Reoperation for Ascending Aortic Aneurysm, Coronary Ostial Aneurysm and Patent Cabrol Trick After Bentall Operation for Aortitis Syndrome

Abstract

ortitis is chronic inflammation of the aorta, its branches and the pulmonary artery that leads to stenosis/occlusion or dilatation. Cardiovascular complications, such as aortic regurgitation and aneurysmal dilatation of the aortic root, can be fatal. The most serious complication after aortic valve replacement (AVR) or root reconstruction for aortitis syndrome is dehiscence of the anastomotic site. We report a patient with aortitis syndrome associated with ulcerative colitis who underwent the Bentall operation for annuloaortic ectasia and aortic regurgitation, but required reoperation for anastomotic dehiscence 9 years later. Case ReportA 38-year-old woman with aortitis syndrome associated with ulcerative colitis underwent an original Bentall operation for annuloaortic ectasia with severe aortic insufficiency in December 1995. At the time of initial operation a composite Dacron graft with a 27-mm mechanical valve was used, and both coronary ostia were directly anastomosed to the composite valved graft, which was wrapped with the native aortic wall, together with interposition using a tube graft between the aorta and right atrium (Cabrol trick). Pathology revealed low-grade inflammation of the aortic wall with interrupted elastic fibers, which was compatible with a diagnosis of aortitis (Fig 1). The patient was well until 5Circulation Journal Vol.69, July 2005 years later when she had shortness of breath and anemia (Fig 2). Preoperative chest computed tomography and angiography revealed a patent Cabrol trick, aneurysmal dilatation of the ascending aorta and aortic arch around the artificial graft, coronary ostial aneurysms, and paravalvular leakage (Fig 3). She had a history of steroid therapy for the ulcerative colitis.At the time of reoperation, dense adhesions were found especially around the Cabrol trick and the ascending aorta was dilated more than 60 mm. The femoral artery was cannulated for arterial perfusion. Two-staged venous cannulation was carried out through a small right atriotomy. After implementation of cardiopulmonary bypass, the ascending aorta was cross-clamped obliquely beyond the distal anastomotic site of the previous graft. After clamping the Cabrol trick, aortotomy of the dilated ascending aorta and Dacron graft revealed that the internal aortic wall was normal color and that the native aortic wall around both coronary ostia was dilated. Cold crystalloid cardioplegic solution was antegradely administered through both coronary ostia. Anastomotic dehiscence was found at the distal anastomosis of the Dacron graft and at the non-coronary cusp site of the proximal composite graft, but not at either of the coronary ostia (Fig 4). The primary dehiscence was considered to be the distal site of the graft, resulting in aneurysmal dilatation of the wrapped aorta. Paravalvular leakage was considered to have begun 5 years after the initial operation when the inflammation deteriorated (Fig 2).The Dacron graft was totally removed, leaving intact the sewing ring of the mechanical valve. A new 30-mm Dacron ...

Clinical Experience with the Bentall Procedure: 28 Years

“…The inclusion technique, as originally described by Bentall and De Bono1 was until 1993 our preferred method. Many authors had reported a relationship between the inclusion/wrapping technique, and the formation of coronary pseudoaneurysm, especially in patients with Marfan syndrome 11-14. The incidence of pseudoaneurysms with this technique ranged from 7% to 25% 15-17.…”

Genetic Analysis of Young Adult Patients With Aortic Disease Not Fulfilling the Diagnostic Criteria for Marfan Syndrome

“…18-21 In contrast, in young individuals, the acquired factors causing aortic diseases are slightly different, including hypertension from young age, sleep apnea syndrome, pregnancy, steroid use, aortitis, etc. [22][23][24][25][26][27] In the present study, 3 cases of aortitis were observed among the first 129 patients before exclusion of some patients. Among the 29 probands in the non-definite MFS group, 3 obstructive sleep apnea cases including 1 with ACTA2 mutations, and 1 pregnancy with ACTA2 mutations, were found.…”

Right Coronary Ostial Aneurysm Following a Bentall Procedure

“…Shiono et al 7 described a case of aneurysmal dilatation of the coronary artery ostium without dehiscence of the anastomotic suture line 5 years after a Bentall procedure. The patient presented with both distal anastomotic dehiscence of the Dacron graft with paravalvular leakage, and an aneurysm of the coronary ostium.…”