Download Annals of Cardiology and Cardiovascular Diseases Open

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