CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 1, January–April 2023 56 AFRICA replacement of the ascending aorta due to acute aortic dissection (Stanford type A) the year before. He was admitted to the clinics for the purpose of scheduled diagnostic examination, with symptoms of shortness of breath and decreased exercise tolerance. The patient had a number of concomitant disorders: deforming kyphoscoliosis of the thoracic spine, significant funnel breast, and binocular vision due to retinal detachment. The anthropometrical data matched with MS: body length was 205 cm and weight was 50 kg. According to data from TTE, the findings included aneurysmatic dilation of the aortic root (up to 5.5 cm), annulodilation of up to 27 mm, and aortic insufficiency (up to degree two). It is worth noting that the diameter of the prosthetically replaced area of the ascending aorta was 3.0 cm. Data from chest CT confirmed the presence of an aneurysm in the aortic root (with no signs of dissection) with a size of 5.3–5.5 cm, located at the level of the Valsalva sinuses. The sagittal dimension of the mediastinum between the posterior surface of the sternum and the vertebral column was 4 cm (at the border of the median and lower third of the body) with the right atrium and ventricle closely adjacent to the sternum (7 cm). The patient was considered as having absolute indications for correcting the abnormality of the aortic root. Taking into consideration the high risk of intra-operative injury of the cardiac structures due to the previous sternotomy-accessed surgery, as well as a redo operation, the most acceptable approach was a left-sided thoracotomy. Thoracotomy procedures provided a 9–11-cm-long approach along the fourth intercostal space on the left side. CPB was applied by cannulation of the femoral vessels (as in the previous case, there was good exposure of the aortic root) (Fig. 2A). Taking into consideration the significant adhesion process, the procedures included an aortholysis and partial cardiolysis, separating the right atrium and pulmonary artery from the aorta with deep mobilisation. After clamping the aorta, the previously implanted supracoronary prosthetic device was removed. Upon valve revision, the three leaflets were mobile and annulodilation up to 28 mm was observed (Fig. 2B). Further procedures included a standard David procedure with the fixation of a linear synthetic vascular prosthetic device number 30 using six U-shaped sub-annular sutures, valve re-suspension and re-implantation of the orifices of the coronary arteries (Fig. 2C). Intra-operative transoesophageal echocardiography did not reveal residual regurgitation. The duration of CPB was 190 minutes, cross-clamping of the aorta lasted for 110 minutes, and the duration of ICU stay was 24 hours. The patient was discharged on day six after surgery with no complications and satisfactory findings from the laboratory tests (Fig. 3). During the control visit six months after surgery, the general status of the patient was classified as NewYorkHeart Association functional class I. According to data from TTE, aortic valve regurgitation was within the range of grade 1, and the diameter of the fibrous ring was 22 mm. CT scans did not reveal signs of insufficiency in the reconstruction. The aortic dimension (root and ascending segment) was 30 mm (Fig. 4). Discussion In recent years, avoiding a median sternotomy, thoracic aortic surgery increasingly includes alternative variants of surgical approaches, which are progressively less and less invasive, such as upper or J-shaped mini-sternotomy, dextralateral minithoracotomy, as well as mini-thoracotomy combined with thoracoscopic visualisation.3 In the case of a successful surgical Fig. 1. A. The patient’s appearance. B. Computed tomography demonstrated a funnel-shaped chest deformation and giant ascending aortic aneurysm. C. Intraoperative view of the Bentall procedure through a left-sided thoracotomy approach. Fig. 2. A. The sternum is marked with a blue line. The incision made in the fourth intercostal space is marked with a green line. B. Intra-operative view of aortic root revision. C. Aortic valve after the David procedure.
RkJQdWJsaXNoZXIy NDIzNzc=