Fate of coronary ostial anastomoses after the modified Bentall procedure

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.     

Giant left coronary ostial aneurysm after modified Bentall procedure in a Marfan patient

We performed surgical repair of a giant left coronary ostial aneurysm after aortic root replacement using composite valve graft (modified Bentall procedure) in a patient with Marfan syndrome. Aneurysmal formation in the left main stem itself is very rare. In order to avoid mobilizing the coronary ostium from severe adhesions after previous surgery and to reduce the tension on the anastomosis, the left main trunk was reconstructed using an interposition Dacron graft. In aortic root surgeries in Marfan patients, the size of the side hole on the composite graft should be kept relatively small to fit the diameter of the native coronary arteries for prevention of coronary buttons from forming aneurysms at the level of the coronary button anastomosis. In addition, close observation to the coronary button anastomosis is indispensable in postoperative check-up.     

Coronary artery bypass grafting to left anterior descending coronary artery diagnosed by multidetector-row computed tomography

A 64-year-old male received coronary angiography because of chest pain. Although coronary angiography showed total occlusion of right coronary artery (RCA) # 2 and left anterior descending branch (LAD) #6, and a significant stenosis of left circumflex (LCx) #11, it could not visualize LAD distal to LAD # 6. Since coronary multidetector-row computed tomography (MD CT) could visualize the distal LAD, coronary artery bypass grafting (CABG) was indicated for this patient. Left internal thoracic artery (LITA) was anastomosed to LAD and saphenous vein graft (SVG) was used for distal anastomoses to obtuse marginal branch (OM) and 4-posterior descending branch (# 4 PD). Postoperative course was uneventful. LITA anastomosed to LAD and SVG to OM and # 4 PD were visualized by postoperative coronary angiography. MD CT in addition to coronary angiography was demonstrated useful to assess precise lesions of the coronary artery disease in this case.     

Atrial thrombosis as a late complication of cardiac surgery computed tomography appearance

We present two cases of large atrial thrombi diagnosed many years after cardiac surgery. In both cases, CT showed homogeneous non-enhancing masses. In one case the mass was immediately adjacent to an area of surgical repair; neither thrombus was in the atrial appendage, a more common location for thrombosis. The combination of appropriate clinical history and CT appearance should permit recognition of delayed postoperative intracardiac thrombosis.     

Long-term results of modified Bentall procedure using flanged composite aortic prosthesis and separately interposed coronary graft technique

We have selected the flanged composite aortic prosthesis and separately interposed coronary graft technique for the aortic root replacement over seven years. We sought to evaluate the long-term results of aortic root replacement with this technique. Between April 1996 and September 2003, 71 patients (mean age 46.1+/-12.9 years, 67.6% males) underwent aortic root replacement with this technique. Sixty-two patients had annuloaortic ectasia, and seven patients acute type A aortic dissection. Marfan syndrome was recognized in 35 patients. Two separate 8-10 mm knitted Dacron grafts were interposed between a valved composite graft and both coronary ostia to avoid kinking of coronary arteries. The early mortality rate was 4.2%. The actuarial survival rate was 93.9+/-3.0% at 5 years. The freedom from operation related complications was 86.7+/-4.1% at 5 years. No patients had anticoagulant-related hemorrhage, valve thrombosis, reoperation, graft thrombosis, or coronary pseudoaneurysm. The separately interposed coronary graft and the flanged composite graft technique is predictable and safe. Coronary pseudoaneurysm and graft thrombosis have been eliminated.     

The detection of coronary ostial lesions by intraoperative transesophageal echocardiography: Report of a case

Transesophageal echocardiography (TEE) is a valuable diagnostic tool for providing clear images of the proximal coronary arteries. We describe herein the case of an elderly man in whom dissection and an atherosclerotic plaque in the proximal coronary arteries were demonstrated by TEE during combined coronary artery bypass grafting and aortic valve replacement. Thus, retrograde cardioplegia was employed, whereby trauma to the coronary ostia was avoided.     

The assessment of the proximal left pulmonary artery by transesophageal echocardiography and computed tomography in neonates and infants: a case series

IMPLICATIONS: Transesophageal echocardiography (TEE) is often used during surgical repair of congenital heart disease. In our case series of 256 newborns and infants, we found that a left paracarinal view of TEE could visualize the proximal left pulmonary artery, a frequent blind spot for TEE, in most patients, except in a few cases with anatomic variations of the esophagus in the right lateral to the vertebra.     

Ureterosciatic hernia: a rare cause of ureteral obstruction visualized by multislice helical computed tomography

Ureterosciatic herniation is an extremely rare cause of ureteral obstruction, of which few cases have been published. We describe a case revealed by pyelonephritis with acute renal failure in an 81-year-old woman. After percutaneous nephrostomy tube placement and antibiotic therapy, urography and multiplanar computed tomography reconstructions of the pelvis confirmed the diagnosis. The symptoms resolved, and the hernia was then corrected surgically.     

A comparison of aortic root measurements by echocardiography and computed tomography

Objectives

The aim of the study is to evaluate an optimal way to assess the dimensions of the aortic root and each of the sinuses of Valsalva and examine how a single measurement in 1 plane (echocardiography or 2-dimensional computed tomography) can underestimate the maximum dimension of the aortic root.

关节镜下双袢法Latarjet手术后喙突骨块塑形的研究

目的应用CT观察关节镜下双袢法Latarjet术后喙突骨块塑形变化过程，报道一种新的不同于传统螺钉固定Latarjet术后喙突骨块的塑形方式。 方法2014年10月至2016年10月，70例肩关节复发性前脱位患者接受了关节镜下双袢法Latarjet手术治疗。根据术后CT上喙突骨块与关节盂平面的水平关系分为：高于关节盂平面组（A组，n=28）和与关节盂平面相平或低于关节面5 mm以内组（B组，n=42）。所有患者术后1个月、3个月、6个月和12个月时进行CT检查并观察喙突骨块的塑形过程。随访时肩关节功能采用美国肩肘外科协会评分（American shoulder and elbow surgeons，ASES）和ROWE评分系统进行功能评估。 结果1例患者在术后6个月失访。从CT横断面观察，A组患者高于关节面的骨质被吸收，最终与关节面呈同心圆的弧形，均达到骨性愈合，未出现肱骨头与喙突骨块撞击形成的盂肱关节骨关节炎。B组骨块外缘与关节盂距离随着时间延长有轻度的吸收，平均（0.32±1.10）mm，最终也为骨性愈合，未出现盂肱关节骨关节炎。从CT三维重建en-face面观察，A组和B组 喙突骨块上下缘均发骨痂形成，骨块-关节盂之间的骨质相互融合现象，多余的骨质被吸收，形成与健侧关节盂"梨"形结构类似的形态。所有患者术后随访时间12~24个月，平均（14.0±2.8）个月，所有患者均恢复正常生活，无再脱位和不稳感，恐惧试验和再复位试验阴性。61例（90%）患者可进行剧烈对抗运动。A组术前及终末随访时平均ASES评分为（60.8±18.1）分和（90.7±15.5）分（P<0.01），ROWE评分为（48.4±10.5）分和（88.6±17.5）分（P<0.01）。B组术前及终末随访时平均ASES评分为（58.7±13.2）分和（85.4±17.8）分（P<0.01），ROWE评分为（40.4±9.8）分和（87.3±15.4）分（P<0.01）。 结论关节镜下双袢法Latarjet手术后喙突骨块的塑形过程不同于螺钉固定法。喙突骨块放置高于（偏外）关节盂平面后，高于关节面的骨质逐渐被吸收，最终形成与肱骨头同圆的弧形关节盂，不会发生撞击而导致肩关节退变；喙突骨块的上下缘产生大量骨痂形成与骨构建，趋向于形成en-face面正常关节盂"梨"形态。