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Personalized External Aortic Root Support (PEARS)

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posted on 2022-04-26, 14:12 authored by Adam El-Gamel, Conal Austin


The patient is a twenty-one-year-old man with Marfan syndrome and a strong family history of type A aortic dissection. This personalized external aortic root support (PEARS) operation is approached through a sternotomy but can also be approached through minimally invasive incisions. 

To start, the pericardium is opened, and the aorta is fully exposed to the level of the innominate artery. Then comes the circumferential dissection to clear the aorta from its surroundings. With the aneurysm, during the dissection it is very important to control the hypertension with systolic blood pressure. It should not be above 80, and the means of pressure should be in the 50s. This reduces the chance of trauma to the aneurysm or the choreography of the aorta. 

Next, the aneurysm is exposed, and dissection is continued circumferentially to clear the aneurysm from the surrounding structure. Then, dissection of the pulmonary artery from the aortic root and the aneurysm is performed. This is an important step to expose all the required area. It’s important to check the graft to check the orientation of the coronary arteries and the shape of the aneurysm. Also, one must check the distance between the coronary artery orifices and the annulus while dissection continues. Next, the aortic annulus, the left atrial wall, and the right outflow tract are gently isolated from the root aneurysm. Dissection continues gently with a low-energy Bovie and blunt dissection. 

The most important step is isolating the left main coronary artery with a gentle yet blunt dissection as well as sharp dissection. The origin of the left main will start to show. 

After this, dissection continues to clear the aneurysm to the level of the annulus below the left nine, which is where a tongue of the graft is going to go. Now the most important part of dissection is going around the left main and ensuring clearance of tissue to make the positioning of the tongue of the graft and sliding around the root as easy as possible. The left main is isolated with no tissue behind it. A tip here is to prepare the graft, creating enough space for the coronary buttons by resecting some of the graph tissue to make the opening wide enough for the left and right main coronary arteries. Their position is predetermined on the customized graft. The graft is trimmed, unraveled, and opened in preparation for wrapping. After the graft is opened, its tongues will drop below the coronaries that are created by cutting the graph circumferentially after marking it to allow the graft to lie above and below the right and left main coronary arteries surrounding the root from the annulus. 

The graph is well lubricated with pure paraffin oil or K-Y jelly to allow smooth, nonobstructive, gentle passage behind the aorta. Extreme gentleness, especially if the tissues are weak, is needed to ensure the passage of the tongues below the coronaries without injury. The rest of the graft is gently passed around the aorta, making sure to avoid twisting. The inferior tongue is also gently brought back around the root and adjusted in position. Then the anterior tongue is passed behind the right coronary artery, which is a little bit more delicate and fragile than the left. With the lubrication, the tongue is easily passed below the right coronary artery once the graft is orientated appropriately. The process continues gently to close all the gaps and make sure the needle is not inserted into the aortic tissue or the adventitia. 

The process is continued until the innominate artery is reached. A second continuous suture line can be applied to tighten the graft around the aorta. The process is now complete.  



1. Nienaber CA, Yuan X, Ernst S. Pears procedure and the difficulty to provide evidence for its benefits. Eur Heart J 2020;41(42):4086-4088.

2. Treasure T, Takkenberg JJ, Golesworthy T et al. Personalised external aortic root support (pears) in marfan syndrome: Analysis of 1-9 year outcomes by intention-to-treat in a cohort of the first 30 consecutive patients to receive a novel tissue and valve-conserving procedure, compared with the published results of aortic root replacement. Heart 2014;100(12):969-975.


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