Double-valve intervention with staged hybrid repair for post-traumatic aortic incompetence and aortic rupture

Excerpt

A 56-year-old male policeman who had sustained a fall from a tree (about 10 m) 2 weeks earlier presented with chest discomfort and progressive dyspnea on exertion—FC3. Physical examination revealed a grade 3/6 diastolic murmur in the aortic area. Echocardiogram revealed a dilated left ventricle with severe aortic incompetence with a moderate to severe mitral incompetence. Suspecting possible aortic injury due to history of deceleration injury plus a doubtful lesion on echocardiogram, computerized tomography (CT) scan of the chest was taken which revealed distal aortic arch rupture with pseudoaneurysm, close to the origin on the left subclavian artery (Fig. 1). Patient was taken up for emergency surgery. Midline sternotomy was done and patient was placed on cardiopulmonary bypass. After cardioplegic arrest, aorta was opened .The commissure between the right coronary cusp and the noncoronary cusp was avulsed with an additional tear in the right coronary leaflet. Left atrium was opened and mitral valve inspected. Leaflets were found to be normal with annular dilatation. Aortic valve replacement was done with #21-mm TTK-Chitra heart valve prosthesis (TTK Healthcare, Kerala, India) and mitral annuloplasty was performed with a # 27-mm SJM Tailor annuloplasty ring (St.Jude Medical, Minn, USA). Left common carotid debranching done by ascending aorta—left common carotid (proximal to bifurcation) bypass using #8-mm gelatin-coated polyester dacron graft (Unigraft, Braun, Germany) and the left common carotid artery stump was transfixed and ligated .The patient was transferred to the cath lab for endovascular stenting of the distal arch .Digital subtraction angiogram showed a double density in the post subclavian area suggesting a pseudoaneurysm. 34 × 167 cm Medtronic Valient stent graft (Medtronic Inc., Minn, USA) was deployed (Fig. 2) .Post procedure CT reconstruction was unremarkable with sealed off pseudoaneurysm and no endoleak (Fig. 3). The patient made a full recovery and is on regular follow-up.

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