Aortic Root & Ascending Aortic

Aneurysm
Mustafa kamal
 Objective
• Residents will be able to:

– Understand the anatomy of Aortic root and

ascending aorta
– Pathophysiology of AAA
– Enlist causes of AAA
– Surgical options for AAA repair
– Steps of operation
 OUTLINE
• Anatomy of Aortic Root and Ascending Aorta
• Aortic Root & Ascending Aorta Aneurysm
• Management Plan
• Surgical options
 History
• Thoracic Aortic Aneurysms described in late
1500s
• First reported Ascending Aorta replacement:
– in 1956 by DeBakey & Cooley
 Anatomy of Aortic Root

Aortic Root is in the middle of the heart

Surrounded by everything else
Anatomy of Aortic Root
Anatomy of Aortic Root
Anatomy of Aortic Root
Anatomy of Aortic Root

3.5 cm
3 cm

3.5 cm
3 cm
Anatomy of Aortic Root

5 cm Length

0.2 cm Length
 Anatomy of Aortic Root
• Sino-tubular junction diameter is 20% less
than Aortic annular diameter.
 Anatomy of Aortic Root
If STJ involved in aneurysm  Aortic Valve
Insufficiency
 Aortic Aneurysm
Permanent localized dilation > 150% diameter of the normal caliber
Aortic Aneurysm
Ascending Aortic Aneurysm
Ascending Aortic Aneurysm
Ascending Aortic Aneurysm
Ascending Aortic Aneurysm
Ascending Pseudo aneurysm
Ascending Aortic Aneurysm
 Ascending Aortic Aneurysm
Why aortic wall become weak?

Imbalance between elastin/collagen deposition

Vs
Degradation of elastin/Collagen by Proteases
Ascending Aortic Aneurysm
Pathophysiology
Ascending Aortic Aneurysm
Pathophysiology
Also Mechanical mechanisms involved !
Ascending Aortic Aneurysm
Natural History
AAA is TIME BOMB in chest
 Ascending Aortic Aneurysm
Natural History:
- Aortic Dissection
- Aortic Rupture
- Death
 Ascending Aortic Aneurysm
Etiologies
- Connective tissue disorders
- Marfan Syndrome
- Ehler Danlos syndrome
- Familial Thoracic Aortic Aneurysms
 Ascending Aortic Aneurysm
Etiologies
- Infectious & Inflammatory
- Bicuspid Aortopathy
 Clinical presentation
• Asymptomatic
• Incidental finding on CXR & ECHO
• Anterior chest pain
– Acute (Impending rupture)
– Chronic (compression of sternum)
• Hoarseness of voice
• High output cardiac failure
• ER  Unstable condition
 Clinical presentation
• Mean time from onset of symptoms to
rupture is  2 years
• Independent risk factors for rupture  Aortic
diameter, pain ,Age , COPD and smoking
Diagnosis
Diagnosis
 Diagnosis
• ECHO
 Diagnosis
• ECHO
 Diagnosis
• CT Aortogram:
– Most widely used modality
– Differentiate between Aneurysm, dissection and
intramural hematoma .
Diagnosis
Diagnosis
Diagnosis
Diagnosis
Diagnosis
Diagnosis
When to operate ?
 Indication for Intervention

Risk of Rupture & Dissection Operative Mortality

Permanent Neurological deficit
Indication for Intervention

Treat Numbers not patient !

 Indication for Intervention
Indication for intervention:
AA > 5.5cm
Undergoing CABG or AVR  4.5 cm
Connective tissue disorder  4-5 cm
 Indication for Intervention
Symptoms
Rapid Rate of Expansion
Recurrent Emboli
 Approach
- Elective Repair
- Immediate Repair
- Active surveillance
 Immediate Surgery
• Acute dissection
• Rupture
• Acute intramural hematoma
• Acute severe congestive heart failure
• Chest pain & aneurysm > 4.5 cm
Surgical Management

Decided to operate !
 Surgical Management
Location of Aneurysm
Extent of Aneurysm
Aortic valve status
Aortic Root involvement
Coronary Anatomy
 Surgical Management
Valve sparing Aortic Root Replacement

Dr Tiron David Dr Magdi Yaqoub

Valve sparing Aortic Root Replacement

• Yaquob remodeling Procedure

– Excision of ascending aorta till STJ
– Excision of sinuses of valsava up till annulus
– Three Commisural pillars are left intact
– Coronaries are mobilized
– Annular dilation is not addressed
– Not preferred in connective tissue disorder or
annular size > 30mm
Valve sparing Aortic Root Replacement
• Yaquob remodeling Procedure
Valve sparing Aortic Root Replacement
• Yaquob remodeling Procedure
Valve sparing Aortic Root Replacement
• Yaquob remodeling Procedure
Valve sparing Aortic Root Replacement
• Yaquob remodeling Procedure
Valve sparing Aortic Root Replacement
• Yaquob remodeling Procedure
Valve sparing Aortic Root Replacement

• David replantation Procedure

– Excision of ascending aorta till STJ
– Excision of sinus of valsalva up till annular ring
– Three Commisural pillars are left intact
– Coronaries are mobilized
– Annular dilation is addressed
– Preferred in connective tissue disorder or annular
size > 30mm
Valve sparing Aortic Root Replacement

• David replantation Procedure

Valve sparing Aortic Root Replacement

• David replantation Procedure

Valve sparing Aortic Root Replacement

• David replantation Procedure

Valve sparing Aortic Root Replacement

• David replantation Procedure

Valve sparing Aortic Root Replacement

• Repair of prolapsing Aortic valve

Valve sparing Aortic Root Replacement
Remodeling procedure with external ring aortic annuloplasty
Valve sparing Aortic Root Replacement
Valve sparing Aortic Root Replacement
Valve sparing Aortic Root Replacement
Valve sparing Aortic Root Replacement
Valve sparing Aortic Root Replacement

• David replantation Procedure video

 Aortic Root Replacement with Valve

• When Aortic valve is diseased ie severe

stenosis and cant be spared.

• Classic Bentall Procedure

• Modified Bentall procedure
Aortic Root Replacement with Valve
 Aortic Root Replacement with Valve

Modified Bentall procedure

 Aortic Root Replacement with Valve

Modified Bentall procedure

Piehler method

(Piehler method
 Aortic Root Replacement with Valve

Modified Bentall procedure video

 Aortic Root Replacement with Valve

Classical Bentall procedure

Aortic Root Replacement with Valve
Keep length of tube graft short , as it lengthens with time !
 Ascending Aorta Replacement

Classical Bentall procedure

 Aortic Root Replacement with Valve
Cabrol Procedure :
- Tension free coronary button reimplantation
- Prosthetic interposition grafts
Homograft Aortic Root replacement:
- in aortic root abscess
Ross Procedure:
- Aortic root is replaced with pulmonary trunk
- Pulmonary trunk is replaced by pulmonary
homograft
 Ascending Aorta Aneurysm

Ascending Aorta :
Sinotubular junction to Innominate Artery
 Ascending Aorta Replacement

Interposition Graft: Dacron

 Ascending Aorta Replacement

Reduction Aortoplasty:
- Aorta incised along its greater curve
- with or without excision of aortic wall
- two layered everting overlapping closure
Ascending Aorta Replacement
 Ascending Aorta Replacement

Supporting Aortoplasty:
- Dacron or prolene mesh is wrapped
around the aorta
 THANKYOU

• 83 years old Egyptian -British cardiothoracic surgeon

• Professor of Cardiothoracic Surgery at Imperial College London.
• The first surgeon to perform a heart and lung transplant in the UK
• Longest surviving heart transplant recipient , survived for more than 33
years .. WORLD RECORD !
• Yaqoub procedure , switch procedure ,heart transplant