CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 6, July 2012
AFRICA
e11
(Hemashield, Meadox Medicals Inc) during low-flow cerebral
perfusion. After completion of the distal anastamosis, the
brachiocephalic artery was unclamped and cardiopulmonary
bypass was maintained at 4.5 l/min/m
2
to rewarm the patient.
Intra-operative transoesophageal echocardiography showed no
residual AI or MI.
The total cardiopulmonary bypass time was 126 minutes. The
total aortic cross-clamp time was 76 minutes, with 10 minutes
low-flow cerebral perfusion time.
The postoperative course was uneventful, and the patient
was discharged on postoperative day 10. One-month follow-up
transthoracic echocardiography documented neither AI nor MI.
Discussion
Acute aortic dissection type A is a life-threatening disease.
Complications such as aortic rupture, cardiac tamponade and
acute aortic regurgitation require immediate surgical intervention.
Replacement of the aortic valve, root and ascending aorta with
a composite graft carrying a mechanical valvular prosthesis is
one of the most commonly used treatment options, especially if
the aortic root is severely impaired. However it is accompanied
by the disadvantages of mechanical valve prostheses, such
as thromboembolic events and haemorrhage due to lifetime
anticoagulation.
There are several aortic valve-sparing operations for
replacement of the ascending aorta to overcome the shortcomings
of a mechanical prosthesis. The Cabrol type of commissure
sutures with or without resuspension of the valve is one that is
perfectly suited to patients with AADTA.
1,2
The advantages of mitral valve repair over prosthetic valve
replacement, such as better preservation of left ventricular
function and lower incidence of valve-related events, are well
documented. Nowadays, the procedure is the gold standard,
especially for degenerated MI.
3
In contrast to mitral valve repair, aortic valve repair still poses
significant technical challenges. Svensson
et al
.
2
reported on 388
aortic root-preserving procedures, of which 140 (36.1%) were
after AADTA. They performed 197 leaflet repair procedures,
of which 158 (80.7%) were Cabrol/Trusler type of commissure
sutures, with excellent early results.
Kallenbach
et al
.
4
reported the results of 22 emergency
valve-sparing aortic root reconstructions with a re-implatation
technique. There was 14% peri-operative deaths but excellent
results during follow up. Thirty-six patients with valve-sparing
aortic root remodeling/re-implantation forAADTAwere reported
by Erasmi
et al
.,
5
with excellent mid-term aortic valve function.
Our case is unique in that in the above reports, there were no
concomitant mitral valve repairs or replacement.
In contrast, mitral valve insufficiency is present in 68 to
91% of patients with Marfan’s syndrome, who are more prone
to aortic dissection.
6
Forteza
et al
.
7
reported on 37 aortic valve-
sparing procedures in patients with Marfan’s syndrome, where
six (16%) concomitant mitral valve repairs were done, with
good short- and midterm results. In their series, none were
diagnosed with AADTA. Another report from Kallenbach
et
al
. described 59 aortic valve-sparing procedures in Marfan’s
syndrome patients, of whom seven had mitral valve repair. There
were also four AADTA patients in the report but they did not
mention the concomitance of double valve repair in any of the
acute dissection patients.
8
There are only a few reports of combined aortic and mitral
valve repair and durability, even under elective conditions.
Gillinov
et al
.
9
reported acceptable late survival, an excellent
freedom from valve-related morbidity, but limited long-term
durability, with a 10-year freedom from re-operation of 65%.
The risk factors they reported for valve-related re-operation
were aortic stenosis, rheumatic valve disease and anterior mitral
leaflet pathology. Kazui
et al
.
10
reported excellent early results
with a 100% 30-day survival rate and no valve-related morbidity
during one year of follow up.
In our institution, mitral valve repair is attempted first,
regardless of the aetiology of the mitral insufficiency, and the
Cabrol commissure sutures have been the mainstay of aortic
valve repair, particularly after AADTA. AADTA dilates the
aortic root and annulus, separates the aortic valve leaflets, and
makes the valve incompetent. 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. The suture
alone will result in a competent valve when combined with
resuspension of the valve.
Surgeons are generally more familiar with valve replacement
than reconstruction. Prolonged operation time, with expansion
of aortic cross clamp and extracorporeal circulation time, is
another potential drawback for the application of reconstructive
techniques, particularly with AADTA. The benefits of double
valve repair (low risk of valve-related complications such as
endocarditis, thromboembolism and haemorrhage, and better
preservation of left ventricular function) should be pointed
out during the ongoing discussions and surgeons should gain
experience with reconstructive techniques in elective cases.
Conclusion
We believe that valve repair should be attempted, even under
emergency conditions, and double valve repair should be carried
out whenever possible.
References
1.
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2.
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et al
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