CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 1, January/February 2014
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AFRICA
(300 units/kg). The femoral artery and two-stage venous cannulae
were placed. The ascending aorta was pulled slightly proximally
and, after the innominate artery was rotated and pended, it was
explored. The diameter was approximately 11 mm. After the
innominate artery was rotated with plastic tape, a purse suture
was placed in it, and it was cannulated. The femoral arterial line
was connected to the innominate arterial line (cerebral line) with
the use of a Y-shaped connector, and cardiopulmonary bypass
was initiated.
The vent tube was inserted into the left ventricle via the right
upper pulmonary vein. Myocardial protection was provided by
systemic hypothermia at 30°C with antegrade administration
of cardioplegia solution, and then by cold retrograde blood
perfusion. After the pump flow rate was decreased to 10 ml/kg/
min, the femoral arterial line and proximal innominate artery
were clamped. Then the femoral artery cardiopulmonary bypass
was stopped and antegrade cerebral perfusion was provided
using only the innominate artery cannula.
Following this, a vertical incision was made in the aneurysm
for an open aortic technique. The dilated ascending aorta was
excised. A marked mural thrombus was present in the false
lumen of the ascending aorta but the dissection did not extend
to the coronary ostium (Fig. 3). A 30-mm tubular woven Dacron
prosthesis (UB Shield GraftTM, Ube Medical Co. Ltd., Tokyo,
Japan) was anastomosed, using 3-0 polypropylene and the open
anastomosis technique, to the distal ascending aorta.
After the distal stump was reinforced with a strip of
polytetrafluoroethylene (ePTFE) felt on the outside of the
aorta, a cross clamp was placed on the ascending aortic graft.
Cardiopulmonary bypass was started with a normal flow rate
using only the femoral artery, and the cannula in the innominate
artery was removed.
Later, the aortic valve was excised and an aortic valve
replacement was performed with a number 21 mechanical
aortic valve. The ascending aortic graft was sutured to the
proximal aorta. The aortic wall layers in the proximal stump
were reinforced with 3-0 polypropylene, using a mattress-suture
technique, with two expanded ePTFE felt strips, one on each side
of the aorta. Thus, the procedures of a tubular ascending aortic
graft and separated aortic valve replacement were completed
(Fig. 4).
De-airing of the left heart was carried out via the aortic
root catheter, followed by declamping of the graft, and the
patient was re-warmed. The heart spontaneously resumed
beating into ventricular fibrillation, underwent cardioversion
into a slow rhythm, and was then paced. About five minutes
after declamping the aorta, the haemodynamics stabilised with
good left ventricular contraction. During re-warming, a double
coronary artery bypass to the right coronary artery (with
saphenous vein) and the left coronary artery (with LIMA) was
performed on the beating heart with a 6-0 and 7-0 running
polypropylene suture. Then the saphenous vein was anastomosed
to the right coronary artery with a side clamp, which was sutured
to the ascending aortic graft. CPB was withdrawn uneventfully.
Fig. 1.
Computed sequential tomographic images of a
66-year-old man diagnosed with acute type II aortic
dissection three years previously. CT-scan illustrated
dissection of the ascending aorta, dilatation of the
ascending aorta and circulation in both the true (T)
and false (F) lumens.
Fig. 2.
Intra-operative view of the chronic dissecting, ascend-
ing aortic aneurysm. The ascending aorta dilated to
10 cm in diameter.
