Complete aortic obstruction owing to the proximal dehiscence of a stentless root bioprosthesis

Abstract

A 67-year-old man was admitted for chest pain. Eighteen months earlier, he underwent replacement of his aortic USA) owing to annuloaortic ectasia. Immediate postoperative and one-year echocardiograms and chest computed tomography (CT) examinations showed a well-functioning bioprosthesis, with no aortic root complications. The patient was asymptomatic until the recent onset of chest pain. A thallium myocardial scan showed mild ischemic changes in the inferoapical distribution. Coronary angiography demonstrated normal coronary arteries. However, contrast injection within the aortic root depicted complete obstruction of the ascending aorta during end-systole (Figure 1). A peak gradient of at least 80 mmHg was measured between the left ventricle and the ascending aorta. The CT scan was not conclusive. Figure 1) Aortogram depicting full Freestyle root (Medtronic Inc, USA) expansion during diastole (A), partial occlusion of the aortic root during early systole with only minimal opacification of the aortic root (white arrow) (B) and complete aortic occlusion of ... At reoperation, one-half of the proximal anastomosis of the Freestyle root was dehisced. During systole, the surrounding tissues, mainly the pericardium, created a ‘cul-de-sac’ around the Freestyle prosthesis, with the inward displacement of the dehisced Freestyle graft creating the aortic occlusion. With the Freestyle graft expanded in diastole, the space between the Freestyle wall and the surrounding tissue was minimal, thus explaining the absence of a pseudoaneurysm on CT. No signs of infection were present. A modified Bentall procedure, using a custom composite stented bioprosthesis graft, was performed. The postoperative course was uneventful and the patient was free of complications 12 months after the surgery.