We describe a case of a 49-year-old man who presented with an uncomplicted aortic root aneurysm, aortic insufficiency, and ST-elevation myocardial infarction (STEMI) without obstructive coronary artery disease on angi...We describe a case of a 49-year-old man who presented with an uncomplicted aortic root aneurysm, aortic insufficiency, and ST-elevation myocardial infarction (STEMI) without obstructive coronary artery disease on angiography. The computed tomo- graphy angiogram (CTA) of the thorax, performed without cardiac gating, was misinterpreted as normal. In retrospect, an overlooked extravasation of contrast material lateral to the aortic root was detected on non-gating magnetic resonance angiography (MRA). Exploration of the aortic root revealed an unsuspected horizontal intimal tear of the left sinus of Valsalva with limited extramural hematoma. The presence of an otherwise silent intimal tear on preoperative imaging studies makes the overall management more problematic. For example, initiating early broad empirical anticoagulants or fibrinolytics therapy to treat the accompanied myocardial infarction may extend the tear into a full life-threatening aortic dissection, tamponade or rupture. We highlight many of the difficulties associated with the diagnosis and treatment of limited sinus tear when aortic root aneurysm is presenting with cryptogenic STEMI. Accurate morphologic characterization of intimal tear would be best defined with either an electrocardiogram-gating CTA or MRA imagings. These non-invasive tests are needed to make appropriate management decisions. Depending on other pathologic components of aortic root, cusps and the commissural geometry, sinus tear is a critical component for the overall treatment plan and it shifts the surgical intervenetion from valve-sparing operation, commissural resuspension and leaflet repair to composite aortic root replacement (modified version of the Bentall procedure).展开更多
The aortic aneurysm is the 13th leading cause of death in Western countries. The incidence of thoracic aortic aneurysms is estimated at 4.5 cases per 100,000. The diagnosis is often made on a chest x-ray or other imag...The aortic aneurysm is the 13th leading cause of death in Western countries. The incidence of thoracic aortic aneurysms is estimated at 4.5 cases per 100,000. The diagnosis is often made on a chest x-ray or other imaging tests, such as an echocardiogram done for other heart diseases. Echocardiography is the first test to assess the diameter of the ascending aorta and its progression over time. Most patients are first assessed and followed up with spiral thoracic computed tomography with injection of contrast medium, supplemented by 3-dimensional reconstruction of the aneurysm in order to improve the accuracy of measurements, identification of its proximal part and distal. When dilation of the ascending aorta reaches the critical diameter of 50 mm, there is a risk of aortic dissection or rupture. Supravalvular aneurysms are treated by replacing the ectatic portion with a Dacron<span style="white-space:nowrap;">®</span> tube in the supracoronary position. Aortic root aneurysms, including coronary ostia, require tube replacement, reimplantation of coronary ostia, as well as surgery on the aortic valve. In this article, we report a case of aneurysm of the aortic root and the ascending aorta treated by aortic valve replacement and the ascending aorta associated with the Cabrol hemi-mustache technique and we review the literature.展开更多
Background: Acute myocardial ischemia, seen in about 2% of aortic root replacements (ARR), is acutely life-threatening, manifesting as failure to wean from bypass, ventricular fibrillation, or unstable hemodynamics. T...Background: Acute myocardial ischemia, seen in about 2% of aortic root replacements (ARR), is acutely life-threatening, manifesting as failure to wean from bypass, ventricular fibrillation, or unstable hemodynamics. The exact precipitating anatomic cause is usually not apparent at the time of surgery. In this report, we take advantage of late computed tomographic (CT) angiograms of long-term survivors of peri-operative ischemia after ARR to determine what abnormalities of the coronary button reattachments produced the peri-operative ischemia. Methods: The database of the Aortic Institute at Yale-New Haven was reviewed to identify all patients undergoing ARR over a 15-year period. Operative records, patient charts, and CT angiograms of patients who had peri-operative ischemia were reviewed in detail, including analysis by an imaging specialist. Results: 271 patients underwent ARR, 220 with mechanical and 51 with biological valved conduits. Hospital mortality was 2.95%. Clinical follow-up ranged from 1 to 182 months. Survival in discharged patients was 97.7% at 5 years and 95.2% at 7 years. Peri-operative ischemia was seen in 4 of 271 patients (1.5%). All four affected patients survived—with interventions including supplemental coronary bypass grafts (4 patients), intra-aortic balloon pump placement (2 patients), and left ventricular assist device insertion (1 patient). Late CT angiograms revealed severe but non-obstructive left main calcification serving as a focal point for coronary angulation in 2 patients, angulation without calcification in 1 patient, and totally normal anatomy in 1 patient. Conclusions: Myo- cardial ischemia after ARR is rare but acutely life-threatening. Prompt recognition and treatment by supplemental coronary artery bypass grafting preserves life and leads to good late survival. Intramural calcification (non-obstructive) of the distal left main coronary artery predisposes to angulation after coronary button creation and should be a “red flag” for this potential problem.展开更多
文摘We describe a case of a 49-year-old man who presented with an uncomplicted aortic root aneurysm, aortic insufficiency, and ST-elevation myocardial infarction (STEMI) without obstructive coronary artery disease on angiography. The computed tomo- graphy angiogram (CTA) of the thorax, performed without cardiac gating, was misinterpreted as normal. In retrospect, an overlooked extravasation of contrast material lateral to the aortic root was detected on non-gating magnetic resonance angiography (MRA). Exploration of the aortic root revealed an unsuspected horizontal intimal tear of the left sinus of Valsalva with limited extramural hematoma. The presence of an otherwise silent intimal tear on preoperative imaging studies makes the overall management more problematic. For example, initiating early broad empirical anticoagulants or fibrinolytics therapy to treat the accompanied myocardial infarction may extend the tear into a full life-threatening aortic dissection, tamponade or rupture. We highlight many of the difficulties associated with the diagnosis and treatment of limited sinus tear when aortic root aneurysm is presenting with cryptogenic STEMI. Accurate morphologic characterization of intimal tear would be best defined with either an electrocardiogram-gating CTA or MRA imagings. These non-invasive tests are needed to make appropriate management decisions. Depending on other pathologic components of aortic root, cusps and the commissural geometry, sinus tear is a critical component for the overall treatment plan and it shifts the surgical intervenetion from valve-sparing operation, commissural resuspension and leaflet repair to composite aortic root replacement (modified version of the Bentall procedure).
文摘The aortic aneurysm is the 13th leading cause of death in Western countries. The incidence of thoracic aortic aneurysms is estimated at 4.5 cases per 100,000. The diagnosis is often made on a chest x-ray or other imaging tests, such as an echocardiogram done for other heart diseases. Echocardiography is the first test to assess the diameter of the ascending aorta and its progression over time. Most patients are first assessed and followed up with spiral thoracic computed tomography with injection of contrast medium, supplemented by 3-dimensional reconstruction of the aneurysm in order to improve the accuracy of measurements, identification of its proximal part and distal. When dilation of the ascending aorta reaches the critical diameter of 50 mm, there is a risk of aortic dissection or rupture. Supravalvular aneurysms are treated by replacing the ectatic portion with a Dacron<span style="white-space:nowrap;">®</span> tube in the supracoronary position. Aortic root aneurysms, including coronary ostia, require tube replacement, reimplantation of coronary ostia, as well as surgery on the aortic valve. In this article, we report a case of aneurysm of the aortic root and the ascending aorta treated by aortic valve replacement and the ascending aorta associated with the Cabrol hemi-mustache technique and we review the literature.
文摘Background: Acute myocardial ischemia, seen in about 2% of aortic root replacements (ARR), is acutely life-threatening, manifesting as failure to wean from bypass, ventricular fibrillation, or unstable hemodynamics. The exact precipitating anatomic cause is usually not apparent at the time of surgery. In this report, we take advantage of late computed tomographic (CT) angiograms of long-term survivors of peri-operative ischemia after ARR to determine what abnormalities of the coronary button reattachments produced the peri-operative ischemia. Methods: The database of the Aortic Institute at Yale-New Haven was reviewed to identify all patients undergoing ARR over a 15-year period. Operative records, patient charts, and CT angiograms of patients who had peri-operative ischemia were reviewed in detail, including analysis by an imaging specialist. Results: 271 patients underwent ARR, 220 with mechanical and 51 with biological valved conduits. Hospital mortality was 2.95%. Clinical follow-up ranged from 1 to 182 months. Survival in discharged patients was 97.7% at 5 years and 95.2% at 7 years. Peri-operative ischemia was seen in 4 of 271 patients (1.5%). All four affected patients survived—with interventions including supplemental coronary bypass grafts (4 patients), intra-aortic balloon pump placement (2 patients), and left ventricular assist device insertion (1 patient). Late CT angiograms revealed severe but non-obstructive left main calcification serving as a focal point for coronary angulation in 2 patients, angulation without calcification in 1 patient, and totally normal anatomy in 1 patient. Conclusions: Myo- cardial ischemia after ARR is rare but acutely life-threatening. Prompt recognition and treatment by supplemental coronary artery bypass grafting preserves life and leads to good late survival. Intramural calcification (non-obstructive) of the distal left main coronary artery predisposes to angulation after coronary button creation and should be a “red flag” for this potential problem.
