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Aortic root and ascending aortic aneurysm in an adult with a repaired tetralogy of fallot.
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PMID:  22263172     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
Surgical repair of the tetralogy of Fallot is one of the most successful operations in the treatment of congenital heart diseases. We report the case of a 65-year-old man who had an aortic valve replacement at the time of complete repair of the tetralogy of Fallot at the age of forty-three. He subsequently had progressive aortic root and ascending aorta dilation to 9 cm. The aortic root and ascending aorta replacement was done using a composite valve-graft and was performed along with other procedures. Thus, meticulous follow-up of aortic root and ascending aorta after corrective surgery for tetralogy of Fallot is recommended following initial curative surgery.
Authors:
Tae Sik Kim; Chan-Young Na; Jong Hyun Baek; Jin Sung Yang
Publication Detail:
Type:  Journal Article     Date:  2011-08-18
Journal Detail:
Title:  The Korean journal of thoracic and cardiovascular surgery     Volume:  44     ISSN:  2093-6516     ISO Abbreviation:  Korean J Thorac Cardiovasc Surg     Publication Date:  2011 Aug 
Date Detail:
Created Date:  2012-01-20     Completed Date:  2012-08-23     Revised Date:  2013-05-29    
Medline Journal Info:
Nlm Unique ID:  101563922     Medline TA:  Korean J Thorac Cardiovasc Surg     Country:  Korea (South)    
Other Details:
Languages:  eng     Pagination:  292-3     Citation Subset:  -    
Affiliation:
Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Korea.
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Journal Information
Journal ID (nlm-ta): Korean J Thorac Cardiovasc Surg
Journal ID (publisher-id): KJTCS
ISSN: 2233-601X
ISSN: 2093-6516
Publisher: Korean Society for Thoracic and Cardiovascular Surgery
Article Information
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© The Korean Society for Thoracic and Cardiovascular Surgery. 2011. All right reserved.
open-access:
Received Day: 18 Month: 2 Year: 2011
Revision Received Day: 13 Month: 4 Year: 2011
Accepted Day: 31 Month: 5 Year: 2011
Print publication date: Month: 8 Year: 2011
Electronic publication date: Day: 18 Month: 8 Year: 2011
Volume: 44 Issue: 4
First Page: 292 Last Page: 293
ID: 3249323
PubMed Id: 22263172
DOI: 10.5090/kjtcs.2011.44.4.292

Aortic Root and Ascending Aortic Aneurysm in an Adult with a Repaired Tetralogy of Fallot
Tae Sik Kim, M.D.*
Chan-Young Na, M.D.*
Jong Hyun Baek, M.D.*
Jin Sung Yang, M.D.*
*Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Korea.
Correspondence: Corresponding author: Chan-Young Na, Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, 91-121, Sosabon 2-dong, Sosa-gu, Bucheon 422-711, Korea. (Tel) 82-32-340-1732, (Fax) 82-32-340-1236, koreaheartsurgeon@hotmail.com

CASE REPORT

A 65-year-old man without any symptoms was referred for an operation on the aortic root and ascending aortic aneurysm. He had undergone a total correction of tetralogy of Fallot (TOF) and aortic valve replacement with mechanical valvular prosthesis 22 years earlier (in 1987, at the age of forty-three).

In August 2009, a huge aneurysmal dilatation (9 cm) of aortic root and proximal ascending aorta, severe tricuspid regurgitation, and good left ventricular ejection fraction were found on echocardiography. Atrial fibrillation was found on electrocardiography. Computed tomography showed a huge saccular aneurysm of the aortic root and proximal ascending thoracic aorta (Fig. 1).

The patient underwent a Bentall procedure involving a composite conduit with a mechanical valvular prosthesis. The operation also included pulmonary valve replacement using a bioprosthesis, tricuspid annuloplasty, subaortic pannus resection, maze procedure, and coronary artery bypass surgery (saphenous vein to proximal right coronary artery). Because the right coronary artery orifice was deviated to the left side and was close to the aortic annulus, coronary artery bypass surgery was chosen despite availability of the button technique.

After the operation, there was the microscopic finding of cystic medial degeneration in the ascending aortic wall (Fig. 2). The postoperative period was uneventful apart from the wound disruption of femoral cannulation site. He was discharged on his 37th postoperative day. At follow-up, he remains well 17 months after this latest procedure.


DISCUSSION

In 1997, Dodds and colleagues described the first series report about progressive aortic regurgitation and aortic root dilatation after complete, uncomplicated repair of TOF [1].

A long-standing volume overload of the aortic root may cause aortic root dilatation in adults with a repaired TOF [2]. The right to left shunt through the ventricular septal defect in unrepaired TOF increases the volume overload effect on the aortic root.

Another causative mechanism for progressive aortic root dilatation is marked histological abnormalities in the aortic root and ascending aortic wall [3]. Intrinsic histological changes were found in TOF patients; including medionecrosis, fibrosis, cystic medial necrosis, elastic fragmentation and elastic lamellae disruption.

Our patient had initial reparative surgery at the age of forty-three in 1987. The phrase of the enlarged aorta was described in the record of the first operation. We could not obtain any data about the size of the ascending aorta. Also, we did not know why correction was not performed in the initial operation. In 2002, ascending aortic aneurysm (7 cm) was found on echocardiography. An operation for ascending aortic aneurysm was recommended, but he refused any surgery at that time.

The pathologic conditions of aortic root and ascending aorta in repaired TOF are no longer a benign problem. In recent reports, cases of aortic root dissection in repaired TOF are described [4,5]. These are the first reports of aortic dissection in tetralogy of Fallot. After an initial curative operation for TOF, meticulous monitoring of aortic root and ascending aorta is mandatory.


Notes

This manuscript was presented at the 224th Seoul-Gyeonggi Local Academic Meeting of the Korean Thoracic and Cardiovascular Society.

References
1. Dodds GA 3rd,Warnes CA,Danielson GK. Aortic valve replacement after repair of pulmonary atresia and ventricular septal defect or tetralogy of FallotJ Thorac Cardiovasc SurgYear: 19971137367419104983
2. Niwa K,Siu SC,Webb GD,Gatzoulis MA. Progressive aortic root dilatation in adults late after repair of tetralogy of FallotCirculationYear: 20021061374137812221055
3. Tan JL,Davlouros PA,McCarthy KP,Gatzoulis MA,Ho SY. Intrinsic histological abnormalities of aortic root and ascending aorta in tetralogy of Fallot: evidence of causative mechanism for aortic dilatation and aortopathyCirculationYear: 200511296196816087793
4. Rathi VK,Doyle M,Williams RB,Yamrozik J,Shannon RP,Biederman RW. Massive aortic aneurysm and dissection in repaired tetralogy of Fallot; diagnosis by cardiovascular magnetic resonance imagingInt J CardiolYear: 200510116917015860407
5. Kim WH,Seo JW,Kim SJ,Song J,Lee J,Na CY. Aortic dissection late after repair of tetralogy of FallotInt J CardiolYear: 200510151551615907429

Article Categories:
  • Case Report

Keywords: Aneurysm, Aorta, ascending, Tetralogy of Fallot, Adult.

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