[HSF] Ao Wraping, One more question!

[Ajit Damle]

Thank you Igor, Michael, Prasanna, Hal, Ed and Manoj for your thoughtful
replies.

I do not know what to make of the diameter as a threshold for an operation.
Is it 4.0, as Igor recommends? In a 19 year old, who has plenty of time to
plot against us, my threshold would be lower still. But replacing the
ascending aorta without (or a brief) circulatory arrest is a different deal
than replacing the arch with a longer circ arrest. I must admit, though,
that I am astonished every time that patients wake up without a detectable
neurological deficit!

Part of the reason is the relative ease and absolute success rate of arch
replacements in low risk patients. I did lose a patient some years ago, who
I treated with a Cabrol shunt for coronary ostial implantation. I could not
prove it, but I do think that the shunt somehow (twisted or compressed)
induced coronary insufficiency. Since then,  I have switched to the Valsalva
graft and direct coronary implantation, and have been just giddy with
success.

I had never considered wrapping to be a serious option, but there was a
recent paper that showed external wrapping was a viable option, and that got
me thinking.

BTW, I have yet another aortic aneurysm coming up. 52 yr man, non-ischemic
cardiomyopathy, QRS 110 ms, EF 25-30%, NYHA II, PAP 55/20, new onset A.Fib.
MR 2+, AI 1+, tricuspid aortic valve, no coronary angiogram yet, Asc Ao 6.1
cms.(not arch, I think I can do him without, or a brief, circ arrest). My
plan is to replace the asc aorta, repair mitral, do a maze, excise the LA
appendage, and CABG if needed. I wonder if I should replace his aortic valve
as well, because he may be on coumadin anyway and, with his cardiomyopathy I
may not have the luxury to bring him back in 5-10 years.

What do you think? Too much an operation for this man? Should I replace his
aortic valve?

Ajit Damle
Fargo ND