Aortic Composite Graft Research Articles

Repairing left ventricular outflow after aortic composite graft pseudoaneurysm: case report

BackgroundWe present a technique for aortic composite graft implantation after left ventricular outflow tract destruction due to its proximal dehiscence.Case presentationA 53-year-old gentleman with rheumatoid arthritis and history of Bentall procedure, presented with heart failure symptoms for the past month. Transthoracic echocardiogram identified prosthetic valve dysfunction, and transesophageal echocardiogram detected that its mechanism was by dehiscence. After excluding infectious etiology, it was hypothesized that the cause was the absence of endothelialization, owing to immunosuppressive therapy. Repair surgery was successful, and 2 years later, the patient is fully asymptomatic.ConclusionsImmunosuppressive drugs are a rare cause of aortic composite graft dehiscence. Left ventricular outflow tract surgical reconstruction remains an extremely complex and high-risk intervention, with the need for reentry into cardiopulmonary bypass and graft proximal segment implantation in a lower position.

Endocarditis in patients with ascending aortic prosthetic graft: a case series from a national multicentre registry.

Endocarditis in patients with ascending aortic prosthetic graft (AAPG) is a life-threatening complication. The purpose of this study was to examine the clinical presentation and prognosis of patients with AAPG endocarditis included in a large prospective infectious endocarditis multicentre study. From January 2008 to April 2015, 3200 consecutive patients with infectious endocarditis according to the modified Duke criteria, were prospectively included in the 'Spanish Collaboration on Endocarditis Registry (GAMES)' registry. Twenty-seven definite episodes of endocarditis (0.8%) occurred in patients with AAPG. During the study period, 27 cases of endocarditis were detected in patients with AAPG. The median age of patients was 61 years [interquartile range (IQR) 51-68 years] and 23 (85.2%) patients were male. The median time from AAPG surgery to the episode of AAPG infection was 24 months (IQR 6-108 months). The most frequently isolated micro-organisms were coagulase-negative staphylococci and S. aureus (11 patients, 40.7%). Four patients (14.8%) underwent medical treatment, whereas surgery was performed in 21 (77.7%). Two patients (7.4%) died before surgery could be performed. The median hospital stay prior to surgery was 7 days (IQR 4-21 days). Surgery consisted of replacing previous grafts with a composite aortic graft (10 cases) or aortic homograft (2 patients), and removal of a large vegetation attached to the valve of a composite tube (1 case). Nine patients had an infected aortic valve prosthesis without evidence of involvement of the AAPG. Isolated redo-aortic valve replacement was performed in 8 (88.9%) of these patients. Reinfection occurring during 1 year of follow-up was not detected in any patient. Two patients (7.4%) died while awaiting surgery and 6 did so after surgery (22.2%). A New York Heart Association (NYHA) Class IV was associated with mortality in patients undergoing surgery (P < 0.019). Most cases of endocarditis in patients with AAPG occur late after initial surgery. Mortality rate of patients with AAPG endocarditis who undergo surgery is acceptable. NYHA Class IV before surgery is associated with an increased postoperative mortality.

Combined Surgical and Interventional Radiologic Management Strategies in Patients with Arterial Pseudo-Aneurysms After Multivisceral Transplantation

Multivisceral transplantation has recently evolved to be a life-saving procedure for patients with intestinal failure and complex abdominal pathology. A composite aortic graft is always needed to restore the arterial flow to the transplanted organs. Accordingly, arterial complications can be life-threatening requiring prompt intervention. Herein, we describe innovative technical approaches in seven recipients who developed pseudo-aneurysm (PA) after transplantation. With a total of 285 composite visceral transplants, 15 (5.2%) patients experienced vascular complications. Of these, 7 were life-threatening PAs that were diagnosed 61 to 2677 days after transplantation. Due to the anatomic and technical complexity of the allograft vasculature, endovascular techniques were introduced alone (n=2) or in conjunction with surgical intervention (n=5) in an attempt to rescue patients and salvage the transplanted organs. The endovascular and surgical technical approaches used for each of the 7 PA actively bleeding patients was successful in 5 (71%). Of these, 2 (40%) are alive 86 to 117 months after the intervention. The remaining 5 recipients died of recurrent hemorrhage (n=2), liver failure (n=1), and pneumonia (n=1). The cause of death was unknown in the remaining patient. Retransplantation and intra-abdominal infections were major risk factors. Candida was the most common isolated microorganism. Recipients of composite visceral allografts are at risk of developing life-threatening PAs, particularly in those with early posttransplantation abdominal infections. Prompt multidisciplinary diagnosis and therapeutic approaches are crucial management strategies.

Modified Aortic Root Replacement Technique in Destructive Ventricular-Aortic Discontinuity

We describe a simple technique for aortic root replacement in destructive prosthetic aortic valve endocarditis wherein the fragile aortic annulus tissue is not suitable for suture placement. Therefore, we first reconstructed the intervalvular part with a nontreated pericardial patch and then implanted the aortic composite graft on the aortic root through the roof of the left atrium and reconstructed the defect thus made with another pericardial patch. No complication was seen at 6-month follow up.

Reversed Root for Entirely Biological Aortic Valve and Ascending Aorta Replacement in a Patient with Endocarditis and Mediastinitis

A 59-year-old patient developed endocarditis with coagulase-negative staphylococci after aortic composite graft replacement and pacemaker implantation. She underwent complete pacemaker removal and tricuspid valve reconstruction. Pus was present in and around the aortic graft. Re-replacement of the aortic root and ascending aorta using only biological material was performed. A 23-mm full root stentless prosthesis (Vascutek Root Elan, Vascutec, Terumo, Leeds, UK) was used for aortic root replacement, and a second 25-mm full root prosthesis with removed cusps implanted in a reversed fashion was used for ascending aorta and proximal aortic arch replacement.

Long-term follow-up, computed tomography, and computational fluid dynamics of the Cabrol procedure

The Cabrol procedure is characterized by insertion of an ascending aortic composite graft with reimplantation of the coronary arteries by the interposition of a graft tube. Our purpose is to report the clinical long-term follow-up and computed tomographic findings in patients having undergone the Cabrol procedure and to determine blood flow in the Cabrol graft using computational fluid dynamics. Clinical follow-up (76.6 +/- 16.6 months) and dual-source computed tomographic angiography data of 7 patients (all men, mean age 54.9 +/- 9.6 years) with 12 Cabrol grafts (left main coronary artery, n = 7; right coronary artery, n = 5) were reviewed. In 2 patients, the right coronary artery was directly reattached to the aortic graft. Computational fluid dynamics were calculated using computed tomographic data of a patient with the Cabrol procedure and compared with those in a Valsalva graft and a healthy aortic root. Computed tomography showed Cabrol graft occlusions to 1 of 7 (14%) left main and of 2 of 5 (40%) right coronary arteries. Six grafts to the left main and 3 to the right coronary artery were fully patent, similar to the 2 directly reattached right coronary arteries to the aortic graft. Computational fluid dynamics results show similar blood flow parameters into the coronaries for the healthy aortic root and Valsalva graft. In the Cabrol graft, a spiraling flow pattern with low flow into the right coronary artery was found (right coronary artery = 1 mL/min at both systole and diastole). Our study indicates low flow rates particularly in the right Cabrol graft correlating with a higher incidence of occlusions of the right as compared with the left Cabrol graft at long-term follow-up.

Rescue Coronary Artery Bypass Grafting (CABG) after Aortic Composite Graft Replacement

Aortic root replacement (ARR) has been recognized as the standard therapy for diseases of the aortic root since its introduction into clinical practice. ARR currently provides excellent long-term benefit with acceptable perioperative risk and excellent long-term morbidity and mortality. During ARR, coronary button misalignment may produce myocardial ischemia, ventricular arrhythmias, and pump failure leading to death if unrecognized. Here we review our experience with coronary insufficiency after ARR. Between January 1995 and March 2006, 139 consecutive patients underwent ARR at Yale-New Haven Hospital. A retrospective review of their medical records was conducted. The mean age of the patients was 54.5 years. Aortic root aneurysm was the indication for surgery in 123 patients, acute type A dissection in 14, and endocarditis in two. All patients underwent a modified Bentall operation with a mechanical (87%) or biological (13%) valve prosthesis and coronary artery button reimplantation. The overall 30-day mortality was 4.3% (six patients). Three patients (2.2%) underwent rescue coronary artery bypass grafting (CABG) to the left, right, or both coronary arterial systems for ischemia due to presumed coronary button misalignment. These patients presented with ventricular arrhythmias or hemodynamic compromise. All three showed excellent response to rescue CABG and remain alive and well in late follow-up. Coronary insufficiency after reconstruction of the aortic root is an uncommon but acutely life-threatening occurrence. This lethal condition may present with difficulty in weaning from cardiopulmonary bypass; echocardiographic signs of major wall motion abnormalities; and electrocardiographic evidence of ischemia, pump failure, and ventricular arrhythmias. Rescue CABG in this situation is life-saving. Immediate rescue CABG should be performed if coronary ischemia is suspected after composite graft replacement of the aortic root.

AN UNUSUAL CAUSE OF ANGINA PECTORIS: RARELY A LATE COMPLICATION OF THE CABROL PROCEDURE.

Introduction The Cabrol graft is a Dacron tube between the coronary arteries and the composite aortic graft in aortic root replacement. Very late presentation of myocardial ischemia related to the Cabrol conduit graft is exceedingly rare. Knowledge of this technique is vital for the accurate interpretation of the coronary angiograms and CT scan findings and crucial for the treatment planning in patients who have had previous implantation of the Cabrol graft. Case A 44-year-old female with Marfan syndrome and aortic valve replacement 13 years prior presented to cardiology clinic with complaints of exertional chest pain and dyspnea. On examination, she had jugular venous distention, prosthetic metallic click, and peripheral edema. Myocardial perfusion imaging revealed 40% reversible defect involving the anterior, lateral, apical, and inferior segments of the left ventricle. Coronary angiography reported a dilated left main coronary artery originating from the right coronary cusp. However, CT scan of the chest demonstrated a single origin of the left main and right coronary arteries, with both measuring 8 mm. Old microfilm data documenting the surgical procedure were then obtained. The surgical procedure was a replacement of her aortic valve and ascending aorta, with the Cabrol interposition graft. With failure of medical management, the patient finally underwent left anterior descending artery bypass graft. At 4 and 12 months postoperatively, she remains angina free. Discussion In the Cabrol technique, a Dacron graft provides sound anastomosis and prevents pseudoaneurysm formation at coronary ostia. However, complications such as coronary Dacron graft occlusion via thrombosis, stenosis, or kinking caused by migration of the Cabrol limbs due to fibrosis can occur rarely. This case is unique as the ischemia was caused by surgical anatomic alteration, which has not been reported 13 years after the initial Cabrol procedure. Conclusion This case illustrates the risk of misdiagnosis when performing and evaluating coronary angiography post-Cabrol procedure and allows a review of the differing mechanisms of coronary ischemia post-Cabrol grafting.

Pulmonary Stenosis Caused by Extrinsic Compression of an Aortic Pseudoaneurysm of a Composite Aortic Graft

Pulmonic stenosis and stenosis of the right ventricular outflow tract related to extrinsic compression have been described in patients with tumors, in a patient with a pericardial cyst, and in patients with vascular abnormalities as an unruptured sinus of Valsalva aneurysm, a giant coronary artery pseudoaneurysm and an aortic arch aneurysm. Composite graft replacement of the ascending aorta and aortic valve with reimplantation of the coronary arteries has some inherent complications. Our case report describes a patient with a pericomposite graft aneurysm presenting as a stenosis of the pulmonary artery, detected by Doppler echocardiography. (J Am Soc Echocardiogr 1999;12:997-1000.)

Dehiscencia de un injerto valvulado aórtico (técnica de Bono y Bentall) secundaria a endocarditis por Acinetobacter

Acinetobacter sp. are gram-negative bacteria and usually resistant to multiple antibiotics. They are a customary cause of nosocomial infections, but are uncommon etiologic agents of endocarditis. We present a case of endocarditis caused by Acinetobacter iwoffi in a composite aortic graft with a St. Jude prosthetic valve, using the Bono and Bentall procedure, complicated with multiple graft dehiscenses causing first a peritube pseudoaneurysm and finally severe paraprosthetic valve regurgitation to the left ventricle which required emergency surgery.

Thoracoabdominal aorta in Marfan syndrome: MR imaging findings of progression of vasculopathy after surgical repair.

To determine the natural history of vasculopathy of the thoracoabdominal aorta in patients with Marfan syndrome after composite graft repair of the aortic root. A total 224 magnetic resonance (MR) images obtained in 48 patients with Marfan syndrome over a period of 2.3-9.4 years (mean, 5.0 years) were retrospectively reviewed. On each image, the diameter of the thoracoabdominal aorta was measured and the presence of dissection or major peripheral artery aneurysms was determined. In 31 (65%) of the 48 patients, no statistically significant change (3 mm or less increase in diameter) in the diameter of the aorta occurred during the study (group 1); in the remaining 17 (35%) patients, a significant change occurred (greater than 3 mm increase) (group 2). The mean initial diameter of the native aorta was slightly larger in group 2 (mean, 27 mm +/- 8 [standard deviation]) than in group 1 (mean, 23 mm +/- 6). In group 1, the mean rate of dilation was 0.07 mm/y +/- 0.2; in group 2, the rate was 2.3 mm/y +/- 3.3. Two patients with aortic dissection were in group 1, whereas 14 such patients were in group 2 (P < .001). Aneurysms that involved major peripheral arteries were present in four (13%) of the 31 group 1 patients and in 12 (71%) of the 17 group 2 patients (P < .001). Surgical intervention was necessary in two group 1 patients and in 14 group 2 patients (P < .001). A subset of patients with Marfan syndrome manifested multiple forms of vasculopathy, including progressive aortic dilation, dissection, and peripheral artery aneurysm after composite aortic graft repair of the ascending aorta. Patients with these characteristics merit more frequent MR follow-up since further surgery was often necessary in these individuals.

“Legs” technique for management of widely separated coronary arteries during ascending aortic repair

Widely separated coronary arteries with significantly diseased tissue continues to challenge surgeons repairing ascending aortic aneurysms. Occasional troublesome leaks around coronary ostial anastomoses and Cabrol graft thrombosis prompted a change of our operative management of this condition. Collagen-impregnated 8-mm "legs" grafts are used to connect the coronary arteries to the composite graft. Ten patients, aged 14 to 70 years, underwent the operation. The first patient is 15 years after the operation and is symptom free. One patient died of an arrhythmia 1 month after discharge. Eight patients are living and well 11/2 to 4 years postoperatively. Advantages of direct interposition (legs) grafts are as follows: the coronary arteries are separately perfused and the risk of catastrophic thrombosis from a longer high-volume graft is eliminated. Problems with coronary ostial mobilization are avoided. The technique allows full visualization and hemostatic suture line testing with cardioplegia before aortic declamping. Space constraints with reoperations are easily managed, whereas other techniques may result in graft compression on refilling of the heart and termination of bypass. The technique is carried out with ease and reproducibility, and the availability of new graft material has made it our treatment of choice for ascending aortic composite graft replacement.

Modification of the aortic composite graft using the button-in technique

We describe a modification of the aortic composite graft procedure using a “button-in” technique. This method reduces bleeding, avoids additional graft material, and eliminates anastomotic aneurysm formation.

Mitral valve operation in patients with the Marfan syndrome

Optimal surgical treatment of mitral regurgitation in the Marfan syndrome (valve repair versus replacement) is controversial because the underlying connective tissue defect theoretically might compromise repair durability. To examine the results of mitral valve repair in these patients, we did a retrospective review of 160 patients with the Marfan syndrome who had cardiac surgical procedures between January 1983 and January 1993. Thirty-six patients had mitral procedures, 29 of which were repairs. Mitral valve replacement was necessary in seven patients because of extensive annular calcification and/or severe anterior leaflet abnormalities. The 18 men and 11 women undergoing mitral valve repair had a mean age of 26.5 ± 2.6 years (range 9 months to 54 years); seven patients were less than 18 years of age. Twenty-four of the 29 patients had concomitant aortic root replacement because of aortic dilation or valvular insufficiency. All 29 repairs included annuloplasty, and 11 patients also required leaflet resection. There were no operative deaths. At mean follow-up of 26.6 ± 4.8 months, there have been three late deaths, two caused by arrhythmia and one by complications of type III aortic dissection. All survivors are in New York Heart Association class I or II. In three patients recurrent mitral regurgitation developed (grade III or IV); 5-year actuarial freedom from significant mitral regurgitation was 88.3%. One patient required repeat mitral annuloplasty after endocarditis of the composite aortic graft spread to the mitral valve. No patient required late mitral valve replacement. These results demonstrate that (1) 22% of patients with the Marfan syndrome who undergo cardiac operation require a mitral valve procedure, (2) most can be treated by mitral repair rather than replacement, and (3) at early follow-up, results of mitral repair in this population are satisfactory. (J THORAC CARDIOVASC SURG 1994;107:724-31)

Late Detection of Asymptomatic Chronic Perigraft Aortic Pseudoaneurysm

A fifty-five-year-old man presented with pseudoaneurysm five years after composite aortic graft replacement for aortic dissection. The transthoracic echocardiogram appeared to show a right atrial mass. Transesophageal echocardiography and magnetic resonance imaging correctly delineated the pseudoaneurysm. Cardiac catheterization and superior vena cavagraphy were confirmatory The diagnostic features and natural history of this complication are discussed.

Pseudoaneurysm formation with superior vena caval syndrome 7 years after aortic composite graft placement

With the advent of the composite graft for combined aortic valve and ascending aortic root operations, postoperative bleeding complications have been reduced. Hemorrhage along the suture sites may occur as a late complication and rarely may originate from the coronary-aortic graft junction. We report a case of a massive pseudoaneurysm, seen as “superior vena caval syndrome,” 7 years after operation.

Use of pericardium to control bleeding after ascending aortic graft replacement

We present the case of a patient who required replacement of an ascending aortic composite graft for endocarditis complicated by uncontrollable bleeding from the proximal anastomotic site. A new method of creating a right atrial-to-periprosthetic space fistula with autologous pericardium was used with a favorable result.

Postoperative disc entrapment following cardiac valve replacement--a report of ten cases.

The sudden jamming of a prosthetic valve disc is one cause for postoperative hemodynamic deterioration. This complication occurred in 10 instances (2% of disc valves implanted), resulting in 4 fatalities. In 6 patients the disc entrapment was a complication following mitral valve replacement, and in 4 others the malfunction followed aortic valve surgery. The entrapment of the disc occurred on the second postoperative day in 3 patients. Two of these were due to an unresected chordal strand becoming wedged between the disc and valve rim of a Björk-Shiley mitral prosthesis and resulted in death. In the third patient, the aortic valve disc became attached to the Björk-Shiley composite aortic graft following the repair of an aortic dissection. A firm blood clot had formed between the graft and the oversewn aortic wall. This patient recovered after cardiopulmonary resuscitation and subsequent reoperation. The remaining cases developed while the patients were still either on the operating table or in the recovery room. The mechanisms of the disc entrapments are presented and the significance of an early correct diagnosis and urgent surgical correction is underlined.