Ann Thorac Surg 2003;75:1802
© 2003 The Society of Thoracic Surgeons
Original article: cardiovascular
Invited commentary
Alan D. Hilgenberg, MDa
a Department of Thoracic Surgery, Massachusetts General Hospital, 55 Fruit StreetBoston, MA 02114, USA
e-mail: ahilgenberg{at}partners.org
This study found remarkable freedom from coronary artery anastomotic problems in patients who had composite aortic root replacement by the button implantation technique. In fact, there was zero incidence of anastomotic aneurysms in patients who did not have Marfan’s syndrome or acute dissection followed for an average of 4 years. The Marfan patient developed a true aneurysm of the implanted coronary artery button. To minimize the risk of this problem, we should make the size of the opening in the Dacron graft for coronary implantation only slightly larger than the ostium of the coronary artery. By placing the anastomotic sutures close to the ostium and using a small opening in the graft, there will be a minimal amount of abnormal aortic wall surrounding the ostium available for late aneurysm formation in Marfan patients. The risk of coronary pseudoaneurysm formation in acute dissection patients must depend mostly on how much the dissection process disrupts the layers of the aortic wall at the coronary ostium. It may be possible to decrease the risk of this problem by carefully including all layers of the arterial wall in the suture line and buttressing the button externally with a washer of Teflon felt. There is concern, with respect to the pseudoaneurysms of the distal graft to aorta suture line, that the GFR glue used in the acute dissection repairs could be a facilitating factor by causing necrosis of some components of the aorta.
The message of this study is to expect results free of anastomotic problems, at least over the medium term, in patients who have root replacements for degenerative aneurysms. Those with Marfan’s syndrome and acute dissections are at somewhat increased risk of anastomotic complications. All patients should be followed with periodic routine imaging studies, which should include magnetic resonance angiography in addition to echocardiography. By employing the techniques suggested above, we may be able to achieve additional reduction of anastomotic complications.
