Left Coronary Artery Anastomosis Pseudoaneurysm After Classic Bentall Procedure

A 69-year-old male underwent a classic Bentall procedure for ascending aortic aneurysm at an outside institution. The patient had done reasonably well until 7 years later when he was admitted to an outside hospital with 2 weeks of fatigue and an episode of exertional dyspnea. Chest computed tomography angiogram revealed a large aortic root pseudoaneurysm at the left main coronary artery with pericardial hematoma (Figure 1). The patient was transferred to our institution for further workup. Aortography performed at our institution confirmed the findings (Figures 2 and 3; Videos 1-3 available at www.invasivecardiology.com). The patient underwent a successful operative repair of the pseudoaneurysm and was discharged home 8 days later.

The classic Bentall operation for complete replacement of the aortic valve and ascending aorta¹ consists of insertion of a composite aortic graft valve prosthesis with direct reimplantation of the coronary arteries, and wrapping the graft with the residual aneurysmal wall. This technique entails a high frequency of pseudoaneurysm formation from the disruption of the coronary artery anastomosis.^2-4 As a result, the classic Bentall operation has been replaced by an open modification with total resection of the aneurysm and reimplanation of adequately mobilized coronary buttons to the graft.⁴ The case presented is such an example.

References

1. Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax. 1968;23(4):338-339.
2. Marvasti MA, Parker FB Jr, Randall PA, Witwer GA. Composite graft replacement of the ascending aorta and aortic valve. Late follow-up with intra-arterial digital subtraction angiography. J Thorac Cardiovasc Surg. 1988;95(5):924-928.
3. Svensson LG, Crawford ES, Hess KR, et al. Composite valve graft replacement of the proximal aorta: comparison of techniques in 348 patients. Ann Thorac Surg. 1992;54(3):427-437; discussion 438-439.
4. Kouchoukos NT, Wareing TH, Murphy SF, Perrillo JB. Sixteen-year experience with aortic root replacement. Results of 172 operations. Ann Surg. 1991;214(3):308-318; discussion 318-320.

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From the Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted November 29, 2011, provisional acceptance given January 4, 2012, final version accepted January 23, 2012.
Address for correspondence: Vakhtang Tchantchaleishvili, MD, Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115.