CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 6, July 2012
e10
AFRICA
Case Report
Abstract
Reconstructive valve surgery in acute aortic dissection typeA
(AADTA) remains challenging.We describe a case of success-
ful combined repair of the aortic and mitral valves, and
replacement of the ascending aorta after AADTA with aortic
and mitral insufficiency. Mitral valve repair was achieved
by quadrangular resection of the posterior leaflet, combined
with ring annuloplasty. Aortic valve repair was achieved by
Cabrol commissural sutures with resuspension of the annu-
lus. The postoperative clinical course was uneventful and an
echocardiogram revealed competent mitral and aortic valves.
Mitral and aortic valve repair is an option in AADTA with
mitral and aortic valve insufficiency.
Keywords:
acute aortic dissection type A, aortic valve repair,
mitral valve repair, Cabrol
Submitted 30/3/11, accepted 13/9/11
Cardiovasc J Afr
2012;
23
: e10–e11
DOI: 10.5830/CVJA-2011-056
Case report
A 50-year-old woman with a history of moderate degenerative
mitral valve insufficiency (MI) was admitted to an outlying
hospital with sudden onset of severe back pain. She was referred
to our hospital with a diagnosis of acute aortic dissection type
A (AADTA), based on clinical and echocardiographic findings.
On physical examination, she was tachypnoeic (respiratory
rate 33 per min) and tachycardic (117 per min). Her systolic
blood pressure was 150 mmHg on her right arm, which was
25 mmHg higher than that of the left arm. Bilateral carotid and
femoral pulses were palpable. Chest auscultation revealed fine
inspiratory rales at the basal zones of both lungs and a systolic
murmur was noted in the precordium.
Radiography of the chest showed an increased opacity of
both lower lobes. The electrocardiogram did not demonstrate
any specific changes. Transthoracic echocardiography (TTE)
Successful emergency double valve repair operation
during acute aortic dissection type A
TAYLAN ADADEMIR, ALTUG TUNCER, MEHMET OZKOKELI, AHMET SASMAZEL, HASAN ERDEM,
RAHMI ZEYBEK
Kartal Kosuyolu Yuksek Ihtisas Heart Education and
Research Hospital, Department of Cardiovascular Surgery,
Istanbul, Turkey
TAYLAN ADADEMIR, MD,
ALTUG TUNCER, MD
MEHMET OZKOKELI, MD
AHMET SASMAZEL, MD
HASAN ERDEM, MD
RAHMI ZEYBEK, MD, PhD
revealed an intimal flap in the ascending aorta, severe mitral
and aortic insufficiency (AI) and minimal pericardial effusion.
Computed tomography of the chest confirmed the diagnosis of
AADTA by visualising an intimal flap just above the sinotubular
junction and a slightly dilated ascending aorta.
The patient was immediately taken to the operating
theatre. Cardiopulmonary bypass was established with arterial
cannulation in the right axillary artery. After median sternotomy
and bicaval venous cannulation, the patient was slowly cooled
to 24°C. The ascending aorta was cross-clamped just proximal
to the brachiocephalic artery and aortotomy was performed.
Antegrade direct blood cardioplegia was used selectively to
each coronary ostium to arrest the heart and it was repeated
every 20 minutes. Aortotomy confirmed a type A dissection
with an intimal tear situated 2 cm distal to the ostium of the right
coronary artery. Severe aortic insufficiency was detected.
The mitral valve was exposed through a standard left
atriotomy. The mitral annulus was dilated, with a posterior
mitral leaflet prolapse. The prolapsed posterior mitral leaflet
(P2) was removed by excising a quadrangular portion of the
leaflet. Direct suturing of the leaflet remnants restored posterior
leaflet continuity. Ring annuloplasty was also performed with
a St Jude mitral ring (No 31). Cabrol commissure sutures
(Fig. 1)with resuspension of the valvewere used to repair the aortic
insufficiency. The proximal part of the graft was anastomosed
to the ascending aorta 1 cm distal to the coronary ostiums.
The brachiocephalic artery was selectively clamped
and cross clamped and the ascending aorta was removed.
Cardiopulmonary bypass flow was decreased to 10 ml/min/m
2
and the hemi-arc was replaced by a 30-mm Dacron graft
Fig. 1. The Cabrol suture narrows the intercommissure
angle, and the valvular apparatus just above the annulus
brings the body of the aortic valve leaflets closer together
and improves the critical area of coaptation.
