Hemolytic Anemia Case Caused by an Inverted Inner Felt after Bentall Operation
A 26-yr-old male patient presented to our emergency room with acute chest pain on April 8, 2010. He was diagnosed with type A aortic dissection and underwent an emergency Bentall operation. We reinforced the proximal and the distal anastomoses using inner and outer felt strips. Computed tomography taken two days after the operation to evaluate postoperative mediastinal widening showed no anastomosis site stenosis (). The patient's postoperative course was uneventful.\nThree months after the operation, he developed mild dyspnea on exertion and carotid bruit was audible. An echocardiogram showed normal mechanical aortic valve function. One year after the operation, the patient reported dyspnea and dizziness with exertion and the carotid bruit worsened. There was evidence of hemolytic anemia (hemoglobin 7.8 g/dL, total bilirubin 1.8 mg/dL, direct bilirubin 0.6 mg/dL, lactate dehydrogenase 897 IU/L, schistocytes in peripheral blood). A treadmill test was positive at stage II. Echocardiogram again showed normal mechanical aortic valve function. Coronary angiogram was performed to rule out coronary button anastomosis site stenosis. There was no coronary stenosis however, there was significant stenosis between the graft and the aorta anastomosis and the diameter of stenotic site was about 13 mm ().\nDuring the reoperation, we found the inner felt at the distal anastomosis was stiff and inverted from the 6- to 12-hr direction. The most significant inversion was about 100 degrees (). The inversion was the cause of the stenosis. The luminal diameter of the anastomosis site was 13 mm which was same as measured with the aortogram. The anastomosis site was excised at a 1-cm width including the inner and outer felts used for reinforcement. Reanastomosis between the aorta and the graft was completed without felt reinforcement. Dyspnea, carotid bruit and hemolysis disappeared (Hb 14.2 g/dL) after the reoperation. The patient is still doing well and continuing with regular follow up.