What is a suitable management for a 70 years old male c\o dyspnoea on mild exertion, ? HE DID cabg x4,14 YEARS AGO. Echo 40% EF, severe as peak gradient 70mmhg, AREA 0.9CM. Has colostomy post colectomy? Ct showed ascending aneurysm of 5.6 cm extending to the innominate artery.
Not a big deal.
However, the patient underwent CABG x 4, 14 years ago: What is the current status of the bypass grafts?
It seems a post-stenotic dilatation extending to the brachiocephalic trunk: What is the calcification status of the aortic arch on CT?
I would go for a Bentall and hemi-arch replacement procedure (or the brachiocephalic trunk may be de-branched to the Bentall graft) with right axillary artery and two-stage atrial cannulations (other cannulation options depend on the surgeon) with open distal anastomosis technique + CABG for the necessary coronary arteries. If there is any doubt for cerebral protection during selective cerebral perfusion, a cross-over external carotid artery to external carotid artery bypass is an excellent cerebral protection method (see my publication in Ann Thorac Surg-Cerebral protection with a crossover external carotid artery bypass during arch debranching).
Good luck.
Obviously this is not the best patient to threat., but I believe that you can choose the best surgical strategy only on the base of coronary angiography and myocardial scintigraphy . In my opinion a simple Bentall procedure + reimplantation or +regrafting vital myocardium could be the best in this particular setting. The choice of cannulation sites depends on
This patient deserves an aortic valve replacement with biological prostetis and replacement of the ascending aorta. TAVI is not feasible for the dilatation of the aorta.The risk is the presence of coronary bypass and their injury opening the sternum.
1) Assess the permeability.2) assess the placement with a CT angiography. A LITA can easily be adherent to the sternum.
The extension of the aneurysm until the aortic arch and a complication on the LITA can recommend a femoral cannulation and eventually fall in temperature.
I do not think that the risk is 2-3% but higher and some precautions are necessary
I agree with the above surgeons specially Murat Ugurlucan. Although CABG operated for 14 years ago and EF 40%, he still can be operated with relative high per. operative risk. Post operative complications is not higher that 3% if he is not on dialyse, DM, fragile, KOL.
Best regards,
Khalil Ahmad
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