Aortic root replacement in type A dissection

We read the article by Ergin et al. [1] with great interest. They used Cabrol modification of the Bentall procedure in eight out of 19 patients who underwent radical aortic root replacement for acute type A dissection, that is, the coronary orifices were dissected out as buttons with surrounding aortic tissue prior to end-toend anastomosis to the ‘Cabrol’ graft, and the mattress fixation sutures for the composite graft were placed from outside the perimeter of the root through the annulus. We have also used this same technique in six patients over the past 2 years. Two patient had annuloaortic ectasia (AAE) due to cystic medial necrosis. Five patients were operated on emergently for acute type A dissection and the remaining one for chronic dissecting aneurysm with severely calcified aortic root. There were four male and two female patients, aged between 49 and 78 years with a mean of 65 years. They all had moderate to severe degrees of aortic regurgitation and one patient had a bicuspid aortic valve. The aortic conduit was made of a Haemashield woven Dacron prosthesis and a bileaflet disc valve. The average conduit size was 23.7 mm (range 23–25 mm). A 8 mm sized Haemashield graft was used for coronary reconstruction. Of the six patients with such aortic root reconstructions, five required concomitant partial or total aortic arch repairs. All but one patient survived operations and discharged from the hospital in good condition. One patient having a history of mitral valve replacement 5 years ago died 3 months after the operation of sepsis derived from mediastinitis. No patient had complications related to hemorrhage from proximal suture line or undue tension on the coronary anastomosis. Despite recent advances in surgical technique for type A dissection [2–5], there are still some problems remain unsolved in the aortic root reconstruction for such patients, who had lowlying coronary artery ostia involved by dissection to a large extent and severe degree of aortic insufficiency beyond valve plasty procedure. A major complication in patients with the aortic root reconstruction is bleeding from the proximal suture line and coronary anastomosis. The procedure employed by Ergin and us include proximal transection of the aorta just above the valve commissures and excision of coronary buttons to allow for accurate and full thickness suturing of the aortic wall. This technique is very useful for the approximation of dissected wall of the coronary button involved by aortic dissection. Consequently, the procedure leaves ample space between the coronary button and the fragile aortic annulus, thereby, deep mattress sutures can be passed through easily from outside the aorta to inside the aortic annulus, leading to secure fixation of the aortic conduit with no strain on the coronary ostia (Fig. 1). This procedure has the advantage of technical ease in the coronary artery reconstruction and prevents clinically significant hemorrhage, thus making the wrapping procedure unnecessary. We believe that our technique will prove to be helpful especially for patient with acute * Corresponding author. Tel.: +81 992 755368; fax: +81 992 685711.