American one-cut ascending and aortic root resection technique

Central MessageThe American one-cut root resection technique is a safe technique to quickly resect the aortic aneurysm in one piece and can be used in almost any procedure that requires root aneurysm removal. The American one-cut root resection technique is a safe technique to quickly resect the aortic aneurysm in one piece and can be used in almost any procedure that requires root aneurysm removal. Thoracic aortic aneurysm is an important disease, affecting more than 424,000 people in the world each year.1Gouveia E Melo R. Silva Duarte G. Lopes A. Alves M. Caldeira D. Fernandes E Fernandes R. et al.Incidence and prevalence of thoracic aortic aneurysms: a systematic review and meta-analysis of population-based studies.Semin Thorac Cardiovasc Surg. 2022; 34: 1-16Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar The root and ascending aorta are commonly affected in these patients.1Gouveia E Melo R. Silva Duarte G. Lopes A. Alves M. Caldeira D. Fernandes E Fernandes R. et al.Incidence and prevalence of thoracic aortic aneurysms: a systematic review and meta-analysis of population-based studies.Semin Thorac Cardiovasc Surg. 2022; 34: 1-16Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Surgical intervention by resecting the aneurysmal segment and replacing it with a Dacron graft is the only definitive treatment to prevent catastrophic consequences such as life-threatening bleeding or rupture.2Isselbacher E.M. Preventza O. Hamilton Black J III, Augoustides J.G. Beck A.W. Bolen M.A. et al.Writing Committee Members2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on clinical practice guidelines.J Am Coll Cardiol. 2022; 80: e223-e393PubMed Google Scholar In patients who have dysfunctional aortic valves with severe calcification, for example, root replacement using the Bentall procedure is indicated.2Isselbacher E.M. Preventza O. Hamilton Black J III, Augoustides J.G. Beck A.W. Bolen M.A. et al.Writing Committee Members2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on clinical practice guidelines.J Am Coll Cardiol. 2022; 80: e223-e393PubMed Google Scholar However, in patients whose aortic valves are functional without calcification or fenestration or those who have aortic regurgitation due to functional aortic annulus dilation, the valve-sparing aortic root replacement (VSARR) procedure is an excellent choice.2Isselbacher E.M. Preventza O. Hamilton Black J III, Augoustides J.G. Beck A.W. Bolen M.A. et al.Writing Committee Members2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on clinical practice guidelines.J Am Coll Cardiol. 2022; 80: e223-e393PubMed Google Scholar,3Zhu Y. Woo Y.J. Cusp repair techniques in bicuspid and tricuspid aortic valves.JTCVS Tech. 2021; 7: 109-116Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar The traditional technique for resecting the root aneurysm in preparation for root replacement procedures, especially for the VSARR procedure, is a multistep process, typically consisting of aneurysmal tissue resection in a piece-by-piece fashion with iterative fine adjustments by removing extra root tissues. This process can be time-consuming, and the results may vary significantly depending on surgeon expertise. We describe a streamlined, easy-to-adopt, one-cut technique that can safely expedite the ascending and root aneurysm resection portion of the procedure. The Video 1 illustrates the one-cut technique to resect the aneurysmal aortic tissue. First, the aorta is transected just proximal to the aortic cross-clamp. Next, a longitudinal incision is made toward the left-right commissure. At the level of 0.5 cm distal to the left-right commissure and sinotubular junction (STJ), a horizontal incision is made toward the right noncommissure in the clockwise direction staying 0.5 cm above the STJ. This will leave plenty of aorta above the usually located right coronary ostium. Care should be taken in the case of a higher location of the right coronary ostium. Upon reaching the right noncommissure, the cut is curved downward into the noncoronary sinus, leaving approximately 0.5 cm of aortic tissue. This cut is stopped at the sinus nadir. Then, returning to the same left-right commissure position, a counterclockwise horizontal incision is made toward the left noncommissure again, staying 0.5 cm above the STJ and clearing the left coronary ostium. Upon reaching the left noncommissure, the cut is curved downward into the noncoronary sinus to reach the nadir and complete the resection. The ascending and root aneurysm is then removed en bloc from the thoracic cavity, and the resected aortic tissue resembles the continental US map unfortunately without Texas (Figure 1), thus the name “American” one-cut resection technique. In this article, we describe an easy-to-adopt, safe, one-cut technique that can quickly resect the ascending aortic and root aneurysm in its entirety. This technique is highly versatile and can be applied to most aortic root aneurysm replacement procedures that require aortic root aneurysm removal, such as the Bentall and VSARR procedures.4Paulsen M.J. Imbrie-Moore A.M. Baiocchi M. Wang H. Hironaka C.E. Lucian H.J. et al.Comprehensive ex vivo comparison of 5 clinically used conduit configurations for valve-sparing aortic root replacement using a 3-dimensional-printed heart simulator.Circulation. 2020; 142: 1361-1373Crossref PubMed Scopus (19) Google Scholar Distal aortic resection also can be performed under circulatory arrest when the arch is also aneurysmal. With this technique, the aneurysmal tissues can be safely removed in an expedited fashion while leaving the left and right sinuses intact for coronary button dissection and preparation as the next steps. Injuries to the coronary arteries are highly unlikely if the anatomy is normal and the horizonal incision plane remains at the level of 0.5 cm above the STJ. In some cases, however, the traditional, piece-by-piece technique may be more suitable when there is a concern regarding remaining tissue available for distal anastomosis, further aortic root and cusp assessment is indicated before proceeding with root replacement, or when abnormal root anatomy is encountered. Otherwise, we believe this American one-cut technique can be safely adopted to help facilitate the ease of aortic ascending and root aneurysm resection. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI1YzkwMTdlZmY3ZDVkNDE0NjRmYTNmY2UwYWU3NjM4ZiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk1MDg1MTI3fQ.YSW7qMNqEo-4wNS4OXaK8ffm9X81BTVSiq7epB8cNJrK_-b4eqXeWHn0SsshMoW6OSJ68S6ztxQIZ5yiVJErfKVvxH2mFD-eK8BAKixAUE_c1_VTkRbL2aecBqwJGaxBQ95jfJAK8bp2Q7z9GPC4DRXsMjFYxmsCmaC8xvtZVatgSqjUG6E1Z2Tjmv2Hp_vA6edhLSceGl59AEFcLuTGRizEXkUdhseYHdk0bORYzVhx2VfBRBZrmHY88eQNCdjyKn76oSeUV8SyfLDnNu4tJRUg8FZigwUsPTqlnTTLNKgZ_0QioiaVrI2lf2OBMri4ShGY4L1rrgwWFOwvgqiNhw Download .mp4 (7.87 MB) Help with .mp4 files Video 1Intraoperative video illustrating the one-cut technique to resect the aneurysmal aortic tissue. Video available at: https://www.jtcvs.org/article/S2666-2507(23)00072-X/fulltext. Download .jpg (.16 MB) Help with files Video 1Intraoperative video illustrating the one-cut technique to resect the aneurysmal aortic tissue. Video available at: https://www.jtcvs.org/article/S2666-2507(23)00072-X/fulltext.