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Year : 2013  |  Volume : 16  |  Issue : 2  |  Page : 153-154
Giant aortic root after previous aortic valve replacement


Department of Cardiothoracic Surgery, Southampton General Hospital, United Kingdom

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Date of Web Publication29-Mar-2013
 

How to cite this article:
Roubelakis A, Karangelis D, Kaarne M. Giant aortic root after previous aortic valve replacement. Ann Card Anaesth 2013;16:153-4

How to cite this URL:
Roubelakis A, Karangelis D, Kaarne M. Giant aortic root after previous aortic valve replacement. Ann Card Anaesth [serial online] 2013 [cited 2019 Dec 13];16:153-4. Available from: http://www.annals.in/text.asp?2013/16/2/153/109776


A 55-year-old male patient was admitted to our department with a giant ascending aortic aneurysm, which was incidentally found during assessment for pulmonary sarcoidosis. The patient presented with vague symptoms which included, shortness of breath, fatigue, and cough. From the past medical history it was recovered that he was submitted to an aortic valve replacement (AVR) back in 1981. At that time he did not present any dilatation of the ascending aorta. The native valve, which was bicuspid, was excised and a mechanical valve (old fashioned single tilting disk valve) was implanted.

During current assessment of the patient's respiratory symptoms a chest X-ray revealed a prominent widening of the mediastinum and a subsequent computed tomography (CT) scan confirmed an ascending aortic aneurysm measuring 10 cm [Figure 1]. The aortic arch appeared normal. Intraoperative transoesophageal echocardiography (TEE) showed normally functioning previous aortic valve prosthesis, there were no regurgitant jets or gradient/stenosis of the prosthesis and the patient maintained a good left ventricular function [Figure 2] and [Figure 3]. Cardiopulmonary bypass was established by cannulating transverse aortic arch, innominate artery and right atrium. The patient underwent an aortic root replacement with a 27 mm mechanical composite graft. Although the previous prosthesis was nicely seated, it had to be removed due to the fact that the thin walled aneurysm started immediately above it. Both coronary ostia were implanted to the tube graft. Post-operative TEE examination was unremarkable and the patient was discharged on the 7 th post-operative day [Figure 4]. On follow-up after 4 months, he remains well.
Figure 1: Computed tomography chest showing saccular aneurysm

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Figure 2: Mid oesophageal long axis aortic valve view. The size of the aortic root can be appreciated. The opening jet of the previous aortic prosthesis is also noted

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Figure 3: Mid oesophageal short axis AV view. The size of the aortic root at the level of the sinotubular junction is increased

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Figure 4: Transthoracic echocardiogram on the 4th post-operative day. Parasternal long axis view showing the left ventricular outflow tract and the aortic root. The new prosthesis is noted (yellow arrow)

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Classification of aneurysms can be done according to their location, morphology, and etiology. Aneurysms can be investigated by means of CT angiography, Magnetic Resonance Imaging (MRI), and TEE and can be described as saccular and fusiform. [1] The indications for intervention on thoracic aortic aneurysms are: Size above 5.5 cm or above 4.5 cm in patients undergoing AVR or Coronary Artery Bypass Grafting; Ascending aortic aneurysms measuring 4-5 cm for patients with Marfan syndrome or connective tissue disorders; Aneurysms of the aortic arch above 5.5 cm; and, Rapid expansion, more than 1 cm/year or symptoms related to expansion. [2]

It has been recognized that bicuspid aortic valve involves a pathology of the entire proximal ascending aorta, including the aortic annulus, the sinuses of Valsalva, the coronary ostia, the sinutubular junction, and the tubular part of the ascending aorta. [3] Patients with bicuspid aortic valve show a higher propensity for aortic root and ascending aortic aneurysms at a younger age than patients with tricuspid aortic valves. [4] Furthermore, according to Michelena et al., 4 out of 10 patients develop a dilation of the ascending aorta of more than ≥ 40 mm. [5] This report highlight that massive aortic root aneurysms can be managed in a routine fashion. Alternative cannulation strategies of the healthy vessels like innominate artery and arch as practiced in this case with Y-connection aid in successful management of giant aortic root aneurysm.

 
   References Top

1.Nair HC. Transesophageal echocardiaography evaluation of thoracic aorta. Ann Card Anaesth 2010;13:186.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Elefteriades JA. Natural history of thoracic aortic aneurysms: Indications for surgery, and surgical versus nonsurgical risks. Ann Thorac Surg 2002;74:S1877-80.  Back to cited text no. 2
    
3.Matthias Bechtel JF, Noack F, Sayk F, Erasmi AW, Bartels C, Sievers HH. Histopathological grading of ascending aortic aneurysm: Comparison of patients with bicuspid versus tricuspid aortic valve. J Heart Valve Dis 2003;12:54-9. discussion 59-61.  Back to cited text no. 3
    
4.Etz CD, Zoli S, Brenner R, Roder F, Bischoff M, Bodian CA, et al. When to operate on the bicuspid valve patient with a modestly dilated ascending aorta. Ann Thorac Surg 2010;90:1884-90.  Back to cited text no. 4
    
5.Michelena HI, Desjardins VA, Avierinos JF, Russo A, Nkomo VT, Sundt TM, et al. Natural history of asymptomatic patients with normally functioning or minimally dysfunctional bicuspid aortic valve in the community. Circulation 2008;117:2776-84.  Back to cited text no. 5
    

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Correspondence Address:
Dimos Karangelis
Wessex Cardiac Centre, Southampton University Hospitals, NHS Trust, Hampshire
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.109776

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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