Root Replacement With "French Cuff" Technique: A Challenging Redo Case

<div>Aortic root reoperation represents a great challenge for the cardiovascular surgeon, with a hospital mortality that ranges between 8% and 15% in the literature [1-4]. Arch repair interventions with zone 0 (or zone 1) distal anastomosis and arch vessel reimplantation with separate branches are increasingly performed. On the one hand, this technique both simplifies distal suturing and minimizes the risk of recurrent nerve injury; however, it complicates secondary root interventions due to the encumbrance of the arch vessel branches in the mediastinum that make chest reopening, arterial cannulation, and aortic clamping more hazardous and problematic. Valid surgical techniques and strategies are crucial to obtain a successful final result. Chest re-entry, arterial and venous cannulation, and myocardial and cerebral protection have to be carefully planned based on the patient's anatomy and clinical conditions [5].</div><div>The aim of this video is to share the approach the authors adopted for a redo Bentall intervention in a patient who had undergone, one year earlier in the authors' institution, arch replacement interventions with zone I distal anastomosis and arch vessels reimplantation with separate branches for a DeBakey type I acute aortic dissection. After careful dissection of the old vascular prosthesis, rerouting of the arch vessel branches was performed to facilitate both aortic cross-clamping and access to the aortic root, while the "French cuff" technique [6] was used for the construction of the biological composite valved conduit and the root replacement. The procedure was successful, and the patient was uneventfully discharged seven days postoperatively.<br></div><div><p><strong>References</strong></p><ol><li>Etz CD, Plestis KA, Homann TM, et al. Reoperative aortic root and transverse arch procedures: a comparison with contemporaneous primary operations. <em><a href="https://doi.org/10.1016/j.jtcvs.2007.11.071">J Thorac Cardiovasc Surg. 2008;136(4):860-867</a></em>.</li><li>Malvindi PG, van Putte BP, Heijmen RH, Schepens MA, Morshuis WJ. Reoperations on the aortic root: experience in 46 patients. <em><a href="https://doi.org/10.1016/j.athoracsur.2009.09.014">Ann Thorac Surg. 2010;89(1):81-86</a></em>.</li><li>LeMaire SA, DiBardino DJ, Koksoy C, Coselli JS. Proximal aortic reoperations in patients with composite valve grafts. <em><a href="https://www.ncbi.nlm.nih.gov/pubmed/12440664">Ann Thorac Surg. 2002;74(5):S1777-S1799</a></em>.</li><li>Di Eusanio M, Berretta P, Cefarelli M, et al. Reoperative aortic root replacement: short- and long-term outcomes in 111 patients [in Italian]. <em><a href="https://doi.org/10.1714/1168.12951">G Ital Cardiol (Rome). 2012;13(11):745-750</a></em>.</li><li>Shrestha M, Khaladj N, Baraki H, et al. Aortic root reoperation: a technical challenge. <em><a href="https://www.ncbi.nlm.nih.gov/pubmed/20369500">J Heart Valve Dis. 2010;19(2):177-181</a></em>.</li><li>Yan TD. Mini-Bentall procedure: the "French cuff" technique. <em><a href="https://doi.org/10.1016/j.athoracsur.2015.06.092">Ann Thorac Surg. 2016;101(2):780-782</a></em>.</li></ol></div>