Redo Aortic Root and Total Arch Replacement for a Giant Ascending and Arch Aneurysm After a Previous Double Mechanical Valve Replacement

Redo replacement of the ascending aorta and aortic arch after previous double mechanical valve replacement is rare and technically challenging. Surgical re-entry is particularly hazardous in the presence of giant aneurysms because dense adhesions, distorted mediastinal anatomy, and prosthetic valves increase the risks of complications. We report the successful management of a giant compressive aneurysm using a staged strategy incorporating pre-sternotomy left ventricular (LV) apical decompression. A 63-year-old man with previous mitral commissurotomy and double mechanical mitral-aortic valve replacement presented with progressive dysphagia and severe dyspnea. Computed tomography revealed a giant ascending and arch aortic aneurysm (117 × 116 mm) causing marked tracheoesophageal compression. Given the high risk associated with redo sternotomy, a staged surgical strategy incorporating pre-sternotomy LV apical decompression through a left anterolateral thoracotomy, systemic cooling, and selective antegrade cerebral perfusion was employed. Redo aortic root and total arch replacement was successfully performed with a 24-mm quadrifurcated graft and reimplantation of the supra-aortic trunks and coronary buttons. Despite a complicated postoperative course, the patient recovered fully, and four-month follow-up imaging confirmed graft integrity and resolution of compressive symptoms. This case demonstrates that giant ascending and arch aneurysms occurring after previous double mechanical valve replacement can be successfully managed using a carefully staged reoperative strategy. Pre-sternotomy LV apical decompression may represent a valuable adjunct for safe re-entry in selected patients with large sternal-adherent aneurysms.