Acute Aortic Disease.. - Index of

258 Elefteriades and Griepp
Figure 6 The three common patterns of chronic ascending aortic aneurysm: supracoronary,
annuloaortic ectasia, and tubular. Supracoronary aneurysms are adequately addressed
by a supracoronary tube graft. Annuloaortic ectasia requires composite graft replacement
(or valve-sparing root replacement). Tubular lesions can be treated either by tube graft or
composite graft, usually depending of the patient’s age.
applied in the case of frank annulo-aortic ectasia. For the intermediate condition
of tubular enlargement of the ascending aortic and aortic root, either tube grafting
or composite graft replacement may be applied. In a younger patient, we would
favor composite grafting, whereas in an older individual, we would consider that
a supracoronary tube graft would suffice. The relatively new valve-sparing
techniques for root replacement developed by David et al. (20) and by Yacoub et
al. (21) are just beginning to be applied to acute type A dissection. It is too early
to speculate on the appropriate role of these operations in this condition.
Management of the Aortic Valve
In most cases the aortic valve can be left alone, or the commissures can be resuspended.
Only if the aortic insufficiency is 3+ or more does the operation need
to be prolonged by concomitant aortic valve replacement. Intraoperative transesophageal
echocardiography provides an accurate assessment of the severity of
the aortic insufficiency before initiation of cardiopulmonary bypass. The severity
of aortic insufficiency usually improves even from simple tube graft replacement
of the aorta, which brings the aortic valve leaflets closer to coaptation.
Open or Closed Distal Anastomosis?
An open distal anastomosis is preferable for the technical reasons stipulated previously.
There appears to be a near consensus on this point at experienced aortic
centers. The required brief period of circulatory arrest is uniformly well tolerated.
Does the Arch Need to Be Resected in a Typical
Type A Aortic Dissection?
In the vast majority of acute type A aortic dissections, the intimal tear is located
circumferentially above and lateral to the right coronary artery. While the