Thorax (1968), 23, 338.
`
`A technique for complete replacement of
`the ascending aorta
`
`HUGH BENTALL AND ANTONY DE BONO
`From the Royal Postgraduate Medical School, London, and Hammersmith Hospital
`
`A technique for complete replacement of the aortic valve and ascending aorta in cases of
`aneurysm of the ascending aorta with aortic valve ectasia is described. The proximal aortic
`root was too attenuated to afford anchorage to the aortic prosthesis, so this was sutured to
`the ring of a Starr valve and the prostheses were inserted en bloc. The ostia of the coronary
`arteries were anastomosed to the side of the aortic prosthesis.
`
`Aneurysmal dilatation of the ascending aorta is
`often associated with ectasia of the aortic valve
`ring and presents clinically as aortic incompetence.
`In Marfan's syndrome or cystic medial necrosis
`this may develop with dramatic suddenness in an
`ostensibly healthy individual.
`The dilatation of the valve ring makes repair or
`replacement with other than a prosthetic valve
`difficult. The aneurysm, which is either a true
`dilatation or dissection, is best treated by excision
`and replacement with a tubular prosthesis, as the
`wall is invariably attenuated. This is not difficult
`provided that the aorta distal to the aneurysm and
`proximal to the arch is suitable for anastomosis.
`Proximally, in most cases, the aortic prosthesis
`can be sutured to a rim of aorta, leaving the
`coronary ostia undisturbed, while a valve pros-
`thesis is placed in the usual sub-coronary position
`Bloodwell,
`Beall,
`Hallman, and De
`(Cooley,
`Bakey, 1966).
`However, it sometimes happens that the root of
`the aorta is so involved in the disease process
`that the wall is too attenuated to be sutured to
`the proximal end of the aortic prosthesis. In this
`situation the management of the coronaries is the
`main concern of the surgeon.
`
`CASE REPORT
`
`A man aged 33 years had been in excellent health
`until a few months before admission, when his wife
`had noticed a loud cardiac murmur and he developed
`regurgitation.
`signs and symptoms of gross aortic
`Angiocardiography showed a large aneurysmal dilata-
`tion of the ascending aorta, not involving the vessels
`of the arch but associated with free aortic regurgita-
`
`tion. He was in incipient cardiac failure with an
`effective cardiac output of 1.8 l./min./m.2
`A mid-sternal thoracotomy revealed a
`OPERATION
`large globular dilatation of the ascending aorta. Its
`bulging inelastic wall was so thin that blood could
`be seen eddying within. Figure 1 gives an idea of the
`attenuation of the wall.
`Total cardiopulmonary bypass was established, and,
`after cross-clamping the aorta distal to the aneurysm,
`the aorta was opened, and the coronaries were can-
`nulated and perfused in the usual way. The aortic
`valve ring was much dilated and the wall was
`extremely thinned down to the ring.
`It was clear that it would not be possible to join
`the aortic wall above the coronaries to an aortic pros-
`thesis. It was therefore decided to suture the tube
`prosthesis directly to the ring of a Starr valve. A No.
`13 Starr valve was sutured to one end of a crimped
`Teflon aortic prosthesis, as shown in Figure 2. The
`aortic cusps having been excised, sutures were placed
`in the aortic ring and through the Starr valve ring.
`the Starr valve and the
`fixing
`These were tied,
`attached Teflon tube.
`At this stage the coronary cannulae were outside
`the lumen of the aortic replacement. Holes were cut
`in the aortic prosthesis at the site of the coronary
`ostia, which were then re-cannulated, this time through
`the lumen of the tube (Fig. 3). The aortic wall was
`sutured to the perimeter of the holes in the Teflon
`tube, thus reincorporating the coronary ostia within
`the new aorta.
`The distal anastomosis was then completed, leaving
`a vertical slit (Fig. 3 (5)) through which the coronary
`cannulae were removed and air was evacuated. This
`was then closed with a clamp while the aortic clamp
`was released and retrograde coronary perfusion was
`started again without any delay. The wall of the
`aneurysm was closed over the prosthesis.
`The patient made an uneventful recovery and
`remains well after nine months.
`338
`
`Page 1 of 2
`
`Edwards Lifesciences v. Boston Scientific Scimed
`IPR2017-00060 U.S. Patent 8,992,608
`Exhibit 2006
`
`

`

`A technique for complete replacement of the ascending aorta
`
`339
`
`Section of aortic aneurysm just above aortic valve, showing extreme thinning. Wall
`FIG. 1.
`about one-tenth normal thickness. (L.E.H. V.G. x 40.)
`
`Teflon
`
`Vl
`
`Starr
`valve
`
`Starr valve has been sutured to aortic prosthesis:
`FIG. 2.
`sutures have been placed in aortic ring before fixing the
`combined prostheses.
`
`The technique used is reported as it offers an
`alternative method of dealing with this type of
`aortic disease when the whole of the ascending
`aorta has to be replaced.
`
`Combined prostheses in situ. Insets I to 4 show
`FIG. 3.
`details of holes fashioned in the side wall of the Teflon
`tube to
`reincorporate the coronary ostia within
`the
`lumen of the new ascending aorta. Inset S shows the
`vertical slit in the prosthesis.
`
`REFERENCE
`Cooley, D. A., Bloodwell, R. D., Beall, A. C., Hallman, G. L., and
`De Bakey, M. E. (1966). Surgical management of aneurysms
`of the ascending aorta. Surg. Clin. N. Amer., 46, 1033.
`
`Page 2 of 2
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