How to Perform PEARS: A Comprehensive Guide to Personalized External Aortic Root Support

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This instructional guide presents a comprehensive overview of the personalized external aortic root support (PEARS) procedure. The purpose is to provide cardiac surgeons and trainees with a detailed resource covering case selection, preoperative planning, technical steps, and intraoperative considerations for this patient-specific approach to aortic root preservation. 
 
Case Presentation 

The case discussed involved a 50-year-old female with a 48 mm ascending aortic aneurysm and a bicuspid aortic valve, without evidence of aortic regurgitation. Considering the risk of further aortic dilation, the presence of underlying valve pathology, and the patient’s wish for early intervention, surgical stabilization of the aortic root and ascending aorta was planned. The PEARS procedure was chosen to address these objectives. 

PEARS Prosthesis Concept and Preoperative Planning 

Preoperative contrast-enhanced computed tomography (CT) imaging was utilized to construct a three-dimensional (3D) printed model of the patient’s ascending aorta. On this model, a customized PEARS mesh prosthesis was manufactured, tailored to 95 percent of the aortic inner diameter in diastole. This customization ensured an optimal fit. When implanted, the mesh supported the aortic wall, prevented further dilation, and gradually became incorporated into the adventitia, ultimately leading to aortic wall remodeling and thickening for enhanced long-term stability (1). 
 
Advantages of the PEARS Procedure 

The PEARS technique offers stabilization of the ascending aorta without the necessity for aortic opening, replacement, cardiopulmonary bypass, or aortic cross-clamping (2). However, as a precaution, the heart-lung machine must be fully primed, with a perfusionist present in the operating room to enable immediate initiation of bypass if required. 

Surgical Technique Overview 

The essential steps of the PEARS procedure include the exposure of the aorta and coronary arteries to achieve operative access and mobilization of relevant structures. The preparation of the prosthesis involved finalizing the customized mesh for implantation. During the procedure, the accurate placement of the mesh prosthesis around the aorta was critical. Following this, the closure of the prosthesis secured it to achieve stable support. Finally, there was an evaluation of the coronary arteries to assess coronary patency and the final position of the prosthesis.  

Conclusion 

This guide illustrates the PEARS procedure as an innovative, patient-tailored method for aortic root stabilization, with emphasis on case selection, preoperative planning, and a standardized stepwise surgical approach to optimize patient outcomes. 

References

1. Treasure T, Pepper J. Personalised External Aortic Root Support (PEARS) Compared with Alternatives for People with Life-Threatening Genetically Determined Aneurysms of the Aortic Root. Dis Basel Switz. 2015;3(1):2-14. doi:10.3390/diseases3010002
2. Golesworthy T, Lampérth M, Mohiaddin R, Pepper J, Thornton W, Treasure T. The Tailor of Gloucester: a jacket for the Marfan’s aorta. Lancet Lond Engl. 2004;364(9445):1582. doi:10.1016/S0140-6736(04)17308-X

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