Re-operation for a detached left coronary button from an aortic root conduit causing a large retro-sternal pseudoaneurysm.

Our goal was to replace the previous composite graft with a bioprosthesis. The approach involved axillary artery and femoral vein cannulation and cardiopulmonary bypass with moderate hypothermia for re-entry of the chest and deep hypothermia with circulatory arrest to get control of and to clamp the aorta when entering the pseudoaneurysm. The myocardial protection strategy was general cooling and retrograde cardioplegia through direct coronary sinus cannulation and antegrade cardioplegia in the coronary ostia when possible. After the pseudoaneurysm was entered, the graft was divided in the middle, and the distal end was dissected out under circulatory arrest sufficiently to allow clamping and to resume systemic circulation. The graft was not dissected out beyond the previous anastomosis. Under another period of circulatory arrest, the distal graft was removed to the mid-arch, and a new graft was attached with a hemiarch anastomosis. Then the root was dissected out, and both coronary ostia were mobilized. The mechanical aortic valve and previous graft material were explanted. A new bioprosthetic valved conduit was used to replace the aortic root, and the coronary buttons were re-implanted directly in the new graft.