Tuesday 20 November 2012
Saturday 3 November 2012
Case of the Month- Annulo aortic ectasia- Bentalls Operation.
A 66 year old male referred for evaluation of palpitations and dyspnoea on exertion(class III). ECG was suggestive of left ventricular hypertrophy. Transthoracic echocardiography revealed a tricuspid aortic valve with moderately severe aortic regurgitation. The aortic annulus was dilated (30 mm). There was dilation of the ascending aorta (6.7cm). A CT aortogram was done (see images below), which showed dilatation of the aortic annulus and the aortic sinuses with aorta tapering to a near normal diameter just before the arch vessels.The images were typical of annulo aortic ectasia. the coronary arteries were normal on angiogram.
The patient underwent a aortic root replacement (modified Bentalls operation)using a size 25 valved conduit.
Comment-Annulo aortic ectasia is a condition in which there is dilatation of the aortic annulus and the aortic sinuses. this leads to stretch on the aortic valve leaflets resulting in variable degrees of aortic regurgitation. This condition is found in patients with Marfans syndrome but aging and hypertension are also the causes. The basic defect is weakness of the medial layer of aorta resulting in dilation which progresses with time. As the size of the aorta increases, the chance of dissection, rupture also increase. The treatment of this condition is surgery. There are well defined guidelines for aortic size when intervention is indicated. If the aortic valve can be preserved, a valve sparing (David I) operation can be performed. In others the aortic valve and the aorta are replaced using a composite graft (Bentalls operation) with reimplantation of the coronary arteries.
Other conditions in which Bentalls procedure is performed are type A aortic dissection with irreparable aortic valve, symptomatic bicuspid aoric valve disease with ascending aortic dilatation. The current aortic size guidelines above which ascending aorta should be replaced are:
Bicuspid aortic valve- 4.5 cm.
Marfans Syndrome- 5.0 cm
Others------------- 5.5 cm
 |
| Classical pear shaped appearance of aortic root. |
The patient underwent a aortic root replacement (modified Bentalls operation)using a size 25 valved conduit.
Comment-Annulo aortic ectasia is a condition in which there is dilatation of the aortic annulus and the aortic sinuses. this leads to stretch on the aortic valve leaflets resulting in variable degrees of aortic regurgitation. This condition is found in patients with Marfans syndrome but aging and hypertension are also the causes. The basic defect is weakness of the medial layer of aorta resulting in dilation which progresses with time. As the size of the aorta increases, the chance of dissection, rupture also increase. The treatment of this condition is surgery. There are well defined guidelines for aortic size when intervention is indicated. If the aortic valve can be preserved, a valve sparing (David I) operation can be performed. In others the aortic valve and the aorta are replaced using a composite graft (Bentalls operation) with reimplantation of the coronary arteries.
Other conditions in which Bentalls procedure is performed are type A aortic dissection with irreparable aortic valve, symptomatic bicuspid aoric valve disease with ascending aortic dilatation. The current aortic size guidelines above which ascending aorta should be replaced are:
Bicuspid aortic valve- 4.5 cm.
Marfans Syndrome- 5.0 cm
Others------------- 5.5 cm
| Composite graft and valve conduit |
| Modified Bentalls procedure |
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