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Annals of Cardiology and Cardiovascular Diseases Open Access Short Communication: Simple Management Technique for Moderate Ascending Aortic Dilatation in OPCAB Patients: The Aortic Jacket Button ErdemÇetin1 and Arda Özyüksel2* 1Department of Cardiovascular Surgery, 2Department of Cardiovascular Surgery, Medikar Hospital, Turkey Medipol University, Turkey Submitted: 17 May 2016 Accepted: 17 June 2016 Published: 21 June 2016 Copyright © 2016 Özyüksel et al. Abstract Ascending aortic dilatation is a frequent co-existing pathology in elder patients undergoing coronary artery bypass graft procedure. Although there is a widely accepted consensus at diameters exceeding 6cm, the indications of intervention for border line dilatations at the time of cardiac surgery is debatable. Herein, we describe a simple and reproducible technique in elder patients who are undergoing off pump coronary artery bypass surgery with a border line dilatation of the ascending aorta. Keywords: Aortic aneurysm; Dacron graft; Beating heart; Coronary artery bypass Corresponding author: Arda Özyüksel, Istanbul Medipol University Department of Cardiovascular Surgery, Medipol Mega Hospital, TEM Göztepe Çıkışı No: 1, 34214, Bagcilar, Istanbul, Turkey, Telephone: 90 212 4607777; Fax: 90 212 4607070; E-mail: [email protected] Citation: Özyüksel A, Çetin E. (2016Simple Management Technique for Moderate Ascending Aortic Dilatation in OPCAB Patients: The Aortic Jacket Button. Ann Cardiol Cardiovasc Dis. 2016. 1(1): 1002 Introduction Dilatation of the ascending aorta may be encountered due to different etiologies such as atherosclerosis, collagen metabolism disorders, degenerative processes in the elderly, cystic medial necrosis and Marfan’s disease [1]. Depending on the underlying pathological mechanism, guidelines generally address diameters over 45mm for surgical intervention both for patients with an isolated aneurysms or undergoing other cardiac surgical procedures [2]. In cases where a significant underlying aortic wall pathology is lacking, reduction aortoplasty and external wrapping are accepted approaches [3,4]. Herein, we present a simple and reproducible surgical technique in patients undergoing off-pump coronary artery bypass(OPCAB) procedures with moderately dilated ascending aorta The patient was operated on with the diagnosis of ischemic coronary artery disease (ICAD). The left pleura presented with heavy fibrotic adhesions. A distal dissection over the endothoracic fascia revealed a pulseless, underdeveloped and calcified left internal thoracic artery. The left internal thoracic artery was no further harvested both with regard to the patient’s age and its gross findings. The ascending aorta was 4.3 cm. Three target arteries (LAD, OM1, and OM2) were revascularized after appropriate positioning of the heart with the off-pump beating heart technique. Before the proximal anastomosis were completed at the ascending aorta, a 34mm Dacron graft was cut longitudinally and trimmed. Afterwards, three holes were created in order to pass the saphenous vein grafts through that host multiple proximal vein grafts. these openings. Then the proximal anastomosis were completed and the graft was secured Operative Technique with running adventitial sutures to the ascending aorta A seventy-three years old male patient was admitted to above the sinotubular junction and below the our hospital with exertional dyspnea. His blood innominate artery (Figure 1A). A significant size chemistry studies were within normal limits except for reduction was not performed with this external moderately elevated serum low density lipoprotein wrapping, and the diameter of the ascending aorta was and triglyceride levels. He was a retired coal mine measured to be 3.6 cm at the postoperative contrast worker with moderately effected respiratory function enhanced tomography (Figure 1B). The surgical tests (Forced expiratory volume-FEV 0.9lt). Coronary technique is illustrated in (Figure 2). The patient did angiography revealed multiple stenotic lesions in LAD well after the operation and a contrast enhanced (90%, proximal) and optusmarginalis (OM) branches imaging study is scheduled at the first year after the of the circumflex artery (OM1:90%, mid segment; operation (Figure 3). 1: OM2: 75%, proximal). Transthoracic echocardiography revealed a left ventricular ejection fracture of 45%, mild mitral and tricuspid regurgitation with a pulmonary artery pressure of 45mmHg. The trileaflet aortic valve was competent and the diameter of the ascending aorta was 43mm. Citation: Özyüksel A, Çetin E. (2016Simple Management Technique for Moderate Ascending Aortic Dilatation in OPCAB Patients: The Aortic Jacket Button. Ann Cardiol Cardiovasc Dis. 2016. 1(1): 1002 Figure 1: Intraoperative view of the heart after the aortic button jacket (AJ) is positioned with holes created in order to provide openings for the vein grafts (arrows). LV: left ventricle, RV: right ventricle. Figure 3: Postoperative contrast enhanced tomography reveals the Dacron graft (black arrows) wrapping the ascending aorta with a diameter of 36mm and the holes created for the vein grafts (white arrows). Figure 2: The dilated ascending aorta (A) and the surgical procedure are illustrated. A Dacron graft is cut longitudinally and holes are created at the appropriate location where the vein grafts will pass through (B). The ‘jacket’ is then positioned on the aorta with proximal and distal suture lines in order to prevent dislocation in the postoperative period (C).The suture line of the proximal anastomosis is completely unattached to the graft. Discussion surgery may be significantly increased with advanced Although indications for surgical intervention in ascending aortic aneurysms are clearly defined, the intraoperative decision-making process may be challenging in cases with moderate dilatations of the ascending aorta. This situation is more complex in elder patients where a degenerative etiology is age, previous coronary artery bypass grafting (CABG) and prolonged cardiopulmonary time [5]. Therefore, every cardiac surgeon might encounter a patient with a dilated ascending aorta with the diameter below the limits for intervention but over the normal size with the risk of progression. concerned. The reoperative mortality for ascending aortic aneurysm in patients with a history of cardiac There are a couple of questions with regard to the technique to be applied for the dilated aorta. External Citation: Özyüksel A, Çetin E. (2016Simple Management Technique for Moderate Ascending Aortic Dilatation in OPCAB Patients: The Aortic Jacket Button. Ann Cardiol Cardiovasc Dis. 2016. 1(1): 1002 wrapping, reduction aortoplasty and lineer plication are well-defined techniques in patients where an onpump cardiac surgical procedure is to be performed [4,6]. However, when the patient is undergoing an offpump surgery, external wrapping seems to be the only validated technique. Although traditional papers addressed the danger of aortic wall injury and necrosis at the wrapped segment, a recent biomechanical analysis proved that wrapping of the dilated aorta Conclusion We consider this modified wrapping procedure of the ascending aorta in patients undergoing OPCAB procedure as a useful method for elder patients with moderately dilated aorta. In case a reoperation for aortic aneurysm is deemed necessary in CABG patients where the aorta is left unwrapped, the operative morbidity and mortality will be obviously high. results in lower stress and risk for dissection [7]. Our main idea in this patient was a simple wrapping Acknowledgements procedure of the ascending aorta, which may even be The regarded as a ‘non-repair’ solution in case the aorta illustration of the surgical technique. authors thank SabriÇağrıSezgin for the dilates to a diameter more than 5-5.5 cm in the followup period of the patient. In such a situation, a redo References surgery for any intervention for the ascending aorta 1. will be with high morbidity and mortality, since the M, et al. (2006). Ascending aorta dilatation in aortic patient has a very limited respiratory capacity. We valve disease: morphological analysis of medial aimed to intervene a moderately dilated aorta which changes. Heart Vessels. 2006; 21: 213-220. has a diameter less than the usual accepted indications for repair or replacement. 2. Agozzino L, Santè P, Ferraraccio F, Accardo Erbel R, Aboyans V, Boileau C, Bossone E, et al. (2014). 2014 ESC Guidelines on the diagnosis Park and colleagues reviewed the indications for and treatment of aortic diseases: Document covering wrapping procedures and they recommend these acute and chronic aortic diseases of the thoracic and interventions for the diameter of the ascending aorta abdominal aorta of the adult. The Task Force for the between 4 and 6 cm, where the dilatation is limited to Diagnosis and Treatment of Aortic Diseases of the the ascending segment of the aorta [8]. The wrapping European Society of Cardiology (ESC). Eur Heart procedure may be ideal in patients with comorbidities J. 2014; 35: 2873-2926. where a prolonged operation and cardiopulmonary bypass time would obviously increase the mortality. In our technique, since we performed an off pump surgery, wrapping technique only increased the operation time for 10 to 15 minutes. In our opinion, 3. Feindt P, Litmathe J, Börgens A, Boeken U, et al. (2007). Is size-reducing ascending aortoplasty with external reinforcement an option in modern aortic surgery? Eur J Cardiothorac Surg. 2007; 31: 614-617. the modified aortic button jacket procedure is an important accompanying procedure in OPCAB 4. Ozcan AV, Alşalaldeh M, Boysan E, Goksin patients, since aortic side clamping for proximal I. (2013). Ascending aortic aneurysm treatment with anastomosis may lead to progression of the dilatation linear plication and external wrapping technique: mid- process in the follow-up period. term results. J Card Surg. 2013; 28: 421-426. Citation: Özyüksel A, Çetin E. (2016Simple Management Technique for Moderate Ascending Aortic Dilatation in OPCAB Patients: The Aortic Jacket Button. Ann Cardiol Cardiovasc Dis. 2016. 1(1): 1002 5. Girardi LN, Krieger KH, Mack CA, Lee LY, 7. Plonek T, Rylski B, Dumanski A, Siedlaczek et al. (2006). Reoperations on the ascending aorta and P, et al. (2015). Biomechanical analysis of wrapping of aortic root in patients with previous cardiac surgery. the moderately dilated ascending aorta. J Cardiothorac Ann Thorac Surg. 2006; 82: 1407-1412. Surg. 2015; 10: 106. 6. 8. Arsan S, Akgun S, Kurtoglu N, Yildirim T, et Park JY, Shin JK, Chung JW, Kim JS, et al. al. (2004). Reduction aortoplasty and external (2012). Short-term Outcomes of Aortic Wrapping for wrapping tubular Mild to Moderate Ascending Aorta Dilatation in concomitant Patients Undergoing Cardiac Surgery. Korean J for moderately ascending aorticaneurysm with sized operations. Ann Thorac Surg. 2004; 78: 858-861. Thorac Cardiovasc Surg. 2012; 45: 148-154. Citation: Özyüksel A, Çetin E. (2016Simple Management Technique for Moderate Ascending Aortic Dilatation in OPCAB Patients: The Aortic Jacket Button. Ann Cardiol Cardiovasc Dis. 2016. 1(1): 1002