Redo Aortic Root and Total Arch Replacement for a Giant Ascending and Arch Aneurysm After a Previous Double Mechanical Valve Replacement
Source: PubMed Central Open Access, NCBI / U.S. National Library of Medicine
Redo replacement of the ascending aorta and aortic arch after previous double mechanical valve replacement is rare and technically challenging. Surgical re-entry is particularly hazardous in the presence of giant aneurysms because dense adhesions, distorted mediastinal anatomy, and prosthetic valves increase the risks of complications. We report the successful management of a giant compressive aneurysm using a staged strategy incorporating pre-sternotomy left ventricular (LV) apical decompression. A 63-year-old man with previous mitral commissurotomy and double mechanical mitral-aortic valve replacement presented with progressive dysphagia and severe dyspnea. Computed tomography revealed a giant ascending and arch aortic aneurysm (117 × 116 mm) causing marked tracheoesophageal compression. Given the high risk associated with redo sternotomy, a staged surgical strategy incorporating pre-sternotomy LV apical decompression through a left anterolateral thoracotomy, systemic cooling, and selective antegrade cerebral perfusion was employed. Redo aortic root and total arch replacement was successfully performed with a 24-mm quadrifurcated graft and reimplantation of the supra-aortic trunks and coronary buttons. Despite a complicated postoperative course, the patient recovered fully, and four-month follow-up imaging confirmed graft integrity and resolution of compressive symptoms. This case demonstrates that giant ascending and arch aneurysms occurring after previous double mechanica
Abstract
Redo replacement of the ascending aorta and aortic arch after previous double mechanical valve replacement is rare and technically challenging. Surgical re-entry is particularly hazardous in the presence of giant aneurysms because dense adhesions, distorted mediastinal anatomy, and prosthetic valves increase the risks of complications. We report the successful management of a giant compressive aneurysm using a staged strategy incorporating pre-sternotomy left ventricular (LV) apical decompression. A 63-year-old man with previous mitral commissurotomy and double mechanical mitral-aortic valve replacement presented with progressive dysphagia and severe dyspnea. Computed tomography revealed a giant ascending and arch aortic aneurysm (117 × 116 mm) causing marked tracheoesophageal compression. Given the high risk associated with redo sternotomy, a staged surgical strategy incorporating pre-sternotomy LV apical decompression through a left anterolateral thoracotomy, systemic cooling, and selective antegrade cerebral perfusion was employed. Redo aortic root and total arch replacement was successfully performed with a 24-mm quadrifurcated graft and reimplantation of the supra-aortic trunks and coronary buttons. Despite a complicated postoperative course, the patient recovered fully, and four-month follow-up imaging confirmed graft integrity and resolution of compressive symptoms. This case demonstrates that giant ascending and arch aneurysms occurring after previous double mechanical valve replacement can be successfully managed using a carefully staged reoperative strategy. Pre-sternotomy LV apical decompression may represent a valuable adjunct for safe re-entry in selected patients with large sternal-adherent aneurysms.