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Giant postdissection aneurysm of the ascending aorta after aortic valve replacement
Giant Postdissection Aneurysm of the Ascending Aorta After Aortic Valve Replacement Sofı`a Martı`n-Sua`rez, MD, Marcello Bergonzini, MD, Davide Pacini, MD, Luca Di Marco, MD, and Roberto Di Bartolomeo, MD
CASE REPORTS
Department of Cardiac Surgery, Policlinico S. Orsola, University of Bologna, Bologna, Italy
Fig 1.
Fig 3.
A
72-year-old man was referred to our department with a diagnosis of ascending aorta aneurysm discovered in a control chest radiograph. The patient had been operated on for thoracic aorta replacement in 1990, for abdominal aorta replacement in 1994, and for aortic valve replacement with biological prosthesis in 1998. After the operation and for the following 3 years the patient was well without any relevant clinical problem. Considering the roentgenographic image (Fig 1), which showed the massive enlargement of the mediastinum with pulmonary compression, a computed tomographic scan of the chest was performed. That imaging study demonstrated a large aneurysm of 10 cm in diameter (true lumen of 7 cm) with a large thrombus surrounding the distal ascending aorta and an intimal flap originating above the right coronary ostium (Fig 2A). Moreover the anterior wall of the ascending aorta was completely adherent to the sternum (Fig 2B). The aortic arch was also dissected and had a diameter of 55 mm. Spiral tomo-
Address reprint requests to Dr Martı`n-Sua`rez, Unita` Ospedaliera di Cardiochirurgia, Universita` degli Studi di Bologna, Policlinico S. Orsola, Via Massarenti 9, 40138 Bologna, Italy; e-mail: [email protected].
© 2003 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 2.
graphic scan reconstruction showed the enormous dimensions of the ascending aorta, which was completely attached to the sternum (Fig 3). Surgery consisted of aortic valve and ascending aorta replacement according to the modified Bentall procedure and aortic arch replacement with separate reimplantation of the innominate artery, left common carotid, and left subclavian arteries. The ascending aorta presented as a dissection with a completely thrombosed false lumen. Histologic findings confirmed the dissected wall: the false lumen wall was formed by adventitia and media, which had signs of elastic fiber fragmentation. Femorofemoral cardiopulmonary bypass was carried out and antegrade selective cerebral perfusion with moderate hypothermia (nasopharyngeal temperature of 26°C) was performed for brain protection. The patient recovered successfully without any complications from his surgery. This case illustrates the potential dimensions the ascending aorta and the arch may reach by a chronic dissection and how diagnostic imaging procedures are so important for taking a correct and safe surgical approach. Ann Thorac Surg 2003;76:1309 • 0003-4975/03/$30.00 PII S0003-4975(03)00146-2
CASE REPORTS
Department of Cardiac Surgery, Policlinico S. Orsola, University of Bologna, Bologna, Italy
Fig 1.
Fig 3.
A
72-year-old man was referred to our department with a diagnosis of ascending aorta aneurysm discovered in a control chest radiograph. The patient had been operated on for thoracic aorta replacement in 1990, for abdominal aorta replacement in 1994, and for aortic valve replacement with biological prosthesis in 1998. After the operation and for the following 3 years the patient was well without any relevant clinical problem. Considering the roentgenographic image (Fig 1), which showed the massive enlargement of the mediastinum with pulmonary compression, a computed tomographic scan of the chest was performed. That imaging study demonstrated a large aneurysm of 10 cm in diameter (true lumen of 7 cm) with a large thrombus surrounding the distal ascending aorta and an intimal flap originating above the right coronary ostium (Fig 2A). Moreover the anterior wall of the ascending aorta was completely adherent to the sternum (Fig 2B). The aortic arch was also dissected and had a diameter of 55 mm. Spiral tomo-
Address reprint requests to Dr Martı`n-Sua`rez, Unita` Ospedaliera di Cardiochirurgia, Universita` degli Studi di Bologna, Policlinico S. Orsola, Via Massarenti 9, 40138 Bologna, Italy; e-mail: [email protected].
© 2003 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 2.
graphic scan reconstruction showed the enormous dimensions of the ascending aorta, which was completely attached to the sternum (Fig 3). Surgery consisted of aortic valve and ascending aorta replacement according to the modified Bentall procedure and aortic arch replacement with separate reimplantation of the innominate artery, left common carotid, and left subclavian arteries. The ascending aorta presented as a dissection with a completely thrombosed false lumen. Histologic findings confirmed the dissected wall: the false lumen wall was formed by adventitia and media, which had signs of elastic fiber fragmentation. Femorofemoral cardiopulmonary bypass was carried out and antegrade selective cerebral perfusion with moderate hypothermia (nasopharyngeal temperature of 26°C) was performed for brain protection. The patient recovered successfully without any complications from his surgery. This case illustrates the potential dimensions the ascending aorta and the arch may reach by a chronic dissection and how diagnostic imaging procedures are so important for taking a correct and safe surgical approach. Ann Thorac Surg 2003;76:1309 • 0003-4975/03/$30.00 PII S0003-4975(03)00146-2