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J Cardiothorac Surg
J Cardiothorac Surg
Journal of Cardiothoracic Surgery
1749-8090
BioMed Central London

3029
10.1186/s13019-024-03029-7
Case Report
Application of preset coronary artery orifice patch in Bentall surgery
Li Chunsheng
Yan Zhongya
Lu Zhong aydluzhong@163.com

https://ror.org/03xb04968 grid.186775.a 0000 0000 9490 772X Department of Cardiovascular Surgery, Second Afliated Hospital of Anhui Medical University, Hefei, Anhui 230601 China
11 9 2024
11 9 2024
2024
19 5259 6 2024
30 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

Bentall surgery is the main method for treating aortic root lesions, but traditional Bentall method is very difficult for patients with mild aortic sinus dilation to directly anastomose the coronary artery orifice with graft.

Case presentation

A 41-year-old man was admitted to hospital after severe chest pain. Computed tomography angiography(CTA)revealed a type A aortic dissection. Echocardiography showed moderate aortic valve regurgitation and an aortic sinus diameter of 38 mm( mm). The patient underwent emergency Bentall surgery (using a preset coronary artery orifice patch), total arch replacement, and implantation of a graft into the descending aorta. Follow-up echocardiography showed the patient cardiac function was good, and there was no residual leakage at the coronary artery orifice.

Conclusions

This method is an alternative to traditional Bentall surgery and is suitable for all aortic root lesions, especially those with mild aortic sinus dilation or concomitant aortic dissection.

Keywords

Bentall surgery
Coronary artery orifice
Patch
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcBackground

Bentall surgery is the classic surgical approach for patients with aortic root lesions. Most patients with type A aortic dissection who have dissection tears involving the coronary artery orifice and concomitant aortic valve disease require aortic root replacement. Most centers still use Bentall surgery to reduce the risk of uncontrollable bleeding or need for repeat valve surgery in patients with an aortic sinus or ascending aorta diameter > 50 mm [1]. However, it is difficult to perform traditional Bentall surgery by anastomosing the coronary artery orifice with artificial blood vessels in patients with mild aortic dilation. In these patients, Bentall surgery can cause damage, distortion, and leakage of blood from the coronary artery orifice and even low cardiac output and postoperative bleeding, potentially resulting in failed surgery. Various methods have been used to address these issues. We have overcome the above-mentioned difficulties associated with anastomosis of the coronary artery orifice by using preset patch, making Bentall surgery simpler to perform, more accurate, and more suitable for widespread clinical application.

Case presentation

A 41-year-old man was admitted to hospital 5 h after onset of severe chest pain and had a blood pressure of 229/109 mmHg upon admission. Computed tomography angiography revealed a type A aortic dissection that originated from the aortic root and involved both iliac arteries distally. Echocardiography showed moderate aortic valve regurgitation and an aortic sinus diameter of 38 mm (Fig. 1). The patient had high preoperative creatinine and a history of nephritis.His aortic sinus did not show significant dilation. He underwent emergency Bentall surgery (using a preset coronary artery orifice patch), total arch replacement, and implantation of a graft into the descending aorta using the stented elephant trunk technique.

Fig. 1 Computed tomography angiogram showing type A aortic dissection originating from the aortic root and involving the descending aorta. The aortic sinus is not significantly dilated. There is a small amount of pericardial effusion

A transverse right subclavian incision and a sternal median incision were used to establish cardiopulmonary bypass(CPB) by inserting an aortic supply tube into the axillary artery and a venous drainage tube into the upper and lower cavities respectively. A longitudinal incision in the ascending aorta revealed aortic dissection involving the upper portion of the left and right coronary artery orifice.We found a approximately 12 mm tear above the noncoronary sinus during the surgery, indicating significant prolapse of the noncoronary sinus. We attempted to suspend the noncoronary sinus, but it still showed significant regurgitation. Aortic annulus diameter of approximately 22 mm.We selected a 21-mm mechanical aortic valve graft (St Jude Medical, St Paul, MN, USA), cut off the aortic valve, intermittently sutured along the valve annulus, and threaded the needle into the artificial valve annulus without tying it temporarily. Two circular patchs with diameter of about 20 mm were cut from the aortic valve graft and opened in the middle using a cautery pen to correspond to the size of the coronary artery orifice. The inner circle of the left coronary artery patch was continuously sutured to the orifice using 5 − 0 Prolene. The needle is inserted into the aortic wall, and released at the boundary between the aorta and coronary artery, approximately 3 mm from the orifice.The right coronary artery orifice was also sutured. The valve conduit was sent to the aortic valve annulus and the artificial annulus was tied separately. Holes were made in the corresponding left and right coronary artery orifice patches of the artificial blood vessel using the cautery pen and the outer edges of the patches were sutured to the artificial blood vessel in a continuous manner using 5 − 0 Prolene (Figs. 2 and 3). The patient was cooled to 25℃ for stent implantation using the elephant trunk method in the descending aorta and total arch replacement. After the heart relapsed, the outer membrane of the original aorta wrapped around the artificial blood vessel and underwent internal drainage to the right atrium. The aortic occlusion time was 180 min, and deep hypothermic circulatory arrest and selective cerebral perfusion were maintained for 21 min. No intraoperative blood transfusion was required, and approximately 550 ml of fluid were drained in the first 2 postoperative days. The patient developed acute renal damage postoperatively and required continuous renal replacement therapy; his renal function recovered thereafter and there were no complications at discharge. Follow-up echocardiography showed that the mechanical aortic valve was functioning well, his cardiac function was good, and there was no residual leakage at the coronary artery orifice. The drainage route from the aortic root to the right atrium was closed (Fig. 4).

Fig. 2 Preset coronary artery orifice patch surgery procedure. (A) A circular patch is cut from the aortic valve graft and opened in the middle to correspond to the size of the coronary artery orifice. (B) The inner circle is continuously sutured to the coronary artery orifice using 5 − 0 Prolene. (C) After suturing, the opening of the coronary artery is checked. (D) Holes are created by cautery pen at the corresponding left and right coronary artery orifice patches of the artificial blood vessel. The outer edges of the left and right patches are attached to the artificial blood vessel using continuous suture thread

Fig. 3 Schematic drawing of the patch after anastomosis with coronary artery orifice and artificial blood vessel. Left main coronary artery(LM), Right coronary artery(RCA)

Fig. 4 Postoperative echocardiogram showing an unobstructed coronary artery orifice and no residual leakage. The drainage route from the aortic root to the right atrium has been closed

Discussion

Bentall surgery was initially used to treat ascending aortic aneurysms, and although the procedure has undergone various refinements, its fundamental idea has remained unchanged. It is now widely used for various aortic root lesions [2]. Type A aortic dissection often involves the aortic root. Many experts now recommend aortic root surgery with preservation of the aortic valve to improve postoperative quality of life. However, because of the complexity of the surgery and that the fact that it may be performed in emergency situations, mortality and reoperation rates are higher in patients in whom the aortic valve is preserved than in those who undergo Bentall surgery regardless of whether the prosthetic aortic valve is mechanical or biological [3]. Other studies have found a 30-day mortality rate of 5.9% for Bentall surgery and a mortality rate of 12.7% for non-elective surgery, with estimated 5-year and 10-year survival rates of 84.4% and 68.7%, respectively. The main causes of death are low cardiac output, major bleeding, and major brain damage in the immediate postoperative period and cardiogenic shock and cerebrovascular disease in the longer term [4]. Regardless of the cause, mortality is related to the accuracy of transplantation at the coronary artery orifice. We suture the artificial blood vessel patch at the coronary artery orifice before fixing the artificial valve ring, which exposes the surgical field well and makes suturing more convenient and accurate. Thus, we ensure the quality of anastomosis at the coronary artery orifice and achieve good short-term surgical results.

The main methods used for coronary artery anastomosis in Bentall surgery include direct anastomosis and button anastomosis. Kouchoukos et al. used albumin precoagulation to treat artificial blood vessels and prevent postoperative bleeding, and there is no longer a need to wrap autologous blood vessels around artificial blood vessels after coronary artery anastomosis [5]. Freeing the left and right coronary artery orifice into button-like anastomosis to the artificial blood vessel, reduces the probability of postoperative anastomotic bleeding and pseudoaneurysm and can also reduce tension on the coronary arteries and avoid twisting of these vessels. Li et al. dissociated the left and right coronary artery openings into button-like structures and implanted them into the aortic valve conduit using continuous sutures [6]. At the same time, they used bovine pericardium to reconstruct the left and right aortic sinuses from the valve annulus; the bovine pericardium was perforated and sutured together with the coronary artery at the corresponding opening of the artificial coronary artery. Padding reinforcement was used as necessary. Finally, the bovine pericardium was wrapped around the aortic root and a channel to the right atrium was created for internal drainage. This procedure can significantly reduce postoperative complications and achieve satisfactory short-term results in patients with acute aortic dissection.

Bentall surgery is required in patients with type A aortic dissection. In view of the high risk of postoperative bleeding, many surgeons choose not to cut off the autologous blood vessels and directly anastomose the coronary artery orifice with the artificial vessel. Finally, the autologous vessels are wrapped around the artificial vessel in the ascending aorta and a Cabrol shunt is created to the right atrium [1]. However, some scholars doubts persist about this outsourcing method [7]. They believe that coronary artery free is relatively easy to complete, but in the case of fragile aortic walls or acute aortic dissection, direct anastomosis is difficult to incorporate the thickness of the entire aortic wall into the suture, resulting in the risk of pseudoaneurysm at the long-term coronary artery orifice after surgery. In addition to the above factors, direct anastomosis poses difficulties in terms of exposing the anastomotic orifice, high anastomotic tension, and even direct tearing of the coronary artery orifice in patients with less significant sinus dilation.

In view of the above-mentioned advantages and disadvantages of the two main surgical methods used for anastomosis of the coronary arteries, we have developed an improved method based on the “coronary artery priority” principle. Using this method, two patches are anastomosed to the coronary artery orifice, the artificial valve ring is then fixed, and finally the patches are anastomosed to the artificial vessel. This method has three main advantages. First, it is easy to expose the coronary artery orifice. In the past, the direct anastomosis method was used to complete the valve ring anastomosis before anastomosing the coronary artery, which significantly constrained the exposure of the artificial valve ring and blood vessels. Furthermore, the operating space was greatly limited, making the anastomosis difficult to perform, especially in patients with type A active aortic dissection where there is no significant expansion of the aortic sinus. Second, the suture method is precise. In view of the large space, the patch is attached to the coronary artery orifice to complete the suturing procedure, making it more convenient for the needle to enter and exit. Even if the exact location is uncertain, the suture needle can be added in a timely manner. Third, the patch anastomosis is completed without tension to avoid distortion or tension at the anastomotic site. Later on, the size of the opening of the artificial vessel can be adjusted according to the distance between the patch and the artificial vessel to reduce tension. Both the Piehler technique and the Svensson’s modification require additional small artificial blood vessels during coronary artery opening anastomosis, which poses a long-term risk of thrombosis and blockage [8, 9]. Therefore, we not only ensure the quality of the coronary artery orifice anastomosis but also reduce the risk of postoperative bleeding by outsourcing, thereby improving the success rate of surgery.

Conclusions

Our preset coronary artery orifice patch method can make Bentall surgery simpler, more accurate, and amenable to widespread clinical application. This method is particularly suitable for patients with mild aortic dilation and type A aortic dissection.

Acknowledgements

Not applicable.

Author contributions

CS and Z were involved in surgery. CS and ZY were involved in preparing the manuscript and revisions. All authors read and approved the final manuscript.

Funding

No funding sources.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Abbreviations

CTA Computed tomography angiography

mm Millimeter

CPB Cardiopulmonary Bypass

LM Left Main Coronary Artery

RCA Right Coronary Artery

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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