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Ann Thorac Surg 2005;80:385-386
© 2005 The Society of Thoracic Surgeons
Division of Cardiac Surgery, I.R.C.C.S. Policlinico San Matteo University-Hospital, Piazzale Golgi 19, Pavia, 27100 Italy
(Email: carlobanfi{at}ticino.com).
We read with great interest the article by Arsan and coworkers [1]. Ascending aortic aneurysms with normal sized sinotubular junctions are generally handled by resection of the aneurysmatic portion and by replacement with a tubular graft. Arsan and coworkers [1] proposed an alternative modified aortoplasty. We found this technique interesting and easy to perform, but we still have some concerns about aortoplasty repair. In fact, with this procedure a diseased and thinned aortic wall is not removed, and a relevant incidence of redilatation may occur in the follow-up period [2]. Moreover the "Windkessel" effect of the aorta and major conduit branches is represented by the capability of the aorta to transform the pulsatile energy provided by the left ventricle into a more steady kind of flow by elastic distension and contraction [3]. During the conventional surgery of the ascending aorta and in aortoplasty reduction with Dacron wrapping (Meadox Vascular Graft, Oakland, NJ), the aneurysmatic portion is replaced with synthetic prosthesis or Dacron wrap. Such a procedure may generate evident alterations in arterial hemodynamic and left ventricular work.
The aneurysm of the ascending aorta sometimes takes the shape of a localized fusiform dilatation of the portion between the sinotubular junction and the innominate artery. The sinuses of Valsalva and the aortic arch are not involved in the dilatation. Here the aneurysm is due to elongation of the lateral wall of the aorta, whereas the posteromedial wall almost maintains its original length. The heart is displaced inferiorly and toward a more horizontal plane of the aneurysm itself. After the resection of the thin excess aortic wall tissue represented by the aneurysm, the heart recovers its original position and the end-to-end anastomosis of the aortic stump is feasible.
Since 1998 to date we have performed almost 150 end-to-end anastomosis of the ascending aorta associated or not with other cardiac procedures, of which 122 have been operated on by a mini-sternotomy approach. All our patients are in a protocol study of serial angiographic computed tomographic scans, and at the moment there is no evidence of recurrence of redilatation or pseudoaneurysm [4].
Recently Massetti and coworkers [5] published a long-term durability in a small series of patients treated with end-to-end anastomosis, and the results showed that this is an effective treatment in patients with ascending aortic aneurysm. In those patients with aortic regurgitation, in which a high recurrence rate of aneurysms with other techniques of aortoplasty were reported, this technique appeared to be an alternative to aortic interposition grafting.
In our opinion, in selected cases, resection of ascending aorta aneurysms through an end-to-end anastomosis may represent a feasible, safe, inexpensive, and fast operation. Moreover, it has many theoretical advantages: it allows a more physiologic correction, shorter cross-clamp time, no foreign material in the mediastinum, and the risk of infection is quite low. With this procedure, the ascending aorta is restored with native aortic segments that presumably have the same physical and mechanical features of a normal aorta.
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