Concomitant Valve Sparing Root Remodeling with Extra Aortic Ring Annuloplasty and E-vita Stented Elephant Trunk Implantation
Igor Rudez, Marko Kusurin, Mislav Planinc, Josip Varvodic, Davor Baric, Daniel Unic, Ante Bosnjak, Robert Blazekovic, Zeljko Sutlic.
University Hospital Dubrava, Zagreb, Croatia.
Patient Demographics: From November 2014 to October 2015 valve sparing root remodeling technique with external ring annuloplasty was used in twenty patients. From November 2011 to August 2015 E-vita stented elephant trunk procedure was used in eighteen patients, of which fourteen in acute setting.
Relevant History: A 49-year-old male, with chronic Stanford B dissection presented to hospital due to paroxysmal atrial fibrillation and chest pain. Transthoracic echocardiography revealed bicuspid aortic valve with AR 2+, dilatation of aortic root up to 40 mm and 42 mm at the level of ST junction. MSCT showed chronic Stanford type B aortic dissection. Dissection spread through the descending aorta down to the level of Th 8, with true lumen diameter 10 x 28 mm, and false lumen diameter 29 x 36 mm at the level of pulmonary bifurcation.
Pre-Operative Plan: Valve sparing root remodeling with external subvalvular ring annuloplasty technique is a newly implemented procedure at our department. It represents excellent alternative to patients with AR and concomitant root and ascending aortic dilatation who were previously treated with modified Bentall procedure. E-vita stented elephant trunk is a good modality for treatment of complex cases of aortic pathology which were previously treated with frozen elephant trunk in two stages. Plan was to preserve native aortic valve and stabilize dissected aorta without need for secondary intervention.
Discussion of what was actually done and the challenges, deaths and complications encountered. (Unless case is still pending): Peripheral cannulation using axillary artery was performed, aortic root was dissected, cusp free edges were aligned and root remodeling with Gelweave Valsava graft was preformed. Cusps resuspension followed by subvalvular extra-aortic Coroneo ring positioning with coronary ostia reimplantation was done. Circulatory arrest with bilateral antegrade cerebral perfusion was established for 43 minutes during which the stent was deployed and the graft sutured to the distal aorta with separate reimplantation of the supraaoritc branches. Patient recovered uneventfully and early TTE findings show no AR. MSCT showed exclusion of the false lumen. The patient was discharged from hospital nine days after surgery and 3 months following surgery is doing well.
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