case_images: PMC10525341_01
case_images: On computerized tomography angiography (CTA) performed at the time of his discharge three years ago, the aortic diameter was measured to be a normal 3.0 cm (A, asterisk). The preoperative computerized tomography angiography (B) confirmed a giant aortic root aneurysm (asterisk) bulging against the sternum. The transesophageal echocardiography (C) confirmed a giant aortic root aneurysm (asterisk) and a functional aortic mechanical valve during the operation. The aortic aneurysm ruptured suddenly during re-sternotomy (D) previous mechanical aortic valve (E, asterisk) was removed. Three pediatric urinary catheters (F, 1.2.3) were used to block the three branches of the aortic arch during hemi-arch replacement. Postoperative three-dimensional enhanced computerized tomography angiography (G) showed a normal-diameter aorta as well as relief of compression of the surrounding tissues. Hematoxylin-eosin staining (H) and Elastic Verhoeff-Van Gieson's staining (I) of aortic aneurysm wall showed the disordered arrangement of smooth-muscle cell and the partial loss of elastin and collagen fibers.
case_images: fcvm-10-1263897-g001.jpg
case_images: PMC10525341_01_fcvm-10-1263897-g001.jpg
case_images: F1
case_images: At the time of his discharge, a Computerized Tomography Angiography (CTA) was performed, which revealed a normal aortic diameter of 3.0 cm (Figure 1A, asterisk). The left ventricle (LV) was of normal size (55 mm in end-diastolic dimension), but exhibited a reduced ejection fraction (EF) of 45%. The diagnosis was confirmed by CTA, which showed a protruding giant aortic root aneurysm pressing against the sternum (Figure 1B, asterisk), causing compression of the right atrium and the pulmonary artery. Once the patient was anesthetized, a transesophageal echocardiogram (TEE) confirmed the presence of a giant aortic root aneurysm (Figure 1C, asterisk) along with a functional mechanical aortic valve. During the carefully prepared sternotomy, the aneurysm unexpectedly ruptured, leading to a sudden rush of bright red arterial blood onto the surface of the sternum (Figure 1D, Supplementary Material, Video S1). Subsequently, the patient underwent hemi-arch replacement using a Hemashield Platinum #32 graft after promptly blocking the three branches of the aortic arch with three pediatric urinary catheters (#8) (Figure 1F, 1.2.3, Supplementary Material, Video S2), facilitating the implementation of unilateral antegrade cerebral perfusion via the right axillary artery. The previous mechanical valve was removed (Figure 1E, Supplementary Material, Video S3), and an aortic root replacement with a composite valve graft (CVG) procedure (Bentall) was performed using a 21 mm St. A three-dimensional CTA performed prior to discharge revealed a normal-sized aortic root with no evidence of pressure on the right atrium and pulmonary artery (Figure 1G). Histological analysis of the aortic aneurysm wall, using Hematoxylin-eosin staining (Figure 1H) and Elastic Verhoeff-Van Gieson's staining (Figure 1I), demonstrated smooth muscle cell disorder and partial loss of elastin and collagen fibers.
case_images: The redo-surgery intervention planning scheme.
case_images: fcvm-10-1263897-g002.jpg
case_images: PMC10525341_01_fcvm-10-1263897-g002.jpg
case_images: F2
case_images: This approach was chosen due to the presence of a massive aneurysm at the aortic root and the potential risk of fatal rupture during the re-sternotomy procedure due to its close proximity to the sternum (Figure 2).