A technique for complete replacement of the ascending aorta.

A technique for complete replacement of the aortic valve and ascending aorta in cases of aneurysm of the ascending aorta with aortic valve ectasia is described. The proximal aortic root was too attenuated to afford anchorage to the aortic prosthesis, so this was sutured to the ring of a Starr valve and the prostheses were inserted en bloc. The ostia of the coronary arteries were anastomosed to the side of the aortic prosthesis. Aneurysmal dilatation of the ascending aorta is often associated with ectasia of the aortic valve ring and presents clinically as aortic incompetence. In Marfan's syndrome or cystic medial necrosis this may develop with dramatic suddenness in an ostensibly healthy individual. The dilatation of the valve ring makes repair or replacement with other than a prosthetic valve difficult. The aneurysm, which is either a true dilatation or dissection, is best treated by excision and replacement with a tubular prosthesis, as the wall is invariably attenuated. This is not difficult provided that the aorta distal to the aneurysm and proximal to the arch is suitable for anastomosis. Proximally, in most cases, the aortic prosthesis can be sutured to a rim of aorta, leaving the coronary ostia undisturbed, while a valve pros-thesis is placed in the usual sub-coronary position However, it sometimes happens that the root of the aorta is so involved in the disease process that the wall is too attenuated to be sutured to the proximal end of the aortic prosthesis. In this situation the management of the coronaries is the main concern of the surgeon. A man aged 33 years had been in excellent health until a few months before admission, when his wife had noticed a loud cardiac murmur and he developed signs and symptoms of gross aortic regurgitation. Angiocardiography showed a large aneurysmal dilata-tion of the ascending aorta, not involving the vessels of the arch but associated with free aortic regurgita-tion. He was in incipient cardiac failure with an effective cardiac output of 1.8 l./min./m.2 OPERATION A mid-sternal thoracotomy revealed a large globular dilatation of the ascending aorta. Its bulging inelastic wall was so thin that blood could be seen eddying within. Figure 1 gives an idea of the attenuation of the wall. Total cardiopulmonary bypass was established, and, after cross-clamping the aorta distal to the aneurysm, the aorta was opened, and the coronaries were can-nulated and perfused in the usual way. The aortic valve …