Emergency fast Bentall operation

Emergency fast Bentall operation Abstract We herein report an emergency technique of composite Bentall operation using a fast release valve. The technique was successfully performed in 2 emergency cases after failed supracoronary ascending aortic replacement in acute Type A aortic dissection. The speed and ease of execution are the main advantages of the procedure. Aortic dissection, Root replacement, Fast release aortic valve INTRODUCTION The primary goal of emergency surgical treatment for acute Type A aortic dissection is to preserve life with the lowest perioperative risk; especially in older patients, in the absence of severe root dilatation or severe disruption of sinuses of Valsalva and with a manageable aortic valve regurgitation, supracoronary ascending aortic replacement is a common and acceptable surgical procedure for acute Type A aortic dissection [1]. At times, despite a careful evaluation of the root tissue and lesions, severe bleeding from root disruption, occurring after cross-clamp removal, imposes a more radical surgery with aortic root replacement. We herein describe a fast technique for root replacement applied after failed conservation of the native root. TECHNIQUE With the patient still on cardiopulmonary bypass, clamp is reapplied on the ascending aorta graft and retrograde cardioplegia is administered. The graft is transected, all Teflon reinforcements and inserts used for proximal repair are removed and coronary buttons are divided from the sinuses (Fig. 1A); the native valve is excised, and the annulus is measured with an aortic sizer. Figure 1: View largeDownload slide Drawings illustrating the surgical technique. (A) The proximal aortic root and coronary buttons are trimmed as in the conventional Bentall operation. (B) Using a continuous 4.0 polypropylene suture, the Dacron graft is sutured to the aortic annulus and then the coronary ostia reimplanted in the anatomic position. (C) The fast release aortic valve (Edwards Intuity Elite—Edwards Lifesciences Inc., Irvine, CA, USA) is deployed with the standard technique. Figure 1: View largeDownload slide Drawings illustrating the surgical technique. (A) The proximal aortic root and coronary buttons are trimmed as in the conventional Bentall operation. (B) Using a continuous 4.0 polypropylene suture, the Dacron graft is sutured to the aortic annulus and then the coronary ostia reimplanted in the anatomic position. (C) The fast release aortic valve (Edwards Intuity Elite—Edwards Lifesciences Inc., Irvine, CA, USA) is deployed with the standard technique. Contrary to what we usually do when preassembling a composite graft with stented-biological valves (where a 3 mm larger—2 sizes—conduit is chosen), a corresponding Valsalva graft (Gelweave Valsalva, Sultzer Vascutek, Renfrewshire, UK) is selected and the bottom skirt is trimmed to 2–3 rings. The graft is then sutured to the valve annulus using a continuous 4.0 polypropylene suture (Fig. 1B). The coronary buttons are anastomosed to the ‘un-valved’ conduit in a standard fashion using 5-0 polypropylene continuous sutures reinforced with a Teflon strip. The conduit is trimmed to fit the distance with the ascending aortic graft. Afterwards, the annulus is measured again, and an Edwards Intuity Elite rapid-deployment bioprosthesis (Edwards Lifesciences Inc., Irvine, CA, USA) is selected by testing the decrease in measurements and choosing the one that ‘first’ fits the neoannulus without entering the left ventricular outflow tract. In general, a bioprosthesis that is smaller than the graft size by 3 mm is required. Then 3 2.0 braided not-pledgeted sutures are passed at the nadir of each aortic sinus, taking either the Dacron graft or the annulus. The 3 guiding sutures are then passed through the sewing ring, and the valve is deployed according to the manufacturer’s directions (Fig. 1C) (http://edwardsqa.blob.core.windows.net/media/Default/devices/heart%20valves/hvt/surgical-aortic/intuity/intuity-instructionsforuse1.pdf). After the valve skirt frame is deployed, the delivery system and holder are removed, and the 3 guiding sutures are tied. Once the valve is seated, the 2 prosthetic conduits are anastomosed using a continuous 4.0 polypropylene suture. After proper deairing manoeuvres, the aortic cross-clamp is released, and the patient is weaned from cardiopulmonary bypass after transoesophageal ultrasound control. COMMENT Root replacement after failed supracoronary ascending aorta replacement is an undesirable occurrence complicating acute Type A aortic dissection repair. It adds supplemental myocardial ischaemic and pumps times at the end of the complex procedures. The mean aortic cross-clamp time for Bentall procedures in acute aortic dissections is longer than in elective patients (in our experience, median is 115 min 25th–75th: 98–159 min). In addition to the complexity of isolation, repair and anastomosis of dissected coronary buttons, much time and care is spent to ensure a safe annular sealing that may differently result in impossible haemostasis and fatal bleeding. The possibility of performing a root replacement in an expedite fashion may improve the outcome under these circumstances. The continuous running suture of the graft minimizes the risk of proximal bleeding when compared with other techniques of composite Bentall using a fast release valve [2]. In our experience with a limited number of 2 patients, the described technique required less than 58 min of additional cross-clamp time. The off-label use of the valvular device was justified by the emergency settings and brilliantly helped to resolve the unexpected situation. In this technique, in addition to the speed of valve implantation, we appreciated the pliability of the ‘un-valved’ graft that makes movement very easy from the tube to the annulus anastomosis and coronary ostia reimplantation; actually, the freedom of the graft reduces the tension on often-diseased coronary buttons [3]. Both patients treated are doing well 6 and 5 months after the procedure. Dedicated studies are warranted to explore the potential of this technique for routine use in elective patients. Conflict of interest: none declared. REFERENCES 1 Rylski B , Beyersdorf F , Blanke P , Boos A , Hoffmann I , Dashkevich A et al. . Supracoronary ascending aortic replacement in patients with acute aortic dissection type A: what happens to the aortic root in the long run? J Thorac Cardiovasc Surg 2013 ; 146 : 285 – 90 . Google Scholar CrossRef Search ADS PubMed 2 Gennari M , Agrifoglio M , Polvani G. Composite graft using an Edwards Intuity Elite rapid deployment bioprosthesis for aortic root replacement . J Card Surg 2017 ; 32 : 193 – 5 . Google Scholar CrossRef Search ADS PubMed 3 Neri E , Toscano T , Papalia U , Frati G , Massetti M , Capannini G et al. . Proximal aortic dissection with coronary malperfusion: presentation, management, and outcome . J Thorac Cardiovasc Surg 2001 ; 121 : 552 – 60 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

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Publisher
Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ISSN
1569-9293
eISSN
1569-9285
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10.1093/icvts/ivx435
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Abstract

Abstract We herein report an emergency technique of composite Bentall operation using a fast release valve. The technique was successfully performed in 2 emergency cases after failed supracoronary ascending aortic replacement in acute Type A aortic dissection. The speed and ease of execution are the main advantages of the procedure. Aortic dissection, Root replacement, Fast release aortic valve INTRODUCTION The primary goal of emergency surgical treatment for acute Type A aortic dissection is to preserve life with the lowest perioperative risk; especially in older patients, in the absence of severe root dilatation or severe disruption of sinuses of Valsalva and with a manageable aortic valve regurgitation, supracoronary ascending aortic replacement is a common and acceptable surgical procedure for acute Type A aortic dissection [1]. At times, despite a careful evaluation of the root tissue and lesions, severe bleeding from root disruption, occurring after cross-clamp removal, imposes a more radical surgery with aortic root replacement. We herein describe a fast technique for root replacement applied after failed conservation of the native root. TECHNIQUE With the patient still on cardiopulmonary bypass, clamp is reapplied on the ascending aorta graft and retrograde cardioplegia is administered. The graft is transected, all Teflon reinforcements and inserts used for proximal repair are removed and coronary buttons are divided from the sinuses (Fig. 1A); the native valve is excised, and the annulus is measured with an aortic sizer. Figure 1: View largeDownload slide Drawings illustrating the surgical technique. (A) The proximal aortic root and coronary buttons are trimmed as in the conventional Bentall operation. (B) Using a continuous 4.0 polypropylene suture, the Dacron graft is sutured to the aortic annulus and then the coronary ostia reimplanted in the anatomic position. (C) The fast release aortic valve (Edwards Intuity Elite—Edwards Lifesciences Inc., Irvine, CA, USA) is deployed with the standard technique. Figure 1: View largeDownload slide Drawings illustrating the surgical technique. (A) The proximal aortic root and coronary buttons are trimmed as in the conventional Bentall operation. (B) Using a continuous 4.0 polypropylene suture, the Dacron graft is sutured to the aortic annulus and then the coronary ostia reimplanted in the anatomic position. (C) The fast release aortic valve (Edwards Intuity Elite—Edwards Lifesciences Inc., Irvine, CA, USA) is deployed with the standard technique. Contrary to what we usually do when preassembling a composite graft with stented-biological valves (where a 3 mm larger—2 sizes—conduit is chosen), a corresponding Valsalva graft (Gelweave Valsalva, Sultzer Vascutek, Renfrewshire, UK) is selected and the bottom skirt is trimmed to 2–3 rings. The graft is then sutured to the valve annulus using a continuous 4.0 polypropylene suture (Fig. 1B). The coronary buttons are anastomosed to the ‘un-valved’ conduit in a standard fashion using 5-0 polypropylene continuous sutures reinforced with a Teflon strip. The conduit is trimmed to fit the distance with the ascending aortic graft. Afterwards, the annulus is measured again, and an Edwards Intuity Elite rapid-deployment bioprosthesis (Edwards Lifesciences Inc., Irvine, CA, USA) is selected by testing the decrease in measurements and choosing the one that ‘first’ fits the neoannulus without entering the left ventricular outflow tract. In general, a bioprosthesis that is smaller than the graft size by 3 mm is required. Then 3 2.0 braided not-pledgeted sutures are passed at the nadir of each aortic sinus, taking either the Dacron graft or the annulus. The 3 guiding sutures are then passed through the sewing ring, and the valve is deployed according to the manufacturer’s directions (Fig. 1C) (http://edwardsqa.blob.core.windows.net/media/Default/devices/heart%20valves/hvt/surgical-aortic/intuity/intuity-instructionsforuse1.pdf). After the valve skirt frame is deployed, the delivery system and holder are removed, and the 3 guiding sutures are tied. Once the valve is seated, the 2 prosthetic conduits are anastomosed using a continuous 4.0 polypropylene suture. After proper deairing manoeuvres, the aortic cross-clamp is released, and the patient is weaned from cardiopulmonary bypass after transoesophageal ultrasound control. COMMENT Root replacement after failed supracoronary ascending aorta replacement is an undesirable occurrence complicating acute Type A aortic dissection repair. It adds supplemental myocardial ischaemic and pumps times at the end of the complex procedures. The mean aortic cross-clamp time for Bentall procedures in acute aortic dissections is longer than in elective patients (in our experience, median is 115 min 25th–75th: 98–159 min). In addition to the complexity of isolation, repair and anastomosis of dissected coronary buttons, much time and care is spent to ensure a safe annular sealing that may differently result in impossible haemostasis and fatal bleeding. The possibility of performing a root replacement in an expedite fashion may improve the outcome under these circumstances. The continuous running suture of the graft minimizes the risk of proximal bleeding when compared with other techniques of composite Bentall using a fast release valve [2]. In our experience with a limited number of 2 patients, the described technique required less than 58 min of additional cross-clamp time. The off-label use of the valvular device was justified by the emergency settings and brilliantly helped to resolve the unexpected situation. In this technique, in addition to the speed of valve implantation, we appreciated the pliability of the ‘un-valved’ graft that makes movement very easy from the tube to the annulus anastomosis and coronary ostia reimplantation; actually, the freedom of the graft reduces the tension on often-diseased coronary buttons [3]. Both patients treated are doing well 6 and 5 months after the procedure. Dedicated studies are warranted to explore the potential of this technique for routine use in elective patients. Conflict of interest: none declared. REFERENCES 1 Rylski B , Beyersdorf F , Blanke P , Boos A , Hoffmann I , Dashkevich A et al. . Supracoronary ascending aortic replacement in patients with acute aortic dissection type A: what happens to the aortic root in the long run? J Thorac Cardiovasc Surg 2013 ; 146 : 285 – 90 . Google Scholar CrossRef Search ADS PubMed 2 Gennari M , Agrifoglio M , Polvani G. Composite graft using an Edwards Intuity Elite rapid deployment bioprosthesis for aortic root replacement . J Card Surg 2017 ; 32 : 193 – 5 . Google Scholar CrossRef Search ADS PubMed 3 Neri E , Toscano T , Papalia U , Frati G , Massetti M , Capannini G et al. . Proximal aortic dissection with coronary malperfusion: presentation, management, and outcome . J Thorac Cardiovasc Surg 2001 ; 121 : 552 – 60 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: Jan 16, 2018

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