Interact CardioVasc Thorac Surg 2008;7:1164-1166. doi:10.1510/icvts.2008.183103
© 2008 European Association of Cardio-Thoracic Surgery
Case report - Aortic and aneurysmal |
Giant left coronary ostial aneurysm after modified Bentall procedure in a Marfan patient
Kazuma Okamoto,
Filip P. Casselman*,
Raphael De Geest and
Hugo Vanermen
Department of Cardiovascular and Thoracic Surgery, OLV Clinic, Moorselbaan 164, 9300 Aalst, Belgium
Received 7 May 2008;
received in revised form 6 July 2008;
accepted 9 July 2008
Corresponding author. Tel.: +32 53 72 46 99; fax: +32 53 72 45 52.
E-mail address: filip.casselman{at}olvz-aalst.be (F.P. Casselman).
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Abstract
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We performed surgical repair of a giant left coronary ostial aneurysm after aortic root replacement using composite valve graft (modified Bentall procedure) in a patient with Marfan syndrome. Aneurysmal formation in the left main stem itself is very rare. In order to avoid mobilizing the coronary ostium from severe adhesions after previous surgery and to reduce the tension on the anastomosis, the left main trunk was reconstructed using an interposition Dacron graft. In aortic root surgeries in Marfan patients, the size of the side hole on the composite graft should be kept relatively small to fit the diameter of the native coronary arteries for prevention of coronary buttons from forming aneurysms at the level of the coronary button anastomosis. In addition, close observation to the coronary button anastomosis is indispensable in postoperative check-up.
Key Words: Aortic root; Aneurysm; Reoperation; Surgery complications
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1. Introduction
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Application of the modified Bentall procedure with the button technique has reduced complications at the anastomotic sites of the coronary arteries in aortic root surgeries using a composite valve graft. However, especially in Marfan patients, aneurysmal formations at coronary ostial anastomoses have not been eliminated in spite of technical improvements for reconstruction of the coronary arteries because of their connective tissue abnormality. Leaving too much native aortic tissue in a too large opening in the graft seems to be the main cause responsible for this type of aneurysm. The development of an aneurysm of the left main stem itself in the presence of a normal ostium is uncommon. We describe here a case of such a rare aneurysmal formation in a Marfan patient. The coronary ostial aneurysm could be potentially lethal when it grows to a large diameter, and a surgical repair should be done to prevent rupture of the aneurysm.
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2. Case report
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A 48-year-old male Marfan patient was referred to our institution. He underwent a modified Bentall procedure for aortic root aneurysm at 28 years of age. Anastomoses of the coronary arteries to the composite valve graft were performed using the button technique. He also received abdominal aortic replacement for abdominal aortic aneurysm at 31 years of age, and at 44 years of age, aortic dissection occurred in the distal ascending aorta requiring ascending aortic replacement. During a routine checking, a computed tomography (CT) revealed an oval aneurysm, 29 mmx49 mm in diameter, at the left coronary ostium at the level of the coronary button anastomosis to the composite valve graft (Fig. 1).
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Fig. 1. The three-dimensional CT shows an oval aneurysm (29 mmx49 mm) at the site of the left coronary button anastomosis.
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After re-re-do median sternotomy, cardiopulmonary bypass (CPB) was established with an arterial cannula (21 Fr) in the right femoral artery, a venous drainage cannula (28 Fr) in the right femoral vein and the jugular vein (17 Fr) [1]. Under mild hypothermia (28 °C), the composite graft was clamped and cold crystalloid cardioplegia was given both antegrade and retrograde. The pulmonary trunk was divided vertically and composite was transected partially for good exposure of the left main stem. A giant left coronary ostial aneurysm was found behind the pulmonary trunk without sign of dissection.
The aneurysm was opened from the coronary anastomosis site to the bifurcation of main stem into the left anterior descending and circumflex artery. The left main trunk of the coronary artery was reconstructed using an interposition 10-mm Dacron graft [2] between the neo-coronary-ostium and the side hole on the aortic composite graft (Fig. 2). Then both the pulmonary trunk and the aortic composite grafts were re-anastomosed. Weaning from CPB was easy without any ischemic changes in electrocardiogram. Postoperative recovery was uneventful.
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Fig. 2. The left main trunk of the coronary artery was excluded using an interposition 10-mm Dacron graft between the neo-coronary-ostium (A) and the previous side hole in the aortic composite graft (B) after being partially transected over half the circumference. The white arrows show the left coronary ostial aneurysm that was transected. A stump of the main pulmonary artery, temporarily divided vertically, is shown in C.
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3. Discussion
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The occurrence of coronary ostial pseudoaneurysms in patients with Marfan syndrome after aortic root replacement using a composite valve graft has been virtually eliminated after the introduction of the coronary button technique [3]. Meanwhile, Meijboom et al. have demonstrated that, in a study with magnetic resonance imaging angiography, they found coronary ostial aneurysms in 17 patients of the 40 patients with Marfan's syndrome who underwent surgery and concluded that coronary ostial aneurysms are not uncommon even when the button technique is used. Especially in patients <35 years old, coronary ostial aneurysms were more frequently seen in 56% of patients (15 of 27) [4]. However, the reason for coronary ostial aneurysms should be classified into pseudoaneurysm, aneurysm of the anastomosis site to the composite graft, and aneurysm of the left main trunk itself. The case we report is classified as the third reason and this is very rare. The reason for true aneurysms at this level seems to be caused by cystic medial necrosis related to Marfan syndrome. Milano et al. have demonstrated that anastomotic pseudoaneurysms after the modified Bentall procedure were observed only in patients with acute dissection and a coronary aneurysm was only identified in a patient with Marfan syndrome [5]. This indicates that connective tissue disorders appear to play a significant role in the development of these anastomotic problems. Therefore, in aortic root surgeries with Marfan patients, close observation to the coronary button anastomosis is indispensable in a postoperative check-up.
According to Kazui et al., in order to reduce the risk of aneurysm formation at the coronary button anastomosis, the size of the side hole on the aortic composite graft must be reduced to fit the diameter of the coronary artery ostium and avoid the redundant native aortic wall from developing aneurysmal changes in the late postoperative period [6]. In our case, the side hole was 10 mm in diameter and was not oversized according to the coronary ostium. This fact demonstrates the necessity of strict follow-up in Marfan patients is necessary despite adherence to principle size consideration.
We applied the graft interposing method, which is a modification of Cabrol's technique [7], to reconstruct the left main trunk to avoid mobilizing the coronary ostium from severe adhesions after previous surgery and to reduce the tension on the anastomosis. This procedure will reduce the physical stress against the native wall of the coronary artery and, as a consequence, reduce the risk of aneurysm formation.
Because the majority of Marfan patients undergoing aortic root surgery are relatively young, valve-sparing aortic root replacement techniques [8, 9] are attractive. Recently, these techniques are becoming reasonable alternatives to the modified Bentall procedure for Marfan patients supported by good long-term results [10]. Even in valve-sparing operations, we should pay attention to the size of the side hole at the anastomotic site and be aware of potential aneurysmal formation at this level.
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References
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- Casselman FP, Van Slycke S, Dom H, Lambrechts DL, Vermeulen Y, Vanermen H. Endoscopic mitral valve repair: feasible, reproducible, and durable. J Thorac Cardiovasc Surg 2003;125:273–282.[Abstract/Free Full Text]
- Piehler JM, Pluth JR. Replacement of the ascending aorta and aortic valve with a composite graft in patients with nondisplaced coronary ostia. Ann Thorac Surg 1982;33:406–409.[Abstract]
- Kouchoukos NT, Marshall WG, Wedige-Stecher TA. Eleven-year experience with composite graft replacement of the ascending aorta and aortic valve. J Thorac Cardiovasc Surg 1986;92:691–705.[Abstract]
- Meijboom LJ, Nollen GJ, Merchant N, Webb GD, Groenink M, David TE, de Mol BA, Tijssen JG, Romkes H, Mulder BJ. Frequency of coronary ostial aneurysms after aortic root surgery in patients with the Marfan syndrome. Am J Cardiol 2002;89:1135–1138.[CrossRef][Medline]
- Milano AD, Pratali S, Mecozzi G, Boraschi P, Braccini G, Magagnini E, Bortolotti U. Fate of coronary ostial anastomoses after the modified Bentall procedure. Ann Thorac Surg 2003;75:1797–1801; discussion 1802.[Abstract/Free Full Text]
- Kazui T, Yamashita K, Terada H, Washiyama N, Suzuki T, Ohkura K, Suzuki K. Late reoperation for proximal aortic and arch complications after previous composite graft replacement in Marfan patients. Ann Thorac Surg 2003;76:1203–1207; discussion 1027–1028.[Abstract/Free Full Text]
- Cabrol C, Pavie A, Mesnildrey P, Gandjbakhch I, Laughlin L, Bors V, Corcos T. Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries. J Thorac Cardiovasc Surg 1986;91:17–25.[Abstract]
- Sarsam MA, Yacoub M. Remodeling of the aortic valve anulus. J Thorac Cardiovasc Surg 1993;105:435–438.[Abstract]
- David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992;103:617–621; discussion 622.[Abstract]
- Karck M, Kallenbach K, Hagl C, Rhein C, Leyh R, Haverich A. Aortic root surgery in Marfan syndrome: comparison of aortic valve-sparing reimplantation versus composite grafting. J Thorac Cardiovasc Surg 2004;127:391–398.[Abstract/Free Full Text]
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Abstract
1. Introduction