Management of Contained Rupture of Wrapped Ascending Aorta: Redo Sternotomy, Replacement of Aortic Valve, and Ascending Aorta

Patient Selection

The standard method of treatment for an ascending aorta aneurysm is replacement with the Dacron tube graft. However, some surgeons use alternative techniques in selected cases for dilated ascending aorta, such as wrap without aortoplasty (1, 2), wrapping of the ascending aorta with a fine transparent and stretchable Dacron mesh (3), manually pre-prepared prosthesis which respects the shape of the aorta (4), and reduction aortoplasty with wrapping (5, 6). The Dacron sleeve is another wrapping technique without division of the Dacron tube graft - the original circumference of the Dacron tube graft remains intact, therefore the strength and contour of the Dacron tube graft does not alter (7).

The biomechanical analysis of wrapping the moderately dilated ascending aorta, using the finite elements method, suggested that after a wrapping procedure, the aortic wall is subject to similar stress that occurs in the normal aorta and lower stress than in the nonwrapped moderately dilated aorta (8). In one study, no late aortic complications were detected in the follow-up (median 71.1 months) of the wrapping of the moderately dilated ascending aorta that had aortic valve replacement for bicuspid aortic stenosis (9).

However, splitting and suturing the Dacron tube graft loses its maximum elasticity that was at 45 degrees between the longitudinal and transverse threads (10). This could lead to the thinning and atrophy of the aortic wall (11). The case report of two patients demonstrated that the aortic wall underlying the reinforcement cuff was extremely atrophic, and normal aortic layers lost their existence. Aortic residual showed typical cellular and neovascular infiltration and a foreign body reaction (11). Late rupture after Dacron wrapping of aortic aneurysms was also reported in 1986 (12). Aortic wrap may cause erosion of the aortic wall due to dislocation of the wrap (13, 14) and even showed that the graft had completely eroded and replaced some areas of the aorta (15).

The patient in this video was a 49-year-old man who was first diagnosed with an aortic valve regurgitation with dilated ascending aorta at the age of 19. He remained under surveillance by a cardiologist, however he continued manual and heavy work. He was referred for his first operation when he was 39 years old. Perioperative transesophageal echocardiogram confirmed a severely incompetent aortic valve with a marginally enlarged left ventricle with good contractility. The ascending aorta was 48 mm with sinuses diameter of 45 mm. The aortic valve was tricuspid with fusion of the right and noncoronary cusps. There was some calcification on the tip of all leaflets and on each commissural level. The valve was excised and a 29 mm Mosaic bioprosthetic aortic valve was implanted. The dilated ascending aorta was wrapped with a 36 mm Dacron graft.

He remained well for following nine years after his first operation, then he developed symptoms of dizziness that generally lasted only for few seconds. His ECG confirmed heart block, therefore a permanent pacemaker was implanted that improved his dizziness. He underwent further investigations:

• Aortogram (Figure 1): indicate contained rupture.
• CT aorta (Figure 2): Dissection and infolding of the wrapped Ascending aorta. Proximal aortic arch measures about 42mm and mid arch 30 mm.
• CT aorta (Figure 3): Ascending aorta measures about 59mm at the level of the right pulmonary artery.
• CT-coronary angiogram (Figure 4): mid LAD plaques with severe stenosis. CT FFR was < 0.50 in the LAD beyond the stenosis. Other coronary arteries were normal.

He remained completely asymptomatic after getting his pacemaker. He was a current smoker for the last 30 years, using 30 cigarettes a day, otherwise there was no significant comorbidity. He was offered the redo operation, which he accepted. However, based on his clinical stability, the authors agreed to delay his operation, awaiting the resolution of the COVID-19 pandemic. Later, he was admitted one day before the operation as planned.

He underwent redo sternotomy, redo aortic valve replacement with Inspiris Resilia bioprosthetic aortic valve, size 27 (patient preference), and replacement of the ascending aorta with interposition Dacron tube graft 30 mm, plus one coronary artery bypass graft (saphenous vein grafted to LAD).

Operative Findings

The ascending aorta was severely dilated and pushed below the right hemi-sternum and firmly attached to the right atrium and superior vena cava. A contained rupture of wrapped ascending aorta is observed parallel to the native aorta contained by the pulmonary artery and the left atrial roof. Cumulative bypass time was 219 minutes, and cumulative cross clamp time was 165 minutes. His postoperative period was smooth and uneventful. He was discharged on the sixth postoperative day with very good recovery.