Surgical treatment with the freestyle bioprosthesis and omentopexy for prosthetic valve endocarditis after aortic root replacement

A 60-year-old woman, who had undergone aortic root replacement with composite graft 5 months previously, suffered from anemia and slight fever. Transthoracic echocardiography showed pseudoaneurysm in the aortic root, and blood culture was positive. She was diagnosed with prosthetic valve endocarditis, and surgical intervention was planned. Intraoperatively necrotic tissue and dehiscence of the suture line in the aortic annulus were found. Re-aortic root replacement with Freestyle bioprosthesis and re-hemiarch graft replacement were performed with the omentopexy around the aortic root and the new graft. Antibiotics were administered intravenously for 6 weeks postoperatively. At 7 months after the operation, no prosthetic valve infection had recurred. Although the long-term results of Freestyle bioprosthesis have not been determined, it might be a valuable option for aortic root infection as an alternative to an aortic homograft. In addition, omentopexy might also be effective in the prevention of recurrent prosthetic valve infection.     

Surgical treatment of a retrosternal pseudoaneurysm arising from the posterior aortic root

We report a case of a 60-year-old male with a retrosternal pseudoaneurysm arising from the posterior aortic root. He had undergone replacement of the aortic root and ascending aorta for an acute aortic dissection. His postoperative course was complicated with composite graft infection. During a redo surgery, femoro-femoral bypass was established prior to sternotomy via the right femoral artery and vein, and ten French cannulas were directly inserted into both carotid arteries through separate skin incisions for brain perfusion. When the sternum was divided, an occlusion balloon catheter introduced through the left femoral artery was inflated to maintain somatic perfusion without compromising clear vision of the operative field. Combined procedures with direct cannulation into both common carotid arteries and balloon occlusion of the distal aortic arch allowed us to safely perform replacement of the aortic root and ascending aorta in the patient with a retrosternal pseudoaneurysm.     

Surgical treatment of pseudoaneurysm of the sinus of valsalva after aortic valve replacement for active infective endocarditis.

Pseudoaneurysm is an uncommon and serious complication of infective endocarditis (IE). It is often fatal because of its rapid progress, high rates of rupture and recurrence, and worsening effects on the systemic condition. We report the rare case of a patient who developed a pseudoaneurysm of the sinus of Valsalva two months after emergency aortic valve replacement for active IE. At the previous operation, we had directly closed a small fistulous hole in the non-coronary sinus of Valsalva using two mattress sutures with autologous pericardial pledgets, because the tissue surrounding the hole did not appear to be infected on visual inspection. A pseudoaneurysm developed from this portion due to detachment of sutures. If the fistula had been completely resected during the first surgery instead of performing a simple closure, the pseudoaneurysm of the sinus of Valsalva would not have formed. However, the primary aim of the first emergency surgery was to spare the life of a critically ill patient. In the second surgery, the pseudoaneurysm was completely resected with the aortic wall--including the non-coronary sinus of Valsalva and the communicating hole. Then, patch plasty of the non-Valsalva sinus was successfully performed.     

Disruption of the vascular prosthesis caused by aortic calcification after replacement of the thoracoabdominal aortic aneurysm

A 52-year-old man underwent a replacement of the thoracoabdominal aorta. The aorta was severely calcified, and was replaced by a 24-mm woven Dacron (Vascutek, Renfrewshire, Scotland) graft wrapped with the calcificated aneurysmal wall. His postoperative course was uneventful; however, he collapsed on the 18th postoperative day. He underwent an emergent thoracotomy and the wrapped aneurysmal wall was taken down. The prosthesis graft had a 1-mm disruption in the middle portion, which did not relate to the anastomoses. Experimental study ex vivo showed that disruption of the prosthesis could have occurred after a 3-week pulsatile force caused by a seashell simulating aortic calcification.     

人工血管旁路移植治疗感染性股动脉假性动脉瘤

目的探讨人工血管旁路移植术治疗感染性股动脉假性动脉瘤的效果。方法回顾性分析2005年1月—2010年12月40例感染性股动脉假性动脉瘤的临床资料,40例患者均为吸毒者,均接受了假性动脉瘤切除、彻底清创及人工血管旁路移植术。结果围手术期内无死亡患者,且均保肢成功,创口均二期愈合。34例(85.0%)术后获得随访3～12个月,平均7.4个月。随访期内发生移植物感染3例(8.8%),取出感染的移植物后2例保肢成功,1例最终因肢体缺血坏死而接受截肢术;彩超检查发现人工血管腔内部分血栓形成4例(11.8%),给予抗血小板治疗,远端肢体均无缺血坏死。结论人工血管旁路移植术是治疗注射吸毒所致感染性股动脉假性动脉瘤的安全、有效的方法。     

Long-term follow-up after aortic valve replacement with a small aortic prosthesis.

Although aortic valve replacement (AVR) is an effective treatment for patients with aortic valvular disease, the implantation of a small aortic prosthesis may result in residual left ventricular outflow stenosis and transvalvular gradient. In this study, the outcome in the long-term period of patients treated with a small aortic prosthesis was analyzed retrospectively. Twenty-four patients with AVR were divided into two groups, group A and group B. Group A consisted of 16 patients with 21 mm-sized prosthetic valves, and group B consisted of 8 patients with 19 or 16 mm-sized prosthetic valves. There were no significant differences in preoperative cardiac function or operative procedure in the two groups. The mean follow-up period (months) was 55.0 in group A and 51.3 in group B. RESULTS: One patient died of cerebral infarction in group A. There were no significant differences in cardiothoracic ratio (CTR), left ventricular ejection fraction (LVEF), and left ventricular mass index (LVMI) between the two groups. Postoperative physical activity according to the New York Heart Association (NYHA) classification showed no significant differences in the two groups. Despite using a small prostheses for AVR, the postoperative course was good in the long-term period, although careful follow-up is necessary.     

Aorto-pseudoaneurysm-ventricular regurgitation after aortic root replacement

We describe a 48-year-old man with aorto-pseudoaneurysm-ventricular regurgitation. It was due to disruption of both proximal and distal anastomoses after aortic root replacement for detachment of a prosthetic valve implanted for a sinus of Valsalva aneurysm with aortic valve regurgitation. The chest was opened during cardiopulmonary bypass using a deep hypothermic circulatory arrest to avoid rupture of the aneurysm because of a close relation between the pseudoaneurysm and the sternum. Aortic root re-replacement was performed successfully.     

Aortopulmonary fistula after aortic root replacement

This report describes a rare case of aortopulmonary fistula in pseudoaneurysm of the left coronary ostial button. A 66-year-old woman suddenly developed congestive heart failure 3 years after aortic root replacement for acute type A aortic dissection. The diagnosis of aortopulmonary fistula was confirmed preoperatively by aortography, heart catheterization, and spiral computed tomography. She was discharged in good condition after surgical treatment. This serious complication should be considered in patients who have severe congestive heart failure after aortic root replacement.     

Long-term outcomes after ascending aortic replacement and aortic root replacement for type A aortic dissection

 Open in a separate windowOBJECTIVESWe investigated whether the selective use of supracoronary ascending aorta replacement achieves late outcomes comparable to those of aortic root replacement for acute Stanford type A aortic dissection (TAAD).METHODSPatients who underwent surgery for acute type A aortic dissection from 2005 to 2018 at the Helsinki University Hospital, Finland, were included in this analysis. Late mortality was evaluated with the Kaplan–Meier method and proximal aortic reoperation, i.e. operation on the aortic root or aortic valve, with the competing risk method.RESULTSOut of 309 patients, 216 underwent supracoronary ascending aortic replacement and 93 had aortic root replacement. At 10 years, mortality was 33.8% after aortic root replacement and 35.2% after ascending aortic replacement (P = 0.806, adjusted hazard ratio 1.25, 95% confidence interval, 0.77–2.02), and the cumulative incidence of proximal aortic reoperation was 6.0% in the aortic root replacement group and 6.2% in the ascending aortic replacement group (P = 0.65; adjusted subdistributional hazard ratio 0.53, 95% confidence interval 0.15–1.89). Among 71 propensity score matched pairs, 10-year survival was 34.4% after aortic root replacement and 36.2% after ascending aortic replacement surgery (P = 0.70). Cumulative incidence of proximal aortic reoperation was 7.0% after aortic root replacement and 13.0% after ascending aortic replacement surgery (P = 0.22). Among 102 patients with complete imaging data [mean follow-up, 4.7 (3.2) years], the estimated growth rate of the aortic root diameter was 0.22 mm/year, that of its area 7.19 mm²/year and that of its perimeter 0.43 mm/year.CONCLUSIONSWhen stringent selection criteria were used to determine the extent of proximal aortic reconstruction, aortic root replacement and ascending aortic replacement for type A aortic dissection achieved comparable clinical outcomes.     

Rapid-deployment aortic valve replacement after aortic root replacement: A safe alternative to redo root replacement

Reoperative aortic root replacement, following prior biologic or mechanical valved conduit aortic root prosthesis, presents a technical challenge. The rapid-deployment aortic valve prosthesis is an approved alternative to traditional bioprosthetic aortic valve replacement. We present three clinical cases in which rapid-deployment aortic valve prostheses were utilized in lieu of reoperative full aortic root replacement. All three patients recovered uneventfully. The rapid-deployment valve insertion in a prior surgical aortic root prosthesis is a safe option to avoid reoperative full aortic root replacement.     

Reoperation for composite graft infection after aortic root replacement

Composite graft infection after aortic root replacement is a serious complication and requires surgical reintervention with a high mortality rate. We report two cases of composite graft infection 3 months and 44 months after the primary operation. Each successfully underwent redo aortic root replacement with a new composite graft and a Freestyle stentless bioprosthesis, respectively. Both patients are currently well and without recurrence of infection 35 months and 48 months postoperatively.     

Extended aortic root replacement with aortic allografts

Complex left ventricular outflow tract obstruction after operation for subaortic stenosis or with hypoplastic aortic anulus remains a challenge for pediatric cardiac surgeons. We have recently applied a new technique of extended aortic root replacement using a cryopreserved aortic allograft to treat two patients who had previously been operated on for subaortic stenosis and a third who had aortic stenosis with a hypoplastic aortic anulus. This new procedure combines the concept of aortoventriculoplasty with aortic root replacement and coronary artery reimplantation. The valved aortic homograft is used in place of an aortic valve prosthesis and the attached anterior mitral leaflet augments the interventricular septum to relieve the subvalvular left ventricular outflow tract obstruction. The coronary ostia are then reimplanted into the allograft and an anastomosis between the distal graft and the ascending aorta is completed. Allograft aortic tissue is then used to patch the right ventricular outflow tract. One patient had aortic stenosis with annular hypoplasia and did well after extended root replacement. Two patients had previous operations for subaortic stenosis before undergoing extended aortic root replacement. One required mediastinal exploration and drainage at 2 weeks for Serratia marcescens mediastinitis and bacteremia, but uncomplicated recovery followed. The other patient had complete heart block for 2 days, but normal sinus rhythm resumed and convalescence was benign. This modified technique with the aortic allograft was very helpful in treating these difficult problems, and the lack of mortality, limited morbidity, and good functional results are encouraging.