Eur J Cardiothorac Surg 2007;32:683-684. doi:10.1016/j.ejcts.2007.06.019
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
The external reinforcement of the aortic wall: a futile attempt
Efstratios Apostolakis,
Nikolaos Panagopoulos*,
Dimitrios Dougenis
Cardiothoracic Surgery Department, Patras University School of Medicine, Patras, Greece
Received 19 May 2007;
accepted 19 June 2007.
* Corresponding author. Address: Potideas 30, GR-263 35, Patras, Greece. Tel.: +30 2610 313605. (Email: npanag{at}upatras.gr).
Key Words: Aortic ectasia • Ascending aorta dilatation • Asymmetric dilatation • Aortic wrapping • Post-stenotic aortic valve dilatation • External reinforcement
We read with great interest the article by Feindt et al. [1]. We would like to note the following concerning the proposed external reinforcement of the ascending aorta:
- (a) Although the authors characterized the ascending aorta as ectatic, they histologically found a normal aortic wall in all cases. Ectasia is usually present in connective tissue diseases such as cystic medial necrosis or Marfan's syndrome [2]. We have observed this ‘normal’ dilatation of the ascending aorta almost exclusively in patients with severe aortic valve stenosis with eccentric orifice of tricuspid or bicuspid aortic valve. Its main characteristics are the asymmetric form of dilatation corresponding to the position of the aortic wall where the jet of blood is expelled, as well as a more striking local thinning of the wall in the same position. In four patients with the above-mentioned characteristics, we performed ascending aortic replacement; the only histological differentiation of the aortic wall in its thinnest positions was the decreased width of all three layers of aortic wall. Indeed, in 80% of the cases they have aortic stenosis [1].
- (b) In our opinion, this method includes the following risks: First, in the cases of diseased aortic wall, it may be dissected later on (such a case is being reported by the authors in their cohort); second, the wrapping cannot embrace the whole ascending aorta since a big part of Valsalva's sinuses cannot be included; and finally, the attempt to dissect the aorta low around the coronary ostia may injure them, or interfere with the proximal part of coronary arteries. In addition this could be related to the relatively high mortality observed in this study (8%), the long ICU stay (4.4 ± 7.8 days), and the high incidence of postoperative acute renal failure (6%).
- (c) Follow-up does not provide valid information because it concerns only a small number of patients (31 out of 46 for 59 months and 13 out of 46 for 72 moths) [1].
- (d) The combined replacement of the dilated ascending aorta with the diseased aortic valve should be the only indicated management, since it is associated with low mortality, less than 7% [3].
- (e) The external reinforcement, in our opinion, could be reserved only for elderly patients with severe comorbidities. We believe that this asymmetric ‘post-jet’ dilatation of the ascending aorta after valve replacement does not include later dilatation and risk of rupture or dissection, even in cases of diseased aortic wall. The postoperative decrease of blood pressure and the abolition of blood jet prevent further dilatation of aorta, except in the cases of bicuspid aortic valve [4,5]. Therefore, the proposed external reinforcement of a dilated ascending aorta is a futile attempt, since in those cases where the aortic wall is diseased, this method does not provide protection, and if it is normal, this method is unnecessary.
References
- Feindt P, Litmathe J, Boergens A, Boeken U, Kurt M, Gams E. Is size-reducing ascending aortoplasty with external reinforcement an option in modern aortic surgery?. Eur J Cardiothorac Surg 2007;31(4):614-617.[Abstract/Free Full Text]
- Roberts W, O’Rourke R, Roldan J. The connective tissue diseases and the cardiovascular system. In: Fuster V, Wayne Alexander R, O’Rourke R, editors. Hurst's the hurt. 11th ed.. MacGraw-Hill; 2004. pp. 2067.
- Carrel T, von Segesser L, Jenni R, Gallino A, Egloff L, Bauer E, Laske A, Turina M. Dealing with dilated ascending aorta during aortic valve replacement: advantages of conservative surgical approach. Eur J Cardiothorac Surg 1991;5:137-143.[Abstract]
- Andrus BW, O’Rourke DJ, Dacey LJ, Palac RT. Stability of ascending aortic dilatation following aortic valve replacement. Circulation 2003;108(Suppl. 1):II295-II299.[Medline]
- Yasuda H, Nakatani S, Stugaard M, Tsujita-Kuroda Y, Bando K, Kobayashi J, Yamagishi M, Kitakaze M, Kitamura S, Miyatake K. Failure to prevent progressive dilatation of ascending aorta by aortic valve replacement in patients with bicuspid aortic valve: comparison with tricuspid aortic valve. Circulation 2003;108(Suppl. 1):II291-II294.[Medline]
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J. Litmathe and P. Feindt
Reply to Apostolakis et al.
Eur. J. Cardiothorac. Surg.,
October 1, 2007;
32(4):
684 - 684.
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