ARTICLE IN PRESS doi:10.1510/icvts.2008.180745
Interactive CardioVascular and Thoracic Surgery 7 (2008) 709–711 www.icvts.org
Brief communication - Aortic and aneurysmal
Modified Bentall procedure – ‘a collar technique’ to control bleeding from coronary ostia anastomoses Dusˇko Nezˇic ´*, Milan Cirkovic, Aleksandar Knezevic, Miomir Jovic ‘Dedinje’ Cardiovascular Institute, Belgrade, Serbia Received 28 March 2008; received in revised form 15 April 2008; accepted 16 April 2008
Abstract Composite conduit aortic root replacement has become widely accepted as the preferred treatment for ascending aorta aneurysm and dissection. We present a patient in whom creation of ‘buttons’ was impossible due to fragility of the ascending aorta wall. The distal anastomosis was made to the transected aorta. The remnant of the proximal ascending aortic wall was fully transected 8–9 mm above the upper edge of coronary ostia anastomoses (incorporated into conduit using inclusion technique), thus forming a ‘collar’ around the proximal part of the conduit. At the end of the procedure the ‘collar’ was anchored to the conduit to control persistent bleeding from coronary ostia anastomoses. 䊚 2008 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Aortic dissection; Modified Bentall procedure
1. Introduction Although the original wrapyinclusion technique (after Bentall and De Bono w1x) is still being used, present stateof-the-art recommends the ‘button’ technique (after Kouchoukos and Karp w2x) to be performed during composite graft implantation in the surgery of the ascending aorta w3 x . However, sometimes, due to fragility and reduced tissue quality of the ascending aorta wall, mobilization of the ‘buttons’ can be almost impossible. We present a modification of the classic Bentall technique to control bleeding from coronary ostia anastomoses in such circumstances. 2. Case presentation A 58-year-old man presented with fatigue, dyspnea, and mild, dull chest pain. Six weeks earlier he suffered an episode of severe, unrelenting chest pain located in the mid-sternum. Transesophageal echocardiography (TEE) confirmed subacute dissection of the ascending aorta (DeBakey type-II) with severe aortic regurgitation. The operation was performed under moderately hypothermic cardiopulmonary bypass (arterial line in right femoral artery, bicaval cannulation). After aortic crossclamping, the ascending aorta was opened longitudinally and the heart was arrested with a single dose of cold blood *Corresponding author. Chief, Department of Cardiac Surgery I, Dedinje Cardiovascular Institute, M. Tepi a 1, 11000 Belgrade, Serbia. Tel.: q38111-3601631y3601647; fax: q381-11-2666392. E-mail address:
[email protected];
[email protected] (D. Nezˇic ´). 䊚 2008 Published by European Association for Cardio-Thoracic Surgery
cardioplegia (1000 ml) delivered into the coronary ostia. Continuous topical cooling with ice slush was maintained throughout the procedure. The primary tear, involving 60% of the aortic circumference, was located on the right posterior aspect of the ascending aorta (2.5 cm above the aortic annulus). Although the false lumen ended blindly approximately 2 cm below the aortic cross-clamp, the ascending aorta was fully transected at that level and prepared for distal anastomosis (Fig. 1). The aortic valve was excised and the annulus size was measured. Although reduced tissue quality of the ascending aorta wall disabled the creation of the ‘buttons’, we decided to use the inclusion technique to incorporate coronary ostia in the graft. The proximal end of the composite valved graft was attached to the aortic annulus. The full thickness of the aortic wall tissue surrounding the left coronary ostium was directly sutured (5-0 monofilament suture) to the opening in the composite conduit. Then, the conduit was pressurized with cardioplegia, and the right ventricle was dilatated (short clamping of the venous line) to determine the exact position of the right coronary ostium to the graft. At that time significant leaking at the level of the left coronary ostium anastomosis was identified. Due to fragility of the aortic wall it was impossible to add any hemostatic stitches. When the right coronary ostium anastomosis to the graft was performed in the same fashion, the aortic wall was fully transected 8–9 mm above the upper edge of coronary ostia anastomoses, thus forming the ‘collar’ around the proximal part of the conduit (Fig. 1). We should wrap the ‘collar’ tightly around the ‘neck’ of the conduit if the bleeding persisted. Then, after the graft length was sized, the distal anastomosis of the conduit to distal aorta was
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Fig. 2. The remnant of aortic wall (in a ‘collar’ formation) that completely covers the proximal part of composite conduit. B – the left coronary ostium incorporated directly to the conduit. A – the right coronary ostium implanted directly in the composite graft. Black arrows – suture lines (horizontal plus longitudinal) anchoring the aortic wall remnant to the composite conduit.
Fig. 1. Black arrows – the aortic wall transected 8–9 mm above the upper edge of coronary ostia anastomoses, thus forming a ‘collar’ around the proximal part of the conduit. Gray arrow – the right coronary ostium implanted directly in the composite graft. B – the left coronary ostium incorporated directly to the conduit.
performed with a continuous 4-0 polypropylene suture. Although the bleeding from coronary ostia anastomoses was significant and persistent (following routine de-airing and rewarming period), we decided to ‘fasten’ a ‘collar’ like remnant of proximal ascending aorta wall to the conduit. A 4-0 running monofilament suture between the cut edge of the proximal aorta and graft wall was used to tightly anchor both layers in a horizontal plane. Longitudinal incision on the ‘collar’ was also tightly anchored to the graft wall (Fig. 2). Excellent hemostasis was obtained (with no accumulation of the blood inside the ‘collar’) and the patient was weaned from cardiopulmonary bypass without difficulty. Predischarge control TEE confirmed no blood accumulation inside the ‘collar’. 3. Discussion Composite graft replacement of the ascending aorta and aortic valve was introduced by Bentall and De Bono in 1968
w1x. According to this technique, the aortic tissue surrounding the coronary ostia is directly sutured to the openings in the composite graft. Although these anastomoses and the distal aortic anastomosis are all made within the interior of the aorta, and then the aortic wall is tightly wrapped over the conduit, this technique has been known as the wrapyinclusion technique. Formation of pseudoaneurysms at all sites of anastomosis of tissue to the conduit (including the aortic annulus, coronary ostia, and distal aorta), has been a troublesome late complication of this technique w4–6x. Such a complication has been attributed to undue tension developing at the suture line of the sideto-side coronary anastomosis in large aneurysms w3, 6x, or by blood accumulation inside the aortic wrap w6x. However, pseudoaneurysms of coronary ostia anastomoses w6, 7x, as well as at the distal aortic suture line w6x, have also been observed when the ‘button’ technique was applied. A few technical modifications have been implemented into the ‘open button’ technique in order to minimize postoperative bleeding. These include a reinforcement suture joining the cut edge of the aortic wall and the prosthetic sewing ring w8x, as well as harvesting of the coronary ostia with a large portion of aortic wall, thus allowing coronary buttons to be sutured in a two-layer fashion (an ‘endobutton buttress’ technique w9x). However, postoperative bleeding from coronary ostia anastomoses (especially localized toward aortic annulus) can still be a cause of major issue, being difficult to control (as well as with the wrapyinclusion technique) once insertion of the conduit is completed w6x.
ARTICLE IN PRESS D. Nezˇic ´ et al. / Interactive CardioVascular and Thoracic Surgery 7 (2008) 709–711
Our modification of the original Bentall technique was an attempt to control significant and persistent bleeding from coronary ostia anastomoses. We strongly believe that an additional horizontal suture line, anchoring the proximal aorta remnant (8–9 mm above the coronary ostia anastomoses) to the conduit wall, has significantly diminished tension on the coronary ostia anastomotic lines (thus decreasing the possibility of pseudoaneurysm formation). Fixation of the longitudinal incision of the aortic wall to the conduit has additionally increased the pressure inside the wrap, thus diminishing the possibility of blood accumulation. It additionally offers better control of the distal anastomosis suture line which has been performed to the fully transected aorta. We do believe that this technique may sometimes be helpful to control bleeding from coronary ostia anastomoses as well as from annulus suture line. The same technique was successfully used to obtain hemostasis in two more cases. References w1x Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338–339.
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w2x Kouchoukos N, Karp RB. Resection of ascending aortic aneurysm and replacement of aortic valve. J Thorac Cardiovasc Surg 1981;81:142– 143. w3x Turina M. Composite graft replacement of the aortic root: ‘button’ technique. Multimedia Man Cardiothorac Surg doi:10.1510y MMCTS.2003.000001. w4x Kouchoukos N, Marshall W Jr, Wedige-Stecher T. Eleven-year experience with composite graft replacement of the ascending aorta and aortic valve. J Thorac Cardiovasc Surg 1986;92:691–705. w5x Panos A, Amahzoune B, Robin J, Champsaur G, Ninet J. Influence of technique of coronary artery implantation on long-term results in composite aortic root replacement. Ann Thorac Surg 2001;72:1497– 1501. w6x Milano D, Pratali S, Mecozzi G, Boraschi P, Braccini G, Magagnini E, Bartolotti U. Fate of coronary ostial anastomoses after the modified Bentall procedure. Ann Thorac Surg 2003;75:1797–1802. w7x Meijboom L, Nollen G, Merchant N, Webb G, Groenink M, David T, de Mol B, Tijssen J, Romkes H, Mulder B. Frequency of coronary ostial aneurysms after aortic root surgery in patients with the Marfan syndrome. Am J Cardiol 2002;89:1135–1138. w8x Copeland J III, Rosado L, Snyder S. New technique for improving hemostasis in aortic root replacement with composite graft. Ann Thorac Surg 1993;55:1027–1029. w9x Northrup W, Kshettry V. Implantation technique of aortic homograft root: emphasis on matching the host root to the graft. Ann Thorac Surg 1998;66:280–284.
