A-12-8-Cm-Diameter-G

Journal of Cardiology and Cardiovascular Research

Mathur A, et al., 2021- J Cardiol Cardiovasc Res Case Report

A 12.8 cm Diameter: Giant Aortic Aneurysm (GAA) Successfully Treated by Department of Cardiothoracic Vascular Bentall’s Procedure- Case Report Surgery, National Heart Institute, East of Kailash, New Delhi 1* 2 3 4 Anirudh Mathur , OP Yadava , Vikas Ahlawat , Anirban Kundu , * Corresponding Author: Anirudh 5 Amita Yadav Mathur, Department of Cardiothoracic Vascular Surgery, National Heart Abstract Institute, East of Kailash, New Delhi, India. Background: Aortic root aneurysm involves dilatation of sinuses of Accepted Date: 05-19-2021 Valsalva, sinotubular junction and proximal ascending aorta. It is a rare Published Date:06-20-2021 complication after aortic valve replacement surgery. Giant aneurysm is © defined as aneurysm of size> 10 cm. Surgical treatment involves Copyright 2021 by Mathur A, et al. All rights reserved. This is an open access Bentall’s procedure. article distributed under the terms of the Creative Commons Attribution License, Case Detail: A 40 year old gentleman with severe aortic regurgitation which permits unrestricted use, and moderate aortic stenosis underwent aortic valve replacement with distribution, and reproduction in any a mechanical prosthetic valve of size 25 mm, 13 years ago. At the time of medium, provided the original author previous surgery the ascending aorta was mildly dilated, measured 3.5 and source are credited. cm in size. Patient came with complaints of breathlessness on exertion from past two months, NYHA class III. Echocardiography and CECT revealed giant ascending aortic aneurysm about 12.8 cm in diameter with intimal flap suggestive of dissection. Prosthetic valve function and other cardiac structures were assessed as normal. Elective surgery was planned. CPB was established. Ascending aortic aneurysm was excised along with prosthetic mechanical valve. Bentall’s procedure was done using 27 mm Dacron composite graft. Patient required permanent pacemaker for complete heart block in post operative period. Thereafter patient was discharged in stable condition.

Conclusion: Aortic aneurysm should be tackled surgically in order to decrease the morbidity and mortality. Regular follow up of such patients should be done.

Keywords:Giant aortic aneurysm, Bentall’s procedure

Background Being one of the rare complications after aortic valve replacement surgery; the An aneurysm is the second most frequent aneurysm of size >5 cm needs surgical disease of the aorta after atherosclerosis [1]. intervention like Bentall's procedure [3]. The dilatation of sinuses of Valsalva involving together sinotubular junction, The exceeding 10 cm diameter of an and the proximal ascending aorta is aneurysm in the aorta is an uncommon referred to as Aortic root aneurysm [2]. clinical entity associated with the risk of Mathur A| Volume 2; Issue 2 (2021) | Mapsci-JCCR-2(2)-026| Case Report Citation: Mathur A, Yadava OP, Ahlawat V, Kundu A, Yadav A. A 12.8 cm Diameter: Giant Aortic Aneurysm (GAA) Successfully Treated by Bentall’s Procedure- Case Report. J Cardiol Cardiovasc Res. 2021;2(2):1-5.

rupture [4]. The rupture risk is directly The medical history was elicited for an proportional to the aneurysm size. The aortic valve replacement with a 25mm yearly rupture incidence for aneurysms mechanical prosthetic valve, 13 years ago. reported in the literature database is 14% In the first operation, mild dilatation in the for GAA greater than 6 cm diameter [5]. ascending aorta measuring 3.5cm in size Among various enlisted etiologies was observed- as per old clinical records of atherosclerosis is the most common cause the patient. of aortic aneurysm. Other causes are giant cell arteritis, Marfan's syndrome, syphilis, Elective surgery was planned as an hereditary hemorrhagic telangiectasia, interventional treatment regimen. tuberculosis, and medial agenesis [6,7]. Cardiopulmonary bypass (CPB) was established initially via the right axillary We herein present a rare 12.8 cm GAA case, artery and right femoral vein, later on after which was successfully treated by Bentall's dissection of the aneurysmal sac, was procedure. converted into central cannulation via ascending aorta and right atrium which Case Report aided in maintaining the circulation of blood and the oxygen content of the A 40-year-old male presented with patient's body. Bentall's procedure was complaints of breathlessness on exertion done using a 27 mm Dacron composite from two months, echocardiography, x-ray graft (Figure 3). Unfortunately, a gross (Figure 1) and contrast-enhanced photograph of the aneurysmal sac could computed tomography (CECT) (Figure 2) not be taken due to hemodynamic revealed features of 12.8 cm of diameter- compromise during the surgery. The giant ascending aortic aneurysm (GAA) patient required a permanent pacemaker with minimal intimal flap suggestive of for complete heart block in the post- dissection. The functioning of prosthetic operative period. Thereafter patient was valve and other cardiac structures were discharged in stable condition. also assessed. The clinical and radiological findings concluded to the diagnosis of severe aortic regurgitation and moderate aortic stenosis.

Figure 1: X-ray PA view showing dilated part of ascending aorta, and sternal wires of previous surgery

Mathur A| Volume 2; Issue 2 (2021) | Mapsci-JCCR-2(2)-026| Case Report Citation: Mathur A, Yadava OP, Ahlawat V, Kundu A, Yadav A. A 12.8 cm Diameter: Giant Aortic Aneurysm (GAA) Successfully Treated by Bentall’s Procedure- Case Report. J Cardiol Cardiovasc Res. 2021;2(2):1-5.

Figure 2: CECT chest showing reconstructed image of dilated ascending aorta approximately 12.8 cm along with aortic mechanical prosthetic valve.

Figure 3: Post Bentall’s Procedure showing Dacron composite graft with central cannulation from ascending aorta and right atrium.

Discussion giant aortic aneurysm are reported in the database. Life expectancy without surgical Giant aneurysms can have various intervention for cases of giant aneurysms is presentations and is a rare clinical entity. very low [12]. The surgical intervention The complications lead to the poor recommended in current guidelines is prognosis associated with rupture &/or indicative of an aneurysm with a diameter dissection [8]. Leaking aneurysms, on other exceeding 5.0 cm [13]. It is not uncommon hand also present the typical feature of that these patients die from either the acute dissection along pericardial rupture of an aneurysm or decompensating tamponade [9,10]. The rupture risk is organs and systems [14]. The 10-year risk of directly proportional to the size and is mortality is high as 15 times the risk of comparable to the rate of growth of the aorta-related death in patients with aneurysm [11]. To the best of our abdominal aortic aneurysm (AAA) in knowledge only some cases of unruptured comparison to any other cardiovascular Mathur A| Volume 2; Issue 2 (2021) | Mapsci-JCCR-2(2)-026| Case Report Citation: Mathur A, Yadava OP, Ahlawat V, Kundu A, Yadav A. A 12.8 cm Diameter: Giant Aortic Aneurysm (GAA) Successfully Treated by Bentall’s Procedure- Case Report. J Cardiol Cardiovasc Res. 2021;2(2):1-5.

cause (e.g. myocardial infarction or stroke) The Bentall procedure has operative [15]. mortality no worse than that for aortic valve replacement as per the literature The recommended guidelines as per the database with a superior long-term survival American Heart Association suggests rate [20]. Bentall technique involves direct interventional treatment regimen even if reimplantation of the coronary arteries. there would not have been any dissection Whereas the modified Bentall technique of adjacent organs to prevent advocated by certain authors requires the complications associated with GAA [16,17]. formation of ostial "buttons" attached to In the present case sparing operation was the graft [21]. The significant not possible because of associated improvements with modified techniques dissection to sinuses of Valsalva involving are still not able to justify intra-operative together sinotubular junction, and blood loss and postoperative complications proximal ascending aorta. Bentall [22]. procedure was performed for the present case using 27 mm Dacron composite graft. Conclusion The Dacron composite graft remains conduit with excellent hemostatic and Aortic aneurysms need an interventional hemodynamic properties & in older treatment regimen to decrease the individuals, aortic root surgery is preferred. associated morbidity and mortality. A biological aortic valve as a composite Regular follow-up of such patients is biological valved conduit is gaining necessary to trace ascending aortic acceptance in such aggressive cases [18,19]. reoperation if the choice is Bentall procedure.

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