD, Shigemitsu Iwai, MD, and Toshiki Takahashi, MD, PhD Department of Surgery, Osaka University, Osaka, Japan
The abnormality of coronary arterial take-off is a limiting factor for a successful aortic valve sparing procedure. We present a 13-year-old boy, with Marfan syndrome and annuloaortic ectasia, whose coronary take-off was found to be abnormal during surgery. Two adjacent coronary orifices were located in the left coronary sinus and very close to the right–left commissure. A modified aortic remodeling procedure was successfully performed without translocation of the coronary artery. (Ann Thorac Surg 2002;74:1687–9) © 2002 by The Society of Thoracic Surgeons
T
here have been remarkable advancements in aortic valve sparing procedures in surgery of the aortic root including annuoaortic ectasia (AAE). When the Accepted for publication June 20, 2002. Address reprint requests to Dr Matsuda, Department of Surgery, Osaka University, 2-2 Yamada-oka, Suita, Osaka 562-0027, Japan; e-mail: [email protected].
0003-4975/02/$22.00 PII S0003-4975(02)03956-5
1688
CASE REPORT MATSUDA ET AL MODIFIED AORTIC REMODELING
Ann Thorac Surg 2002;74:1687–9
aortic valve can be preserved, there are two main options: the reimplantation technique [1] and aortic remodeling [2]. Both methods have the advantages of leaving the native aortic valve leaflets intact, and reconstructing the sinotubular junction and ascending aorta concomitantly. These methods have been widely practiced [3], and an important consideration appears to be the presence of a coronary arterial abnormality. The abnormality of coronary arterial take-off, in particular, is surely a limiting factor for a successful aortic valve sparing procedure, however, this has previously received little attention. We report a patient with Marfan syndrome and AAE, whose coronary take-off was found to be abnormal during surgery, and successfully who underwent a modified aortic remodeling procedure. A 13-year-old boy was previously diagnosed with Marfan syndrome, with subluxatio lentis and tall stature; his father also has Marfan syndrome with a history of aortic dissection. Aortic dilatation was pointed out when the boy was 5 years old. During follow-up by a pediatric cardiologist, the aortic root was found dilated. When he was 12 years old, aortic regurgitation was also noticed by echocardiography. Because of this progressive dilatation of the aortic root and the aortic regurgitation, surgery was indicated. Physical examination revealed his height as 165.4 cm and abnormal subluxatio lentis. Auscultation revealed a moderate degree of aortic regurgitant murmur. Chest roentgenogram showed a moderate cardiomegaly with a cardiothoracic ratio of 50%. Estimated left ventricular volume showed left ventricular end diastolic volume index 107 ml/m2, left ventricular end systolic volume index 44.9 ml/m2, and left ventricular ejection fraction 0.58. Retrograde aortogram was not performed because the family was reluctant to do such a procedure, considering the aortic dissection. The operation was performed on August 2, 2001. Through median sternotomy and pericardiotomy, the heart was inspected and the typical appearance of AAE was found. Cardiopulmonary bypass was initiated with a single two-staged venous cannula and ascending aortic blood return. The aortic root was dilated (50 mm in diameter) just above the sinotubular junction. The size at the upper ascending aorta was 26 mm. An aortic crossclamp was placed and retrograde cold blood cardioplegia was infused. The ascending aorta was transversely opened just above the sinotubular junction, followed by an antegrade cardioplegic infusion. Myocardial protection was conducted through retrograde fashion every 20 minutes. Aortic valvar incompetence was due to dilatation of the sinotubular junction and the loss of coaptation at its center. The leaflets looked intact in appearance. During direct coronary infusion of cardioplegia, it was found that there was no coronary ostium on the right coronary sinus. The left coronary ostium was located on the left coronary sinus, but it was far deviated toward the commissure between left and right coronary cusps. In addition, the right coronary ostium was found just next to the
Fig 1. The two coronary ostia were located close together in the left coronary cusp, near the commissure between the left and right coronary cusp.
left ostium (Fig 1). It was therefore almost a single ostium. Since this ostium was very close to the commissure, the aortic leaflets could not be saved without damage, if the ostium was removed as a cuff. Because the patient was still young, it was advisable to perform an aortic remodeling procedure instead of a valve replacement. It seemed possible to preserve the valve if the coronary ostium was left untouched. In other words, the cusp wall can be removed from the dilated sinus walls as much as possible, with the coronary orifices left on a minimum space of sinus wall without interfering with the commissure. The sinus was removed from the non- and right coronary sinus as usual. From the left coronary sinus, the removal was limited to the center and left side (Fig 1). A 26-mm Hemashield graft (Boston Scientific Corp, Boston, MA) was tailored to fit the aortic root with Valsalva sinuses removed. The height of the cusps of the graft was adjusted to 25 mm. The tongue for the left coronary sinus was slightly reduced in size to adjust its
Ann Thorac Surg 2002;74:1689 –91
shape. The proximal suture was conducted using continuous 5-0 Prolene (Ethicon, New Brunswick, NJ) suture. The distal aorta was removed as much as possible without removing the aortic clamp, and the distal anastomosis was carried out, adjusting the size difference without difficulties. The aortic cross-clamp was removed and cardiac beat was resumed with sinus rhythm. A transesophageal echocardigram during surgery showed trivial aortic regurgitation and good left ventricular function. The postoperative course was uneventful; the patient was discharged home on the 23rd postoperative day. The aortography before discharge showed no obstruction in the coronary orifices. Aortic regurgitation was trivial in degree. The patient was followed up for 6 months without any symptoms.
CASE REPORT KORKOLIS ET AL BIOPROSTHETIC MITRAL VALVE “PSEUDOSTENOSIS”
1689
References 1. Yacoub MH, Gehle P, Chandrasekaran V, Birks EJ, Child A, Radley-Smith R. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg 1998;115:1080 –90. 2. David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992;103:617–22. 3. David TE, Armstrong S, Ivanov J, Feindel CM, Omran A, Webb G. Results of aortic valve-sparing operations. J Thorac Cardiovasc Surg 2001;122:39 –46. 4. Basso C, Corrado D, Thiene G. Congenital coronary artery anomalies as an important cause of sudden death in the young. Cardiol Rev 2001;9:312–7. 5. Taniguchi K, Nakano S, Matsuda H, et al. Long-term survival and complications after composite graft replacement for ascending aortic aneurysm associated with aortic regurgitation. Circulation 1991;84:(Suppl III)31–9.
Comment In aortic ectasia or other aortic regurgitation due to an abnormal aortic root, the aortic valve sparing operations, such as remodeling or reimplantation, are well accepted as the preferred methods when the aortic leaflets are not deformed and the aortic insufficiency is not severe. Such valve sparing procedures have advantages over Bentall type operations because anticoagulation therapy is not required and the left ventricular function is preserved. Therefore, increasing numbers have been indicated. Regarding the operative procedure, there have been many discussions and controversies about the size selection of the graft and how to make the bottom line suitable. However, the anatomical distribution of the coronary ostia has previously been of little concern. This may be due to the rare instance of a combined anomaly in coronary take-off or intramural coronary arteries in the cohort of the patients who had this operation. The coronary origin from wrong sinus is very rare, particularly the right coronary artery from left sinus. This abnormality usually receives attention as a cause of sudden death in the athlete population [4]. In this report, we presented a modification of the remodeling procedure in a case with abnormal coronary artery ostia disturbing the full removal of the coronary sinuses, without damaging the coronary artery ostia, for the reconstruction with a short-length graft. In this case, both coronary ostia were very close to each other, like a single ostium, and were located just next to the commissure. It was, therefore, impossible to remove the coronary ostium with cuffs. This modification of the remodeling procedure has the benefits of preserving the aortic valve and coronary ostium intact. However, there are some concerns in the late follow-up. Since the sinus wall itself was dilated and weak, as is its nature in AAE, particularly in Marfan patients, there might be some risks of progressive dilatation of the sinus around the coronary ostium [5] where removal of the diseased sinus wall was not complete. Nonetheless, considering the benefits of preserving the native aortic valve in younger patients with Marfan syndrome, who risk aortic dissection in the future, such efforts to preserve the valve even in a situation of abnormal coronary ostia may be important. © 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Early Bioprosthetic Mitral Valve “Pseudostenosis” After Complete Preservation of the Native Mitral Apparatus Dimitris P. Korkolis, MD, PhD, Cary S. Passik, MD, Stephen J. Marshalko, MD, PhD, and George J. Koullias, MD Departments of Cardiothoracic Surgery, Section of Cardiovascular Medicine, Yale–New Haven Hospital, New Haven, Connecticut
An advantage of bioprosthetic mitral valve replacement in patients with normal sinus rhythm is avoidance of the need for long-term anticoagulation. Bioprosthetic valve thrombosis is a rare complication, supporting this approach. This case report represents an example of porcine mitral valve stenosis, likely secondary to thrombosis, in which all of the native mitral valve apparatus was left intact. This was successfully treated with standard anticoagulation therapy. This complication should be considered in patients in whom retention of the mitral valve apparatus has been performed. Such patients may benefit from long-term anticoagulation treatment to obviate this event. (Ann Thorac Surg 2002;74:1689 –91) © 2002 by The Society of Thoracic Surgeons
T
hrombosis of prosthetic valves, in general, affect mechanical prostheses. There have been several case reports of bioprosthetic mitral valve thrombosis that have led to early valve explantation. Resurrection of the technique of retention of the mitral valve apparatus during mitral replacement may lead to an increased incidence of this unusual complication. Accepted for publication May 19, 2002. Address reprint requests to Dr Passik, Cardiothoracic Surgeons of New Haven, P.C., 2 Church St South, Suite 507, New Haven, CT 06519; e-mail: [email protected].
0003-4975/02/$22.00 PII S0003-4975(02)03862-6