[HSF] Bicuspid aortic valve and dilated ascending aorta

[Mark Levinson]

On Apr 30, 2007, at 6:11 PM, David Harris wrote:

> Another indication, I have found, in borderline cases
> is a thin aorta, which will often give you problems
> with closure. If I see I am possibly going to have
> problems closing the aortotomy, or on the rare
> occasion where there is inadequate hemostasis, I will
> replace the ascending. This does not add much more
> time to the procedure, but there is obviously the
> increased risk of infection.
>
> Having worked in a teaching hospital for a while, I
> have seen disasters where surgeons could not close the
> aortotomy nicely, (in dilated aortas), got it closed
> eventually, only to have the patient bleed to death
> later.
>
> Dave Harris
>


Dave:

You echo my sentiments exactly.   Beware of the bicuspid
AVR with thin walled ascending aorta.     These can rupture
in the ICU even if their diameter is normal.

In my practice, if the aorta is dilated above the valve, I will
perform an excision, usually a wedge excision as described
by Hartzell Schaff.     I mobilize the head vessels and the heart,
removed the thin walled greater curve of teh supra-coronary
aorta, and then do a primary end to end anastomosis.   This
is a safe repair, and here is no prosthetic graft in the aorta.

If the aorta is thin, but not dilated, I will sometimes wrap
the aorta externally with bovine pericardial material and tack
the gusset both proximally and distally.

I always close my aortas in two layers (underlying horizontal mattress
and overlying running 5-0).   This has also helped me reduce the  
tendency for
suture line disruptions.

Mark

Mark M. Levinson, MD
Founder, Editor-in-Chief,
The Heart Surgery Forum
WWW: <http://www.hsforum.com>
Email: <mmLevinson at hsforum.com>