Successful Reoperation for Annuloaortic Ectasia in a Jehovah’s Witness With Marfan Syndrome: Cabrol Procedure and Cabrol Patch

In aortic root replacement, the Cabrol procedure facilitates tension-free coronary button anastomoses (1, 2), and the Cabrol patch (pericardial hood) technique enables hemostasis of the intractable aortic root bleeding (3). Here the authors present their successful aortic root replacement utilizing both techniques in a Jehovah’s Witness with prior mitral valve repair and Marfan syndrome.

A 60-year-old woman who is a Jehovah’s Witness was referred to the authors’ hospital for annuloaortic ectasia. She had undergone mitral valve repair via sternotomy 12 years ago and was diagnosed with descending thoracic aortic dissection and abdominal aortic aneurysm three years ago. Echocardiography demonstrated severe aortic regurgitation with right coronary cusp tear and mild mitral regurgitation. On computed tomography, the sinus of Valsalva measured 60 mm in diameter. Laboratory examination revealed a hemoglobin level of 12.8 g/dl and a platelet count of 291,000/µl. The patient needed aortic root replacement with reoperative sternotomy without blood product transfusion for her religion issue. Thus concomitant Cabrol procedure and Cabrol patch utilization was planned to minimize mediastinal adhesiolysis and subsequent bleeding. Cardiopulmonary bypass was established via the right axillary artery and the right femoral vein. Redo sternotomy was performed, and periaortic dissection was minimized for the following Cabrol patch application. A left ventricular vent catheter was inserted through the extrapericardial right upper pulmonary vein.

After aortic cross-clamping and aortotomy, modified del Nido solution was delivered directly to the coronary ostia. Both coronary ostia were anastomosed to both ends of a 10 mm-diameter Dacron graft. A 25-mm stented tissue valve was sewn into a 30-mm Valsalva graft, and it was implanted at the aortic annulus with pledgeted noneverting mattress sutures. After the distal graft and the aorta anastomosis, a side-to-side anastomosis was performed between the implanted Valsalva graft and the 10-mm graft connecting the coronary arteries. The aortic cross-clamp was released, and there was no significant bleeding. Weaning from cardiopulmonary bypass, a bovine pericardial patch was trimmed and sewn in place over the composite graft implanted site. The patient was successfully weaned from the cardiopulmonary bypass, and the postoperative course was uneventful.

References

1. Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax. 1968;23:338-339.
2. Cabrol C, Pavie A, Gandjbakhch I, Villemot JP, Guiraudon G, Laughlin L, et al. Complete replacement of the ascending aorta with reimplantation of the coronary arteries: new surgical approach. J Thorac Cardiovasc Surg. 1981:81;309-315.
3. Ikonomidis JS. Surgery for aortic valve endocarditis. Op Tech Thorac Cardiovasc Surg. 2011;16:226-241.

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