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Eur J Cardiothorac Surg 2003;24:309-311
© 2003 Elsevier Science NL

Case report

Resection of the ascending aorta and aortic valve patch closure for type A aortic dissection after Novacor^® LVAD insertion

Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, B-1200 Brussels, Belgium

Received 27 February 2003; received in revised form 8 April 2003; accepted 15 April 2003.

^* Corresponding author. Tel.: +32-2-764-6107; fax: +32-2-764-8960
e-mail: noirhomme{at}chir.ucl.ac.be

	Abstract

Top Abstract 1. Case report 2. Discussion References

 
A 60-year-old patient developed an acute type A aortic dissection in the postoperative course of a Novacor^® left ventricular assist device. We performed a resection of the ascending aorta with an aortic valve patch closure, end-to-end anastomosis of the outflow graft to the distal ascending aorta and two venous grafts to the coronary arteries, in order to avoid residual aortic insufficiency and bleeding related to exposure of the fragilized tissues to high pressures.

Key Words: Aortic dissection • Aortic valve • Left ventricular assist device

	1. Case report

Top Abstract 1. Case report 2. Discussion References

 
A 60-year-old man was referred to our hospital for end-stage heart failure. He had a past history of hypertension and angina. A percutaneous transluminal coronary angioplasty of the first marginal branch of the circumflex artery had been performed 2 years before his admission.

On admission in the intensive care unit (ICU), he was in renal failure (creatinine=2.2 mg/dl) and left ventricular failure (end-diastolic diameter, 73 mm; pulmonary artery capillary wedge pressure, 25 mmHg; cardiac index, 1.3 l/min per m²). A severe mitral insufficiency was noted. Coronary angiography showed no significant vessel disease and the patient was kept with intra-aortic balloon pump and inotropic support in the ICU for 7 days. Because this later could not be weaned, it was decided to bridge the patient for transplantation.

A Novacor^® left ventricular assist system (Worldheart, Ottawa, ON, Canada) was implanted under cardiopulmonary bypass and transesophageal control. No aortic regurgitation was noted at that time. He had initially an uneventful recovery. A routine transthoracic echocardiography on postoperative day 15 showed a severe aortic insufficiency and a pericardial effusion. Repeated echocardiography confirmed the importance of the aortic leakage and the patient was taken to the operating room on postoperative day 18.

Transesophageal echocardiography showed a type A aortic dissection. No intimal flap was seen into the aortic arch or into the descending aorta. After institution of cardiopulmonary bypass, the Novacor^® was stopped; the aorta was crossed-clamped and opened. The tear was located in the proximal ascending aorta, extending from the aortic annulus to 2 cm below the emergence of the brachiocephalic trunk. Both coronary arteries were dissected. The ascending aorta was entirely excised and we performed a direct suture of the outflow conduit to the ascending aorta, and a closure of the aortic valve with a bovine pericardial patch. To maintain blood flow to the coronary arteries, we performed two venous bypasses, one to the ostium of the left main trunk and the other to the first segment of the right coronary artery. The proximal end of the venous graft to the left trunk was sutured on the right side of the outflow graft, and the vein to the right coronary artery was anastomosed on the left graft (Fig. 1) .

View larger version (47K): [in this window] [in a new window]   Fig. 1. Surgical technique.

	2. Discussion

Top Abstract 1. Case report 2. Discussion References

 
In the presence of excessive valvular incompetence with a left ventricular assist device (LVAD), the current recommendation is to replace the valve with a bioprosthetic valve, to avoid circulatory loop due to regurgitant flow and thrombus formation from stasis[1]. An alternative approach in the absence of any chance for ventricular recovery is to permanently close the ventriculoaortic junction with a patch [2].

Rao et al. [3] analyzed the outcome of patients who received the HeartMate LVAD. Seven patients required surgical management of native or prosthetic aortic valvular disease during LVAD implantation. In patients with severe aortic insufficiency, they repaired the native valve by resuspending the prolapsing cups or by creating a bicuspid orifice in patients with a potential myocardial recovery. When the patients were bridged to transplantation without any hope for recovery, they closed the valve by oversewing the free margins of all three adjoining cusps. In patients with a mechanical aortic valve, a Dacron patch was fashioned and sewn to the aortic aspect of the valve, preventing leaflet motion and limiting thrombus formation. Mortality and risk of stroke were identical whether the valve was repaired or the valve orifice closed.

Type A acute aortic dissection is rare but usually fatal in patients with LVADs [4]. This complication requires prompt surgical intervention using circulatory arrest. In the postoperative setting of LVAD implantation, emergent reparative surgery can be complicated by residual aortic insufficiency and persistent postoperative bleeding.

In our case, the aortic dissection appeared as a late complication on postoperative day 15, with severe regurgitation. The conservative surgical option was not considered because of the fragilized tissues and high risk of postoperative bleeding. We believed that the lowest possible number of anastomosis between the artificial graft and the dissected aortic tissue would reduce the risk of bleeding, so we decided not to perform a Bentall procedure.

We therefore resected the ascending aorta with a direct suture of the Novacor^® outflow graft to the ascending aorta just before the innominate artery origin. The aorta was cross-clamped at this level and not dissected. Considering that the patient was not for recovery, we closed the aortic valve with a patch. Thereafter, coronary perfusion was reinstituted with two venous grafts. Naka et al. [5] described a similar repair using a Hemashield graft, followed by a complicated postoperative course.

We chose to perform this repair technique to prevent the fragilized tissues from further lesions. The aortic dissection appeared later in the postoperative course. Evidently, the aortic wall was subjected to progressive shearing by the continuous beating of the graft, due to the elevated pressure waves of the device ejection. By closing the valve, the fragile aorta wall, as well the annulus would not be subjected to the pressure wave of the ejection, but only to low filling pressures. We felt this technique also minimized postoperative bleeding and avoided the risk of residual insufficiency in this patient.

	References

Top Abstract 1. Case report 2. Discussion References

 

1. McCarthy P.M., Smedira N.O., Vargo R.L., Goormastic M., Hobbs R.E., Starling R.C., Young J.B. One hundred patients with the HeartMate left ventricular assist device: evolving concepts and technology. J Thorac Cardiovasc Surg 1998;115:904-912.[Abstract/Free Full Text]
2. Savage E.B., d'Amato T.A., Magovern J.A. Aortic valve patch closure: an alternative to replacement with HeartMate LVAS insertion. Eur J Cardiothorac Surg 1999;16:359-361.[Abstract/Free Full Text]
3. Rao V., Slater J.P., Edwards N.M., Naka Y., Oz M.C. Surgical management of valvular disease in patients requiring left ventricular assist device support. Ann Thorac Surg 2001;71:1448-1453.[Abstract/Free Full Text]
4. Dworschak M., Wiesinger K., Lorenzl N., Wieselthaler G., Wolner E., Lassnigg A. Late aortic dissection in a patient with a left ventricular assist device. Jpn J Thorac Cardiovasc Surg 2001;49:395-397.[Medline]
5. Naka Y., Edwards N.M., Oz M.C. Novel technique to repair type A acute aortic dissection in patients with a left ventricular assist device. Ann Thorac Surg 2001;72:1403-1404.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lacroix, V. Articles by Noirhomme, P. Search for Related Content PubMed PubMed Citation Articles by Lacroix, V. Articles by Noirhomme, P. Related Collections Great vessels Mechanical Circulatory Assistance Valve disease