A Technique For Complete Replacement of The Ascending: Aorta

Thorax (1968), 23, 338.
A technique for complete replacement of

the ascending aorta
HUGH BENTALL AND ANTONY DE BONO
From the Royal Postgraduate Medical School, London, and Hammersmith Hospital
A technique for complete replacement of the aortic valve and ascending aorta in cases of
aneurysm of the ascending aorta with aortic valve ectasia is described. The proximal aortic
root was too attenuated to afford anchorage to the aortic prosthesis, so this was sutured to
the ring of a Starr valve and the prostheses were inserted en bloc. The ostia of the coronary
arteries were anastomosed to the side of the aortic prosthesis.
Aneurysmal dilatation of the ascending aorta is tion. He was in incipient cardiac failure with an
often associated with ectasia of the aortic valve effective cardiac output of 1.8 l./min./m.2
ring and presents clinically as aortic incompetence. OPERATION A mid-sternal thoracotomy revealed a
In Marfan's syndrome or cystic medial necrosis large globular dilatation of the ascending aorta. Its
this may develop with dramatic suddenness in an bulging inelastic wall was so thin that blood could
ostensibly healthy individual. be seen eddying within. Figure 1 gives an idea of the
The dilatation of the valve ring makes repair or attenuation of the wall.
replacement with other than a prosthetic valve Total cardiopulmonary bypass was established, and,
difficult. The aneurysm, which is either a true after cross-clamping the aorta distal to the aneurysm,
the aorta was opened, and the coronaries were can-
dilatation or dissection, is best treated by excision nulated and perfused in the usual way. The aortic
and replacement with a tubular prosthesis, as the valve ring was much dilated and the wall was
wall is invariably attenuated. This is not difficult extremely thinned down to the ring.
provided that the aorta distal to the aneurysm and It was clear that it would not be possible to join
proximal to the arch is suitable for anastomosis. the aortic wall above the coronaries to an aortic pros-
Proximally, in most cases, the aortic prosthesis thesis. It was therefore decided to suture the tube
can be sutured to a rim of aorta, leaving the prosthesis directly to the ring of a Starr valve. A No.
coronary ostia undisturbed, while a valve pros- 13 Starr valve was sutured to one end of a crimped
thesis is placed in the usual sub-coronary position Teflon aortic prosthesis, as shown in Figure 2. The
(Cooley, Bloodwell, Beall, Hallman, and De aortic cusps having been excised, sutures were placed
in the aortic ring and through the Starr valve ring.
Bakey, 1966). These were tied, fixing the Starr valve and the
However, it sometimes happens that the root of attached Teflon tube.
the aorta is so involved in the disease process At this stage the coronary cannulae were outside
that the wall is too attenuated to be sutured to the lumen of the aortic replacement. Holes were cut
the proximal end of the aortic prosthesis. In this in the aortic prosthesis at the site of the coronary
situation the management of the coronaries is the ostia, which were then re-cannulated, this time through
main concern of the surgeon. the lumen of the tube (Fig. 3). The aortic wall was
sutured to the perimeter of the holes in the Teflon
tube, thus reincorporating the coronary ostia within
CASE REPORT the new aorta.
The distal anastomosis was then completed, leaving
a vertical slit (Fig. 3 (5)) through which the coronary
A man aged 33 years had been in excellent health cannulae were removed and air was evacuated. This
until a few months before admission, when his wife was then closed with a clamp while the aortic clamp
had noticed a loud cardiac murmur and he developed was released and retrograde coronary perfusion was
signs and symptoms of gross aortic regurgitation. started again without any delay. The wall of the
Angiocardiography showed a large aneurysmal dilata- aneurysm was closed over the prosthesis.
tion of the ascending aorta, not involving the vessels The patient made an uneventful recovery and
of the arch but associated with free aortic regurgita- remains well after nine months.
338
A technique for complete replacement of the ascending aorta 339
FIG. 1. Section of aortic aneurysm just above aortic valve, showing extreme thinning. Wall
about one-tenth normal thickness. (L.E.H. V.G. x 40.)
Tef lon Vl
Starr
valve
FIG. 3. Combined prostheses in situ. Insets I to 4 show

details of holes fashioned in the side wall of the Teflon
FIG. 2. Starr valve has been sutured to aortic prosthesis: tube to reincorporate the coronary ostia within the
sutures have been placed in aortic ring before fixing the lumen of the new ascending aorta. Inset S shows the
combined prostheses. vertical slit in the prosthesis.
The technique used is reported as it offers an
alternative method of dealing with this type of REFERENCE
aortic disease when the whole of the ascending Cooley, D. A., Bloodwell, R. D., Beall, A. C., Hallman, G. L., and
De Bakey, M. E. (1966). Surgical management of aneurysms
aorta has to be replaced. of the ascending aorta. Surg. Clin. N. Amer., 46, 1033.

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Thorax (1968), 23, 338.

A technique for complete replacement of

FIG. 3. Combined prostheses in situ. Insets I to 4 show

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