Aortic root reinforcement using the Florida sleeve technique in a patient with acute aortic dissection type A

A 60-year-old woman was admitted with acute intensifying pain in the neck radiating to the chest. Coronary angiograms showed proximal occlusion of the LAD; the right coronary artery was not visible. Her echocardiogram showed a dilated ascending aorta with a dissection flap, moderate insufficiency of the bicuspid aortic valve, and hemopericardial tamponade with a reduced left ventricular ejection fraction of 35%. Computer tomography scans showed an ascending aortic aneurysm with an AAD. The proximal tear began near the noncoronary cusp and extended all the way down to the origin of the brachiocephalic artery. The patient was hemodynamically unstable, required vasoactive drugs, and was urgently transported to the operating room.

When the pericardium was partially opened, a large hemorrhagic pericardial effusion was aspirated. A standard arterial cannula with a curved tip (22 Fr; Medtronic, Minneapolis, MN, USA) was inserted in the non-dissected brachiocephalic trunk, and a two-stage venous cannula (32/40 Fr; Medtronic) was placed in the right atrium. Cardiopulmonary bypass (CPB) was established and systemic hypothermia was started. The retrograde cold crystalloid cardioplegia Custodiol (Dr. F. Köhler Chemie GmbH, Bensheim, Germany) was administered directly in the coronary sinus. The left ventricular vent was placed through the right superior pulmonary vein and the aorta was cross-clamped.

An aortotomy was performed, and fresh thrombus was evacuated from the false lumen in the aortic root. Dissection flaps were extended into the noncoronary and right coronary sinuses. The aorta was transected 5 mm above the sinotubular junction, and the bicuspid aortic valve (Sievers type I) was identified. When the aortic valve was excised, the root was completely detached, and proximal portions of the coronary arteries were mobilized. Once the patient reached the target temperature (26°C), circulatory arrest was initiated. For cerebral protection during circulatory arrest, we used selective anterior bidirectional cerebral perfusion. The clamp was removed from the aorta, the brachiocephalic trunk was clamped, and Foley catheters were inserted inside the left common carotid artery and the left subclavian artery. Cerebral oximetry and right radial pressure were monitored throughout the period of systemic circulatory arrest. The aorta was transected a few centimeters proximal to the origins of the branch vessels. Hemiarch replacement with the vascular prosthesis Polythese IC 28 mm (Perouse Medical, Ivry Le Temple, France) with Prolene 4-0 sutures (Ethicon Inc., Bridgewater, NJ, USA) was performed using the sandwich technique according to a standard protocol. We used BioGlue Surgical Adhesive (CryoLife, Kennesaw, GA, USA) to render the anastomotic repair site hemostatic. The clamp was removed from the brachiocephalic artery, the vascular prosthesis was cross-clamped, CPB was renewed, and rewarming was begun.

When the root was completely mobilized, we placed 13 single sutures with Teflon pledgets through the aortic annulus. We then placed 5 subannular 2/0 nonabsorbable braided sutures (e.g., Ethibond, Ethicon Inc.) with Teflon pledgets inside out horizontally below the aortic annulus in a circumferential pattern and brought them out through the left ventricular outflow tract, considering the geometric configurations of the aortic annulus. 

Two of the sutures were placed at the midpoint of the left and right coronary arteries on the sides of the pseudocommissure, and 3 stitches were placed symmetrically under the noncoronary cusp (Figures 1, 2). These sutures are typically used to fix the graft to the left ventricular outflow tract and are not considered to be hemostatic.

The mechanical aortic valve prosthesis (Medtronic, size 21) was implanted, and the graft was placed as a sleeve over the aortic root. A linear collagen-impregnated vascular prosthesis Polythese IC 28 mm was prepared according to the diameter of the aortic annulus. It is well known that the normal ratio of the diameter of the sinotubular junction to that of the aortic annulus should be approximately 1.20 [2]. In our case, the sinuses of Valsalva and the aortic annulus were not dilated (the diameter of the aortic annulus was 21 mm). According to this ratio, we were able to choose a graft from 26 to 30 mm. However, the final diameter of the graft in the case of the dissected aortic root can be determined after the aortic root is mobilized and the thrombus is removed, especially with a bicuspid aortic valve. The positions of the coronary arteries were marked on the graft, and 2 vertical grooves were cut to those marks. The main goal is to avoid any constriction or distortion of the coronary arteries. The length and width of the grooves correspond to the estimated distance from the aortoventricular junction to the top of each coronary artery and their respective external diameters. In our experience, the length is usually approximately 1.5 cm and the width is about 0.7 to 1.0 cm, but these dimensions may vary. 

It was also noted that the coronary grooves were not closed under the coronary arteries to prevent constriction of their proximal parts. Then the ascending aortic graft was anastomosed end to end to the reconstructed proximal aorta and was covered with BioGlue (CryoLife). De-airing was performed, the aortic clamp was removed, and the patient was successfully weaned from CPB.

The aortic cross-clamp time, circulatory arrest time, CPB time, and total surgical time were 140, 29, 197 and 315 minutes, respectively. The patient was extubated after 24 hours. Chest tubes were removed on postoperative day 2. An echocardiogram showed a left ventricular ejection fraction of 52% and a mean gradient of the AV mechanical prosthesis of 9 mm Hg. The postoperative CT scans demonstrated good results for the reconstruction despite a slight kinking of the intergraft anastomosis that was hemodynamically nonsignificant. The postoperative period was uneventful, and the patient was discharged home on postoperative day 14.