[Surgical Correction of Dissecting Aneurysm of Ascending Aorta with Aortic Valvular Insufficiency] [Michael E. DeBakey, M.D., F.A.C.S.][Arthur C. Beall, Jr., M.D.] [From the Cora and Webb Mading Department of Surgery, Baylor University College of Medicine, Houston, Texas] [Illustrations: Edmond Stephenson] [Photography: Gene K. Davis] [Narrator:] Elastic tissue abnormalities in the blood vessels of patients with Marfan's disease predispose these patients to the formation of aneurysms. These aneurysms may be found in a variety of forms and locations, and dissecting processes involving the ascending aorta are not unusual. This 30-year-old man was admitted to the hospital with a history of severe substernal pain radiating through to the back and down into the lumbar region, one and a half years prior to admission. This was followed by transient numbness and weakness in the right leg, but these symptoms subsided spontaneously over the next several days. Three weeks prior to admission, he again experienced an episode of severe substernal pain with radiation to the back. Roentgenographic examination of the chest demonstrated enlargement of his ascending aorta. Examination revealed the patient to be six feet eight inches in height with long, slender hands, fingers, feet, and toes. In both legs there was wide separation between the anterior tibial tubercle and the inferior border of the patella, characteristic of Marfan's disease. No abnormalities were noted in either eye. The heart was slightly enlarged to percussion, and an early grade 2 decrescendo diastolic murmur was heard at the base with radiation toward the apex. The blood pressure was 120 over 60 millimeters of mercury in both arms, and all peripheral pulses were present and of a water hammer characteristic. Intravenous contrast visualization of the thoracic aorta demonstrated aneurysmal dilatation of almost the entire ascending portion. The transverse and descending portions of the thoracic aorta did not appear unusual. There was no roentgenographic evidence of a double density characteristic of a dissecting process. Under general endotracheal anesthesia, a median sternotomy incision was made. [...] The sternum was split with a Lebsche knife. [...] The pericardium was opened longitudinally. As the sternum was spread, the aneurysmal process was seen to extend from the aortic valve annulus to just proximal to the innominate artery. [...] This drawing illustrates the extent of aneurysmal involvement. [...] Cardiopulmonary bypass was instituted employing a disposable plastic oxygenator primed with five percent dextrose in distilled water under normothermic conditions. [...] The vena cavae were drained by gravity into the pump oxygenator, and a sump in the left ventricular apex allowed for a left heart decompression. Oxygenated blood was returned to the femoral artery through a roller pump, and cannulae were used to profuse the coronary arteries during the proximal anastomosis. Clamps were placed across the aorta between the aneurysm and the innominate artery. [...] The aorta was divided between the clamps. [...] The distal cut end of the aorta was freed up to the innominate artery and re-clamped. [...] A small septum representing the distal portion of the dissecting process was excised. A woven, crimped Dacron graft of the appropriate size was selected and anastomosed to the distal cut end of the aorta, employing an over-and-over suture of 3-0 linear polyethylene, as demonstrated in this drawing. While the distal anastomosis was performed, the coronary arteries were perfused through the aneurysm itself, from coronary sinus blood oxygenated by intermittent inflation of the lungs and by bronchial artery return to the left side of the heart. Over-distension of the left heart during the maneuver was prevented by intermittent decompression through the sump in the left ventricular apex. [...] Upon completion of the distal anastomosis, a vascular clamp was placed across the graft, and the integrity of the anastomosis was tested. The left ventricular sump was used to evacuate the aneurysm, and the aneurysm was entered. The double walls of the true and false lumen were seen with a tear in the inner wall, just above the aortic valve annulus. The cusps of the aortic valve were relatively normal. Aortic valvular insufficiency resulted from prolapse of the cusps into the ventricle, secondary to prolapse of their attachments to the inner wall. [...] This prolapse of the cusps in relation to their normal position is demonstrated in this illustration. [...] Coronary cannulae were inserted, and coronary perfusion was begun. [...] A major portion of the aneurysm was excised, leaving part of the outer wall for future support of the graft. [...] The graft was pulled down and cut to length. [...] The proximal anastomosis was begun posteriorly in such a manner as to pull the inner wall with its attachment to the aortic valve cusps back into normal position, during the performance of the anastomosis. [...] This anastomosis was also performed with an over-and-over suture of 3-0 linear polyethylene, incorporating both the inner and outer walls of the aorta, obliterating the false lumen as the prolapsed cusps were pulled back from within the ventricle. [...] As the anastomosis neared completion, the right coronary cannula was removed, but the left coronary cannula was left in place as long as possible. In this manner, excellent cardiac contractions were maintained. [...] Immediately prior to completion of the proximal anastomosis, the tourniquet on the superior vena cava was released and the left heart decompression was stopped temporarily to allow the heart to fill with blood. [...] Prior to tying this suture, the clamp on the distal aorta was released briefly in order to allow the graft to fill in a retrograde fashion, evacuating air from the graft. [...] Finally, the proximal anastomosis was completed, and the clamp was removed from the distal aorta. The sump in the left ventricular apex was used to evacuate any air remaining in the ventricle, following which it was removed. [...] The completed operation is demonstrated in this drawing with a graft extending from the aortic valve annulus to the level of the innominate artery. The outer wall of the aneurysm was cut to size. The proximal anastomosis was wrapped with surgical hemostatic gauze, and the remaining portion of the outer wall of the aneurysm was used to further support the graft. The sternum was closed with interrupted wire sutures. The chest was closed in layers. The patient's course following operation was uneventful. [...] Retrograde contrast visualization of the thoracic aorta was performed two weeks following operation and demonstrated satisfactory function of the graft without evidence of aortic valvular insufficiency. The patient was discharged three days later with a blood pressure of 120 over 75 millimeters of mercury in both arms, and has remained asymptomatic. [The End][Produced by Biological Film Center, The Methodist Hospital, Houston, Texas]