Remodeling valve-sparing pulmonary root replacement repair of giant pulmonary artery aneurysm.

Central MessageA woman with an isolated giant pulmonary artery aneurysm without pulmonary hypertension successfully underwent valve-sparing pulmonary root replacement with no residual pulmonic regurgitation. A woman with an isolated giant pulmonary artery aneurysm without pulmonary hypertension successfully underwent valve-sparing pulmonary root replacement with no residual pulmonic regurgitation. We describe a 76-year-old woman with history of asthma who presented with dyspnea on exertion and angina. Computed tomography (CT) demonstrated an 8-cm giant pulmonary artery aneurysm (PAA) extending from the pulmonic root to the PA bifurcation (Figure 1, A). Notably, the patient did not have pulmonary hypertension (PH) on preoperative heart catheterization, nor did she have coronary disease, although angiography did show ostial compression of the left main coronary artery (LMCA) by the PA (Figure 1, B). Her echocardiogram demonstrated right ventricular dilatation with low normal function, moderate pulmonic regurgitation, and trace tricuspid regurgitation (Figure 1, C). During the 6 months between her initial CT scan and her formal CT angiogram conducted as part of her PH workup, the aneurysm grew 4 to 5 mm. She was taken to the operating room for planned valve-sparing pulmonic root replacement using the Yacoub remodeling technique.1Sarsam M.A. Yacoub M. Remodeling of the aortic valve anulus.J Thorac Cardiovasc Surg. 1993; 105: 435-438Abstract Full Text PDF PubMed Google Scholar She provided consent for publication of this case report preoperatively; per Stanford University policy, institutional review board approval is not required for a case report. The patient underwent median sternotomy and was cannulated for cardiopulmonary bypass (CPB) via the aorta and right atrium. The PAA was compressing the aorta rightward (Figure 1, D). After heparinization, bypass was initiated and the aneurysm was resected from the pulmonic sinuses of Valsalva to the bifurcation. The annulus measured at 27 mm and we used a size 28 straight polyethylene terephthalate graft for our reconstruction. Three scallops were cut into the conduit. An aortic crossclamp was placed and antegrade cardioplegia was administered. We performed a Yacoub remodeling, valve-sparing pulmonic root replacement by anastomosing the graft scallops at each nadir to the corresponding pulmonary sinus using 4–0 polypropylene, sewing up each sinus to the commissures, and tying adjacent sutures on the graft exterior. The repair generated excellent geometry with a competent valve that closed symmetrically upon inspection (Figure 2, A). The distal end of the graft was trimmed, beveled, and anastomosed to the bifurcation. After completing the posterior aspect of this anastomosis, the aortic crossclamp was removed and the repair was finished as the heart reperfused (Figure 2, B). The patient easily weaned from CPB and transesophageal echocardiography confirmed excellent valve geometry without regurgitation (Figure 2, C). Total CPB time was 74 minutes and crossclamp time was 40 minutes. The patient was extubated within 6 hours, downgraded from intensive care on day 2, and discharged home on day 5. Histopathologic examination of the aneurysm revealed nonnecrotizing granulomatous arteritis (Figure 2, D-F). The differential includes sarcoidosis, connective tissue disease-associated vasculitis, or infection. An extensive rheumatological workup was negative. At follow-up, she has fully recovered from surgery and is without dyspnea or chest pain. PAAs are rare, especially without PH.2Gupta M. Agrawal A. Iakovou A. Cohen S. Shah R. Talwar A. Pulmonary artery aneurysm: a review.Pulm Circ. 2020; 102045894020908780https://doi.org/10.1177/2045894020908780Crossref PubMed Scopus (40) Google Scholar Etiologically, PAA can be congenital or acquired, and in most cases, PH is either directly associated (in the case of acquired aneurysms) or coexistent with congenital causes (eg, lesions causing pulmonary overcirculation with resultant Eisenmenger’s syndrome). Biomechanically, this is explained by Laplace’s law whereby vessel wall tension is proportional to pressure and radius, and inversely proportional to wall thickness. Other causes of acquired PAA include infection, vasculitides (eg, giant cell arteritis, Takayasu’s arteritis, or Beçet’s disease), and autoimmune or inflammatory diseases (eg, sarcoidosis).2Gupta M. Agrawal A. Iakovou A. Cohen S. Shah R. Talwar A. Pulmonary artery aneurysm: a review.Pulm Circ. 2020; 102045894020908780https://doi.org/10.1177/2045894020908780Crossref PubMed Scopus (40) Google Scholar, 3Steireif S.C. Kocher G.J. Gebhart F.T.F. Schmid R.A. True aneurysm of the peripheral pulmonary artery due to necrotizing giant cell arteritis.Eur J Cardio Thorac Surg. 2014; 45: 755-756https://doi.org/10.1093/ejcts/ezt411Crossref PubMed Scopus (11) Google Scholar, 4Moghaddam N. Moghaddam B. Dehghan N. Brunner N.W. Isolated large vessel pulmonary vasculitis leading to pulmonary artery aneurysm formation: a case report and literature review.Pulm Circ. 2018; 82045894018765346https://doi.org/10.1177/2045894018765346Crossref PubMed Scopus (5) Google Scholar Typically, PAAs are clinically silent. Symptoms, when present, are usually due to underlying disease processes (eg, PH) or anatomical, such as compression of the LMCA resulting in chest pain, as in this case. Due to the possibility of fatal rupture or dissection, surgical treatment of PAA should be considered in aneurysms measuring ≥5.5 cm, those with diameter increases ≥0.5 cm within 6 months, in cases associated with PH, and when aneurysms cause significant symptoms or compression of adjacent structures.2Gupta M. Agrawal A. Iakovou A. Cohen S. Shah R. Talwar A. Pulmonary artery aneurysm: a review.Pulm Circ. 2020; 102045894020908780https://doi.org/10.1177/2045894020908780Crossref PubMed Scopus (40) Google Scholar Surgery typically consists of replacing the aneurysmal PA and root, when involved, using synthetic conduits or homografts. Whereas valve-sparing approaches to the pulmonic root have been infrequently described, they are technically feasible either in the case of pulmonic root aneurysm or for aneurysmal dilation of pulmonary autografts following the Ross operation.5Goldstone A.B. Woo Y.J. Pulmonary autograft leaflet repair and valve sparing root replacement to correct late failure of the ross procedure.J Card Surg. 2013; 28: 496-499https://doi.org/10.1111/jocs.12150Crossref PubMed Scopus (6) Google Scholar, 6Goldstone A.B. Jensen C.W. Bilbao M.S. Woo Y.J. Autograft valve-sparing root replacement for late ross failure during quadruple-valve surgery.Ann Thorac Cardiovasc Surg. 2017; 23: 313-315https://doi.org/10.5761/atcs.cr.16-00264Crossref PubMed Scopus (3) Google Scholar, 7Goldstone A.B. Woo Y.J. Valve-sparing reoperations for failed pulmonary autografts.J Thorac Cardiovasc Surg Tech. 2021; 10: 408-412Scopus (3) Google Scholar, 8Circi R. Boysan E. Behlul Altunkeser B. Aygul N. Cagli K. Cagli K. et al.David’s procedure for pulmonary artery aneurysm.J Card Surg. 2020; 35: 942-945https://doi.org/10.1111/jocs.14480Crossref PubMed Scopus (4) Google Scholar, 9Carino D. Mehta N. Fernández-Cisneros A. Pereda D. Surgical correction of a pulmonary artery aneurysm with severe pulmonary regurgitation with a valve-sparing technique.Interact Cardiovasc Thorac Surg. 2020; 30: 159-160https://doi.org/10.1093/icvts/ivz224Crossref PubMed Scopus (1) Google Scholar Typically, the reimplantation technique is applied, although due to the close proximity of the pulmonic annulus and LMCA, placing subannular sutures can be treacherous. Hence, we employed the Yacoub remodeling technique in this case, avoiding risks of injuring the LMCA while allowing for complete aneurysm resection. This technique is especially attractive for aneurysms in the absence of PH given the low risk of further aneurysmal dilation and late valve failure with normal right-sided pressures. Regardless of etiology, centers with sufficient expertise in valve-sparing aortic surgery can safely apply these same techniques to the pulmonic root.