1.
|
What major operative
modifications of the original Bentall composite graft procedure are being used at Johns
Hopkins?
|
|
| We currently prefer to use the coronary button technique for virtually
all of our patients receiving a composite graft. Normally, the aortic buttons have a
diameter of 12 to 15 mm and we like to use an overlaying washer of Teflon felt to buttress
the suture line. We use 4-0 polypropylene suture for anastomosis of the coronary button to
the Dacron graft. We also use a narrow strip of Teflon felt to buttress the distal suture
line, which can be carried out either with 4-0 or 3-0 polypropylene suture. As Kouchoukos
first pointed out in 1986, it is important not to construct a blood-tight closure of the
residual aneurysm wall over the composite graft. With this modification of the original
Bentall procedure, the complication of coronary artery dehiscence has been virtually
eliminated. |
|
NEXT Question | TOP
of Page | FAQs HOME | CTSNet HOME
|
2.
|
What is the current role of
the valve-sparing procedure and also the role of the homograft aortic root for Marfan
patients?
|
|
| Although the valve-sparing procedures as popularized by Yacoub and
David appear to have wide application in non-Marfan aortic root aneurysms, most surgeons
performing aortic root replacement feel that Marfan disease is usually a contraindication
to the valve-sparing procedure. This is because of concern about further enlargement of
the aortic annulus in Marfan patients, and also recent findings by Fleischer, et al. from
Johns Hopkins showing moderate-to-marked degeneration of the microfibular structure of the
aortic valve; this microfibular fragmentation has been demonstrated using an
immunofluorescent staining technique for fibrillin in excised aortic leaflets from Marfan
patients. Although caution should be used at the pre sent time with regards to the
valve-sparing procedure in Marfan patients, it is encouraging that this same fibrillin
fragmentation is seen in mitral leaflets of Marfan patients, and yet, the long-term
results with mitral valve annuloplasty in these patients has been extremely good. At the
present time, surgeons at Johns Hopkins would consider the use of the valve-sparing
procedure for a young woman who would like to carry a pregnancy without the complicating
factor of Coumadin anticoagulation. Our use of homograft aortic root replacement of Marfan
aneurysms has been limited to children and very infrequently to young women who wish to
carry a successful pregnancy and for Marfan patients who have developed endocarditis of
their composite graft. |
| NEXT Question |
TOP of Page | FAQs HOME |
CTSNet HOME
|
3.
|
What about the role of
mitral valve surgery in Marfan patients undergoing aortic root replacement?
|
|
| In our experience, virtually all Marfan patients have prolapse of the
mitral valve and about 15% of the patients undergoing aortic root replacement have
required surgery on the mitral valve for regurgitation. Ordinarily, mitral annuloplasty
work s well for these individuals and it's been rare that mitral valve replacement has
been required. We have been very pleased with the excellent long-term results with mitral
annuloplasty in our Marfan patients. Certainly, any Marfan patient undergoing aortic root
replacement with 3+ MR should have mitral annuloplasty; in fact, at the present time, we
would recommend this procedure for patients with 2+ mitral regurgitation who are
undergoing a concomitant aortic root replacement. |
| NEXT Question |
TOP of Page | FAQs HOME |
CTSNet HOME
|
4.
|
What is the best way to
manage composite graft endocarditis?
|
|
| We have seen this problem in eight individuals among 218 Marfan
patients undergoing aortic root replacement. We did successfully treat one patient with
antibiotics alone, but found that reoperating with a second composite graft leads to
continuing endocarditis. It is therefore mandatory that if reoperation is done, a
homograft should be placed. We have had successful replacement of an infected composite
graft using a homograft in three patients. |
| NEXT Question |
TOP of Page | FAQs HOME |
CTSNet HOME
|
5.
|
What are the important
features of late follow-up of Marfan patients undergoing aortic root replacement?
|
|
| It is absolutely mandatory that these patients have an annual CT scan
for several years until it is demonstrated that their residual aorta is stable. For those
individuals who have aortic root replacement surgery with a Type I or Type A dissection,
they need serial CT scans on a regular basis for the rest of their lives. It is also
imperative that patients with a composite graft receive parenteral antibiotic coverage for
dental procedures, rather than oral antibiotics as recommended b y The American Heart
Association. |
| NEXT Question |
TOP of Page | FAQs HOME |
CTSNet HOME
|
6.
|
What is the current
thinking regarding the proper timing of aortic root replacement for Marfan patients?
|
|
| It has been the general feeling of Marfan surgeons that aortic root
replacement should be carried out when the aneurysm diameter reaches 6 cm. Frequently,
patients with this aortic diameter will be completely asymptomatic. With the
almost-routine use of the coronary button technique at Johns Hopkins, we are now
recommending prophylactic surgery when the aortic root reaches 5.5 cm. If there is a
history of dissection in the family, then we would recommend surgery when the root
diameter reaches 5 cm. Determining the proper time for aortic root replacement in children
with Marfan disease can be difficult. Each child has to be individualized; for example, a
nine-year-old child with a 4 cm aneurysm would certainly merit operative intervention.
Also, the rapidity of aortic root enlargement is a factor in determining when to operate
in children. |
| TOP of Page |
FAQs HOME | CTSNet HOME
|
Additional Adult Cardiac Surgery FAQs
|
|
|
|
