Chowdhury UK, George N, Singh S, Hasija S, Sankhyan LK, Sharma S, Pandey NN, Sengupta S, Kalaivani M. Fate of the Coronary Ostial and Distal Aortic Anastomoses after Modified Bentall’s Operation (UKC’s Modification). J Surg & Journal of Surgical Tech.2020;2(1):11-20 Surgery and Surgical Technology Original Research Article Open Access Fate of the Coronary Ostial and Distal Aortic Anastomoses after Modified Bentall’s Operation (UKC’s Modification) Ujjwal K. Chowdhury1*, Niwin George1, Sukhjeet Singh1, Suruchi Hasija2, Lakshmikumari Sankhyan1, Srikant Sharma1, Niraj Nirmal Pandey3, Sanjoy Sengupta1, Mani Kalaivani4 1Departments of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India. 2Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, New Delhi, India. 3Department of Cardiac Radiology ,All India Institute of Medical Sciences, New Delhi, India. 4Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India. Article Info Article Notes Received: May 04, 2020 Accepted: June 13, 2020 *Correspondence: Dr. Ujjwal Kumar Chowdhury, M.Ch, Diplomate NB, Professor, Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029, India; Telephone No: 91-11-26594835; Fax No: 91-11- 26588663, 26588641; Email: [email protected], [email protected]; Orcid ID: http://orcid.org/0000-0002-1672-1502. ©2020 Chowdhury UK. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License. Keywords: Anastomotic pseudo-aneurysm Graphical Abstract: Graphic display (n=140) showing widely patent left and Bentall’s procedure Computed tomographic angiography right coronary arterial systems, intact proximal and distal anastomoses without Coronary ostial aneurysm coronary ostial kinking/narrowing/aneurysm or pseudo-aneurysm formation Coronary button technique Retrograde cold blood cardioplegia Antegrade cold blood cardioplegia Abstract Myocardial preservation Objectives: To ascertain the influence of technique of coronary button implantation in patients undergoing Bentall’s procedure with respect to survival, re-exploration for bleeding, anastomotic complications of proximal and distal aortic suture lines, formation of coronary aneurysm and pseudo-aneurysm, kinking and coronary ostial narrowing. Methods: We reviewed 140 patients (75 males) aged between 22 and 66 years (mean±SD 48.21±1.36 years) receiving a composite aortic conduit from January 1998 to December 2019 for annulo-aortic ectasia (n=98), aortic dissection (n=41), and repaired tetralogy of Fallot (n=1), 24 of whom had Marfan’s syndrome. All patients underwent modified “button technique” by interposing a glutaraldehyde- treated pericardial strip at the graft-coronary anastomoses and proximal aortic conduit suturing using interlocking, interrupted, pledgeted mattress sutures. To detect anastomotic complications of the coronary ostia, proximal and distal aortic anastomoses, survivors underwent echocardiography every 6 months and computed tomographic angiography at 12 months or whenever indicated. Results: Seven (5%) patients died of cardiac-related cause, 45% had transient hemodynamic instability, 55% had low cardiac output and 87.1% had spontaneous return of sinus rhythm. At a mean follow-up of 161.6±69.9 months, the actuarial survival was 92.6±0.02% (95% CI: 86.9%-96.1) and there were no anastomotic aneurysm or pseudo-aneurysm formation, no kinking of the coronary ostia or ostial narrowing. Conclusion: The modified open button technique and proximal aortic conduit suturing is associated with reduced perioperative bleeding, no aneurysm or pseudo-aneurysm formation at the coronary and distal aortic anastomoses. We recommend more extensive use of pericardial strip reinforcement of coronary button and new imaging techniques. Page 11 of 20 Chowdhury UK, George N, Singh S, Hasija S, Sankhyan LK, Sharma S, Pandey NN, Sengupta S, Kalaivani M. Fate of the Coronary Ostial and Distal Aortic Anastomoses after Journal of Surgery and Surgical Technology Modified Bentall’s Operation (UKC’s Modification). J Surg & Surgical Tech.2020;2(1):11-20 Introduction Table 1: Demographic, operative, and postoperative details of the patients in the study (n=140) Long-term results after composite graft aortic root Variables Number (%) replacement may depend on the implantation technique. 48.21±13.6 years Mean age at operation (range) The original Bentall’s procedure employed an in situ (22-66 years) circumferential suture line around the coronary ostia, then Sex- Males 75 (53.5%) complete aortic wrap around to control bleeding. Tension Annulo-aortic ectasia 98 (70%) developing at the suture line of the side-to-side coronary Type A aortic dissection 41 (29.3%) anastomosis and/or blood accumulation within the space Repaired tetralogy of Fallot with aortic valvular 1 (0.7%) reconstruction artery dehiscence, pseudo-aneurysm formation and Moderate-to-severe aortic regurgitation 134 (95.7%) reoperationaround the 1, graft2. Hematoma conveyed in significant the space riskmay ofadditionally coronary Moderate mitral regurgitation 6 (4.3%) compress the graft or cause prosthetic valve dysfunction1-3. Left ventricular ejection fraction <0.40 103 (73.6%) Marfan’s syndrome 24 (17.1%) atrial appendage and subsequently adopted interposition Renal dysfunction 72 (51.4%) To avoid this complication, Cabrol used a fistula to the right Concomitant coronary artery bypass grafting 8 (5.7%) of graft thrombosis and persistent aorto-right atrial Operation timing Dacron4, 5conduits to the coronary ostia with the new risk Emergency 37 (26.4%) Elective 103 (73.6%) fistula . For these reasons, a modified open technique 111.8 ± 28.2 that basically eliminate the prosthetic wrap and allows Mean aortic cross-clamp time (range) reattachmenthas been developed of adequately by Kouchoukos mobilized and coronary associates buttons in 1986 to (89-186 minutes) 154 ± 28.8 the graft with tension free sutures1. Mean cardiopulmonary bypass time (range) (136-218 minutes) In-hospital mortality 7 (5%) complications after composite graft replacement of the Late death 3 (2.1%) ascendingDespite theaorta introduction have not of thesebeen technicaleliminated. modifications, Problems 19±7 days encountered with these techniques include bleeding from Mean hospital stay (range) (6-52 days, median the proximal conduit implant site and reattached coronary 9 days) Low cardiac output artery origins, suture line disruption, coronary artery 77 (55%) Yes distortion and late development of pseudoaneurysms . 63 (45%) No To address these concerns, we interposed a glutaraldehyde-6-14 Average postoperative drainage (12 hours) 242±60 ml treated autologous pericardial strip between the graft and native coronary ostia during coronary ostial implantation by a single surgeon (corresponding author) after obtaining informed consent and institutional ethics committee approval. sutures to ensure perfect haemostatic suture lines and Patients’ demographic details are shown in Table 1. publishedand placed our interlocking, initial experience interrupted, in 2017 pledgeted15-17. mattress Surgical Techniques The objective(s) of this retrospective study were to Intraoperative trans-esophageal echocardiography evaluate: i) the stability of the modified Bentall’s procedure or 5500 ultrasound system on all patients both before for reattachment of the coronary ostia in the fate of the (TEE) was performed with a Hewlett-Packard Sonos 1500 coronaryover time; anastomoses; ii) the influence iii) ofthe surgical occurrence technique of coronary adopted techniques were used throughout the study period. The ostial pseudo-aneurysms, aneurysm of the anastomotic site operationsand after weresurgery. performed Standard under anaesthetic moderately and hypothermic operative cardiopulmonary bypass (CPB) through arterial narrowingto the composite of the graft coronary and aneurysms ostia during of the follow-up, left main and trunk v) and right coronary artery, iv) the occurrence of kinking and and bicaval venous cannulation through the femoral vein andcannulation superior (axillary vena cava. artery n=28; femoral artery n=112) on the short and long-term results in composite aortic root replacement.the influence of technique of coronary artery implantation Patients and Methods wasA usedretrograde in all coronary patients. sinus Trans-atrial cannula withblind self-inflatable cannulation This study conforms to the principles outlined in balloon (RCO 14, Edwards Lifesciences, Irvine, CA, USA) wasof the cannulated coronary sinusthrough was a performedshort right inatriotomy 92 patients. under In the declaration of Helsinki. Between January 1998 and cases of difficult cannulation (n=48), the coronary sinus Bentall’sDecember operation 2019, 140 using consecutive the surgical patients techniques (80 males), described aged observing distension of the posterior inter-ventricular 22-66 years (mean 48.21±13.6 years) underwent modified direct vision. The proper placement was confirmed by Page 12 of 20 Chowdhury UK, George N, Singh S, Hasija S, Sankhyan LK, Sharma S, Pandey NN, Sengupta S, Kalaivani M. Fate of the Coronary Ostial and Distal Aortic Anastomoses after Journal of Surgery and Surgical Technology Modified Bentall’s Operation (UKC’s Modification). J Surg & Surgical Tech.2020;2(1):11-20 vein, maintenance of coronary sinus pressure, palpation of repeated every 20 minutes. Cardioplegic infusions by both the coronary sinus cannula