The endoclamp device as a useful strategy during redo surgery on the aortic root and arch

The endoclamp device has been widely used in mini-invasive mitral valve surgery with very good results compared to the transthoracic clamp [1]. Some authors have underlined the safety and effectiveness of this device in complex and emergency operations [2]. We reported our experience during a redo operation related to a pseudoaneurysm that developed for total proximal anastomosis detachment after a classic Bentall operation.
A 19-year-old man with Marfan syndrome underwent a Bentall procedure due to a 55 mm aortic root aneurysm and severe bicuspid aortic valve regurgitation. Nine months later, he complained of fever, malaise and enteritis. Inflammatory markers were rising. Blood culture showed positivity of Staphylococcus hominis. Combination antibiotic therapy with gentamicin, ceftriaxone and vancomycin was started. An emergency transesophageal echocardiogram (TEE) and color Doppler mapping revealed the detachment of the valve conduit from the annulus and a large pseudoaneurysm. The prosthetic valve appeared to have normal motion and to be free of any vegetation. No aortic regurgitation was noted either (Figure 1 A). Color-flow imaging showed the entrance of most of the cardiac stroke volume into a large pseudoaneurysm covering almost the entire circumference and length of the Dacron graft as far as it could be seen (Figure 1 B). The computed tomography (CT) scan confirmed the TEE evidence (Figure 1 C). An urgent operation was planned. We decided to use an endoclamp device (End^oClamp Intra-aortic Occlusion Device, Edwards Lifesciences Corp); for this reason we inserted in the femoral artery an EndoReturn Arterial Cannula 21 Fr. The cardiopulmonary bypass was initiated prior to resternotomy with cannulation of the femoral vessels. After the resternotomy, massive bleeding from the right atrium happened. Immediately, the endoclamp device was inflated (Figure 2 A), the heart was arrested using Custodiol cardioplegia. A huge pseudoaneurysm was detected and the valve conduit was found to be hanging above the aortic ring, fully detached and suspended in place by the coronary arteries (Figure 2 B). Because the aortic annulus was completely destroyed by a previous endocarditis, we decided to implant a new valve conduit inside the left ventricular outflow tract (Figure 2 C). The postoperative period was uneventful and the patient was discharged home in good general condition.
This is new strategy to treat a giant pseudoaneurysm that...


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