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18 Management ofEndocarditis
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23. Sorabella RA, Han SM, Grbic M, Wu YS, Takyama H, Kurlansky P, etal. Early operation
for endocarditis complicated by preoperative cerebral emboli is not associated with worsened
outcomes. Ann Thorac Surg. 2015;100(2):501–8.
24. Yoshioka D, Sakaguchi T, Yamauchi T, Okazaki S, Miyagawa S, Nishi H, etal. Impact of early
surgical treatment on postoperative neurologic outcome for active infective endocarditis complicated by cerebral infarction. Ann Thorac Surg. 2012;94(2):489–96.
25. Byrne JG, Rezai K, Sanchez JA, Bernstein RA, Okum E, Leacche M, etal. Surgical management of endocarditis: the society of thoracic surgeons clinical practice guideline. Ann Thorac
Surg. 2011;91(6):2012–9.
26. Flynn CD, Curran NP, Chan S, Zegri-Reiriz I, Tauron M, Tian DH, etal. Systematic review
and meta-analysis of surgical outcomes comparing mechanical valve replacement and bioprosthetic valve replacement in infective endocarditis. Ann Cardiothorac Surg. 2019;8(6):587–99.
27. Moon MR, Miller DC, Moore KA, Oyer PE, Mitchell RS, Robbins RC, etal. Treatment of
endocarditis with valve replacement: the question of tissue versus mechanical prosthesis. Ann
Thorac Surg. 2001;71(4):1164–71.
28. Toyoda N, Itagaki S, Tannous H, Egorova NN, Chikwe J.Bioprosthetic versus mechanical
valve replacement for infective endocarditis: focus on recurrence rates. Ann Thorac Surg.
2018;106(1):99–106.
29. Habib G, Thuny F, Avierinos JF.Prosthetic valve endocarditis: current approach and therapeutic options. Prog Cardiovasc Dis. 2008;50(4):274–81.
30. Mihos CG, Capoulade R, Yucel E, Picard MH, Santana O. Surgical versus medical therapy for prosthetic valve endocarditis: a meta-analysis of 32 studies. Ann Thorac Surg.
2017;103(3):991–1004.
31. Mahesh B, Angelini G, Caputo M, Jin XY, Bryan A.Prosthetic valve endocarditis. Ann Thorac
Surg. 2005;80(3):1151–8.
32. Fonseca JP, Pereiro T, Dos Santos DP, Correia JM, Capelo J, Carragoso A.Successful management of prosthetic valve brucella endocarditis with antibiotherapy alone. Eur J Case Rep Intern
Med. 2018;5(4):000808.
33. Akowuah EF, Davies W, Oliver S, Stephens J, Riaz I, Zadik P, etal. Prosthetic valve endocarditis: early and late outcome following medical or surgical treatment. Heart. 2003;89(3):269.
34. Chirillo F, Scotton P, Rocco F, Rigoli R, Pedrocco A, Martire P, etal. Management strategies
and outcome for prosthetic valve endocarditis. Am J Cardiol. 2013;112(8):1177–81.
35. Shrestha NK, Jue J, Hussain ST, Jerry JM, Pettersson GB, Menon V, et al. Injection drug
use and outcomes after surgical intervention for infective endocarditis. Ann Thorac Surg.
2015;100(3):875–82.
36. Tiako MJN, Mori M, Mahmood SUB, Shioda K, Mangi A, Yun J, etal. Recidivism is the leading cause of death among intravenous drug users who underwent cardiac surgery for infective
endocarditis. Semin Thorac Cardiovasc Surg. 2019;31:40–5.
37. Kim JB, Ejiofor JI, Yammine M, Ando M, Camuso JM, Youngster I, et al. Surgical outcomes of infective endocarditis among intravenous drug users. J Thorac Cardiovasc Surg.
2016;152(3):832–841.e1.
38. Fleischauer AT, Ruhl L, Rhea S, Barnes E. Hospitalizations for endocarditis and associated health care costs among persons with diagnosed drug dependence—North Carolina,
2010–2015. MMWR Morb Mortal Wkly Rep. 2017;66(22):569.
39. DiMaio JM, Salerno TA, Bernstein R, Araujo K, Ricci M, Sade RM.Ethical obligation of surgeons to noncompliant patients: can a surgeon refuse to operate on an intravenous drug- abusing
patient with recurrent aortic valve prosthesis infection? Ann Thorac Surg. 2009;88(1):1–8.
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related infective endocarditis. Am J Addict. 2016;25(3):191–4.
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Chapter 19
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Aneurysmal Disease oftheAscending
Aorta, Root, andArch
BartlomiejR.Imielski andLeonardN.Girardi
Anatomy
• The aortic root is composed of the aortic valve (leaets, commissures, and annu-
lus), sinuses of Valsalva, right and left coronary ostia, and sinotubular junction
(STJ) (Fig.19.1).
• The aortic valve annulus is anchored by two brous trigones to the rigid frame-
work of the heart, and with the STJ provides structural stability to the aortic root.
• The root is centrally located within the heart, such that it is adjacent to all cardiac
chambers, which is of importance in aortic valve endocarditis, given that abscess
and stulas may form into any one of these chambers or spaces.
• Diseases affecting the aortic root include intrinsic aortic valve pathology, dila-
tion of the components of the root (annulus, STJ, or sinuses of Valsalva), aneurysms, pseudoaneurysms, acute aortic syndromes (dissections, ruptures),
infectious pathology, as well as inherited conditions such as bicuspid aortic valve
(BAV and genetically triggered aneurysms).
• The ascending aorta emerges as the main blood vessel from the root, taking off
at the STJ and continuing until the aortic arch, just proximal to the innominate
artery. Its slight curve lends to the nomenclature of lesser/inner and greater/outer
curves (Fig.19.1).
B. R. Imielski (*)
Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
Department of Cardiothoracic Surgery, Wake Forest University School of Medicine,
Winston-Salem, NC, USA
e-mail: bimielsk@wakehealth.edu
L. N. Girardi
Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
e-mail: lngirard@med.cornell.edu
Switzerland AG 2024
J. P. Bloom, T. M. Sundt (eds.), Cardiac Surgery Clerkship, Contemporary
Surgical Clerkships, https://doi.org/10.1007/978-3-031-41301-8_19
215© The Author(s), under exclusive license to Springer Nature
216
Aortic arch
a
Ascending
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B. R. Imielski and L. N. Girardi
aorta
Right subclavian
Innominate artery
Tubular
ascending
aorta
Aortic root
artery
Right
coronary
artery
Right common
carotid artery
Zone 0
Sinuses
of valsalva
Zone 1
Left
coronary
artery
Diaphragm
Left common
carotid artery
Zone 2
Zone 3
Zone 4
Zone 5
Left subclavian
artery
Descending
thoracic aort
Fig. 19.1 This illustration demonstrates the thoracic aorta, composed of the aortic root, ascending
arch and descending aorta. The root contains three billowing sinuses of Valsalva, from which the
right and left coronary arteries originate. The root tapers at the sinotubular junction where it transitions to the ascending aorta. A typical great vessel branching pattern is shown
• The aortic arch typically gives off three great vessels: the innominate (aka bra-
chiocephalic), left common carotid, and left subclavian arteries.
• Two common variants are a “Bovine arch” with the left common carotid artery
branching off the innominate artery instead of the arch itself, and AA aberrant
left vertebral artery that arises directly off of the arch as a fourth arch vessel.
• The ascending and aortic arch segments are subject to dilation, aneurysm and
pseudoaneurysm formation, dissection, rupture, aortitis, and entities such as penetrating aortic ulcers, and intramural hematomas.
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217
Etiology ofDilation
• The aortic root and the downstream aorta are subject to dilation given lifelong
pressurization and impulse throughout the cardiac cycle.
• Elastin and collagen are the main structural glycoproteins of the aorta, and con-
ditions affecting their synthesis or metabolism contribute to inherited aortic syndromes (Table19.1).
• Similarly degenerative changes can occur secondary to pro-inammatory states
such as smoking, dyslipidemia, auto-immune conditions, and infections, causing
cystic medial degeneration of the aorta (Table19.2).
• The common consequence is dilation, which once started leads to a vicious cycle
according to the Law of Laplace (wall tension=[intraluminal pressure×radius]/2
× wall thickness). As a result, as the vessel dilates and its wall thins, the wall tension further increases exacerbating the process.
• Ectasia refers to dilation beyond normal, whereas aneurysm refers to pathologic
dilation. Pseudoaneurysm differs from a true aneurysm in that not all components of the aortic wall are involved in the outpouching.
• The clinical risk associated with dilation is free wall rupture or aortic dissection,
events that without surgical intervention are usually fatal. Patients with known
aneurysms should be monitored and referred for elective surgery, in order to
prevent the aforementioned acute aortic events.
Table 19.1 Inherited aortic conditions
Inherited
condition Genetic defect
Marfan syndrome FBN1 1:5000–
Loeys-Dietz
syndrome
Vascular
Loeys-Dietz
Turner syndrome 45X 1:2000 35%
Bicuspid aortic
valve
Heritable thoracic
aortic disease
Table 19.2 Causes of aortic aneurysm formation
Acquired Inammatory Inherited Infections/mycotic
Smoking Takayasu arteritis Marfan Syphilis
Hypertension Giant cell arteritis Loeys-Dietz Traumatic
Hyperlipidemia Bechet’s disease Turner Other
Chronic dissection Ankylosing spondylitis Bicuspid
TGFBR1/2, TGFB2 Unknown 20%
COL3A1 1:90,000 Unknown
ROBO4, DATA5, NOTH1 1:5–1:100 35%
FBN1, TGFVR1/2, SMAD3, TGFB2,
COL3A1, ACTA1, MYH11, MYLK, LOX,
PRKG1, FOXE3
Population
prevalence
1:15,000
Unknown 9–46%
Dissection
prevalence
51%
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Table 19.3 Surgical indications for aneurysm repair
Aneurysm type/condition Indication
Degenerative (root, ascending or arch) without
genetic predisposition
Degenerative or inherited Aortic growth >0.5cm/year
Degenerative or inherited Aortic diameter>4.5cm with concomitant
Inherited Aortic diameter 4–5cm
Aortic diameter>5.5cm
surgery on aortic valve
B. R. Imielski and L. N. Girardi
• The timing of surgical intervention of asymptomatic aneurysms is based on the
size at which the risk of surgery becomes less or equal to the risk of rupture. The
2010 guidelines for Thoracic Aortic Disease are summarized in Table19.3. In
general, aneurysms >5.5cm in diameter, or with growth rate>0.5cm/year should
be considered for surgery [1].
• Expert consensus does additionally support concomitant root replacement when
diameter is <45mm, by experienced surgeons who routinely perform this complex procedure with exceptionally low mortality. Similarly, when the arch is
45mm, arch replacement is reasonable; however, for diameters between 40 and
45 mm, the decision is nuanced and should be based on patient age and comorbidity in addition to individual surgeon and center experience [1, 2].
• There remains ongoing debate on the utility of indexed metrics to height, body
weight, or BMI, as well as wall strain measurements for surgical
prognostication.
• Patients suspected of having inherited aortic conditions should be referred to a
geneticist and enrolled in a surveillance program.
• Patients with suspected infectious etiologies should be completely evaluated to
determine the source of infection.
• The most common cause of mycotic (infected; bacterial or fungal) aortic degen-
eration, as seeding of either disrupted aortic intima or mural thrombus can lead
to an aggressive local infection with rapid aortic expansion and rupture. Bacterial
endocarditis may also contribute to the formation a mycotic aneurysm.
• Patients with mycotic aneurysms should undergo a culture driven anti-microbial
treatment course and urgent surgery given the high rate of rapid growth and rupture in this population. Although TEVAR has been used in some series, removal
of infected tissue and replacement with graft have been shown to be safe with
good long-term outcomes.
Aortic Root Surgery
• One important facet of aortic root aneurysm surgery is whether the aortic valve
can be spared. This is largely determined by the integrity of the aortic valve,
including any aortic regurgitation and/or stenosis.
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219
• As the aortic root dilates, the aortic valve is prone to becoming regurgitant sec-
ondary to one or a combination of the following: aortic annular dilation resulting
in decreased free-edge leaet coaptation, STJ dilation resulting in leaet tethering, leaet degeneration and prolapse, and nally free edge or commissural
fenestrations.
• If the aortic valve can be spared, there are two types of valve sparring root
replacements (VSRR) that can be performed. The rst to be described, but less
common now, is remodeling (Yacoub), where the aortic annulus and commissures are preserved by cutting out scallops in the sinus of Valsalva to which a
scalloped graft is sewn (Fig19.2).
• The second procedure is reimplantation (David), in which the commissures and
annulus are reimplanted within a tube graft (Fig19.3). One long-term advantage
of the reimplantation over the remodeling technique is that the annulus is reinforced by graft material, thereby preventing further dilation, which is especially
important in connective tissue disorder patients. Both techniques have undergone
multiple iterations to improve patient outcomes.
Fig. 19.2 This gure
demonstrates a Yacoub
remodeling technique of
valve sparing root
replacement. The conduit
is trimmed with three
scallops, which are sutured
to the base of each sinus of
Valsalva
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B. R. Imielski and L. N. Girardi
Fig. 19.3 This gure
demonstrates a David
reimplantation technique of
valve sparring root replacement, where each aortic valve
commissure is resuspended
within the conduit. Unlike
Yacoub remodeling, which
has one running suture line,
the David technique anchors
the graft to the basal ring
below the anulus of the aortic
valve, and then uses a
hemostatic suture line to
resuspend the commissures
and rim of each SoV within
the tube conduit (a)
mobilized root and coronary
ostia prior to implantation
into a graft conduit (b)
reimplanted aortic root and
coronary ostia within a graft
condiut, showing commissural resuspension and a
running hemostatis
suture line
a
b
• If the aortic valve cannot be spared, a composite valve graft/conduit is the most
common type of aortic root replacement (Fig. 19.4). This is composed of a
bioprosthetic or mechanical aortic valve attached either by the surgeon or prefabricated to a Dacron tube graft.
• One technical challenge that is shared between valve sparring and composite
conduits is the need for coronary artery reimplantation.
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Fig. 19.4 This illustration
demonstrates the root
dissection for a composite
valve conduit root
replacement. The coronary
buttons have been
mobilized, and the aortic
valve leaets excised and
debrided. Pledgeted valve
sutures are used to secure
the CVG to the root prior
to anastomosing the
coronary buttons
221
Aortic Arch Surgery
• Operating on the aortic arch poses a technical challenge due to intra-operative
management of cerebral perfusion.
• The brain receives blood from the carotid and vertebral arteries which all origi-
nate from the aortic arch. As such, replacement of the aortic arch requires interruption of cerebral blood ow.
• In order to address this, surgeons rely on a combination of techniques including
hypothermia, pharmacologic adjuncts, circulatory arrest with or without cerebral
perfusion (antegrade (ACP) vs retrograde (RCP)), cerebral neural monitoring,
and relying on the assumption of an intact cerebral circle of Willis.
• Depending on the extent of arch aneurysm needing to be replaced, surgeons may
choose a combination of these cerebral protection modalities. These include
deep hypothermic circulatory arrest (DHCA) (18–22 °C) without antegrade or
222
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B. R. Imielski and L. N. Girardi
retrograde perfusion for brief periods of circulatory arrest, DHCA with either
ACP or RCP, or moderate hypothermic circulatory arrest (MHCA) (22–26 °C)
with ACP or RCP [3, 4].
• Hemiarch replacements are frequently done under deep or moderate circulatory
arrest with or without RCP.
• Total arch replacements more likely to be performed under DHCA with ACP,
although other strategies include DHCA and RCP, or MHCA with ACP, or
DHCA alone [4, 5].
• The duration of maximal hypothermic circulatory arrest remains controversial,
with reports showing safety of DHCA/RCP for prolonged periods of circulatory
arrest. [6–8].
• When preparing for hypothermic circulatory arrest with retrograde cerebral per-
fusion, the superior vena cava is cannulated and snared (Fig.19.5). Upon initiation of circulatory arrest, blood is pumped in a retrograde fashion through the
SVC, up through the cerebral venous system and out the arterial system, allowing for washout of debris that may have fallen into the aortic head vessels.
Fig. 19.5 Illustration
demonstrating bicaval
venous cannulation for
cardiopulmonary bypass.
One cannula is positioned
within the SVC and snared,
and the other within the
IVC and snared.
Retrograde cerebral
perfusion can be delivered
via the SVC cannula for
circulatory arrest
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• For antegrade cerebral perfusion, the axillary artery or the innominate artery is
cannulated and snared. Upon circulatory arrest, cerebral blood ow is established in an antegrade fashion and relies on an intact cerebral circle of Willis for
bilateral perfusion. If neuro monitoring suggests a perfusion mismatch, the surgeon may cannulate the left common carotid artery as well, and provide antegrade ow through it.
• The remains little evidence of any difference in unilateral vs bilateral ACP with
regard to temporary or permanent neurological decits.
• Other adjuncts often used for cerebral protection are hypothermia to decrease
cerebral metabolism and oxygen demand (cooling on bypass and ice on head),
iso-electric neural function with proper anesthetic management (i.e., propofol,
Brevital), steroid, and mannitol administration.
223
Surgical Principles andManagement
• When preparing for aortic aneurysm surgery, you must determine the extent of
aneurysm requiring resection, the appropriate cannulation strategy to accommodate for cerebral protection if necessary, plan for cardioplegia and if circulatory
arrest is needed, as well as alternative adjuncts such as left ventricular venting for
myocardial protection and visualization.
• In older patients with degenerative aneurysms, a more conservative approach
may be warranted in which only the aneurysm is resected, whereas ecstatic portions of the aorta are left behind so that cardiopulmonary bypass time, cardiac
ischemic time, and cerebral ischemia can be minimized.
• On the other hand, younger patients with connective tissue disorders may
undergo more aggressive aortic resection and replacement in hopes of avoiding
future surgeries. These may also include standard elephant trunk or frozen elephant trunks, in which unsupported graft material, or a stented graft, respectively, is left distally from a total arch replacement to assist with management of
downstream aortic pathology necessitating intervention. This may include subsequent open thoracoabdominal aneurysm surgery or TEVAR.
• The aortic arch is becoming a frontier for endovascular intervention, especially
in patients who are poor surgical candidates. However, open surgical repair
remains the gold standard. TEVAR traditionally require 2.0–2.5cm of healthy
proximal and distal aortic landing zone to properly anchor the device and prevent
endoleaks.
• With this in mind, TEVAR grafts can be deployed more proximally in certain
cases such as acute or chronic Type B dissections, or aneurysms covering the left
subclavian artery which can be bypassed at the same time, or pre-emptively
before stenting.
• In rare cases, a surgeon may choose to debranch the arch, in which the head ves-
sels are bypassed off the main aorta using a side bitter clamp without cardiopulmonary bypass, and a TEVAR graft is deployed across the entire arch.
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