Florida Sleeve Repair for Aortic Root Aneurysm
A 74-year-old man was referred to our hospital for surgical management of aortic root aneurysm found by echocardiography during a preoperative work-up for spinal surgery. He presented with intermittent left-sided chest pain. His vital signs and laboratory data were unremarkable on admission. His past medical history revealed hypertension requiring drug therapy and herniated nucleus pulposus at the lumbar area. Trans-thoracic echocardiography revealed an enlarged sinus of Valsalva 58 mm in diameter with mild aortic regurgitation (). The left ventricular ejection fraction was 60% without regional wall motion abnormality. A computed tomography (CT) scan identified severe aortic sinus dilatation and a coaptation defect in the aortic valve (). The maximal diameter of the aortic sinus and aortic tubular portion were 60 and 36 mm, respectively. A coronary angiography showed 80% stenosis of the proximal left anterior descending artery (LAD), and total occlusion of the distal left circumflex artery. Thallium single-photon emission computed tomography showed fixed medium-sized moderately decreased perfusion in the basal anterolateral and basal inferolateral wall. Consequently, the patient was scheduled for concomitant aortic root surgery and coronary artery bypass grafting (CABG).\nAt the beginning, the patient underwent off-pump CABG (from the in situ left internal mammary artery to the LAD and the saphenous venous graft to the obtuse marginal branch). After establishing cardiopulmonary bypass (CPB) and aortic clamping (cardioplegic solution was delivered via the coronary sinus in a retrograde manner and concomitant antegrade infusion via saphenous vein graft to the obtuse marginal graft), the ascending aorta was transected above the sinotubular junction and the aortic root was mobilized to the aortic annular level, and the origins of the coronary arteries were mobilized. After measuring the aortic annular size, a 30-mm vascular graft (Gelweave Valsalva; Terumo Inc., Tokyo, Japan) was trimmed with two key holes (). Then, six anchoring sutures were made on the lowest level of the annulus, at the commissure and midpoint of each leaflet. After locating the graft to the patient's aortic root, a running suture was done together with the transected sinotubular junction and the graft. After confirming adequate coaptation of the aortic leaflets, distal anastomosis between the graft and distal ascending aorta was made. After CPB weaning, sternal closure was done. Aortic clamping and cardiopulmonary bypass times were 88 and 128 minutes, respectively.\nThe patient was extubated on postoperative day 1 and transferred to the general ward on day 2. CT and echocardiographic evaluations were performed on postoperative day 4, and they demonstrated a competent aortic valve with no regurgitation, and a stable aortic graft without any distortion or leakage. The diameter of the sinus portion of the aorta was measured at 37 mm with excellent coaptation of the aortic valve (). The patient was discharged on postoperative day 8 without any postoperative complications. Serial follow-up echocardiographic assessments were performed up to one year after surgery. There was no aortic insufficiency and the stability of the sinus portion of the aorta was maintained with its diameter at 38 mm.