blindly punching between aorta and right atrium is dangerous . in that case , there is concerned about leakage between the two referred isolate parts .
besides , as the routine imaging techniques ( echocardiography or computer tomography ) are incompetent to detect this particular anatomic structure preoperatively , the intraoperative inspection appears necessary .
the thrombosis surrounding prosthesis was detected in the first ultrasound examination after the operation , which was considered to be an indication of successful hemostasis .
as the innate fusion between aorta and right atrium appears no rare , the selective creation of left - to - right internal shunt is a valuable maneuver for controlling bleeding in appropriate cases .
bentall procedure using composite valve - graft prosthesis is still considered an economical and reliable alternative for aortic root surgery today ( 1 ) .
we employed the modified bentall procedure with internal shunt technique on complex occasions for hemostasis .
the internal shunt that goes through from within the aortic aneurysm sac to right atrium is considered as a facile approach for suitable case .
an innate fusion between the aortic wall and right atrium is prerequisite for this approach .
this report introduces a simple method of how to identify the fusion and create the internal shunt .
the anesthesia and cannulation procedure for aortic root repair were performed in a standard manner as we described before ( 2 ) . after a longitudinal aortotomy above sinotubular junction ,
the lesion of aortic root should be carefully inspected under direct vision . under the circumstance of enough extent of coronary arteries ( ca ) , a modified bentall procedure was determined .
the affected aortic valve cusps were carefully cut off . a prefabricated mechanical valved conduit open pivot ( medtronic , minneapolis , minnesota )
either continuous running suture or mattress suture was performed for the conduit implantation , depending on the surgeon s preference .
then , two 8 mm holes were made by cautery in the conduit graft opposite to ostia of ca .
the ostia were anastomosed directly to the conduit in end to side fashion with continuous 7 - 0 polypropylene suture ( ethicon , cincinnati , ohio ) .
following the completion of all major anastomosis , essential pledget sutures were added for reinforcement .
the internal shunt was created just before the cardiopulmonary bypass ( cpb ) going to be weaned off . a small purse - string suture with 4 - 0 polypropylene was made in the right atrial wall between venous cannula and tip of right atrial appendage , within which a small incision was made .
a right angle retractor for papillary muscle ( shanghai medical instruments , shanghai , china ) was inserted into the right atrium inside the purse - string to detect the existence of the atrium - aorta fusion .
a silicone rubber shod was placed over the suture line and snared down for holding and hemostasis temporarily . for the fusion site inspection ,
the tip of the stick - like retractor was pushed against atrial wall towards the aorta , the adventitia was pulled away and back to the atrial side simultaneously . by this means , the fusion that locates frequently within non - coronary aortic sinus can be precisely identified ( figure 1 ) .
a puncture was made by using scalpel blade no.11 ( shanghai medical instruments , shanghai , china ) at the very site from within aneurysm , which was then bluntly widened to about 8 mm in diameter by opening forceps tip ( figure 1b ) .
the fistula should be carefully checked for breakage in the atrium - aorta junction . in that case
the probe was taken out , and the purse - string suture was tied to close the incision in right atrium . in the cases of concomitant procedure via right atrium approach ( e.g. mitral valve replacement ) , a right - angle forceps was employed as an alternative forlocating and creating the shunt from within the right atrium .
( a ) diagram of locating the puncturing site using a right angle stick - like retractor , drainage direction was showed in upper left red box ; ( b ) operative image of creating the internal shunt with an right angle forceps .
once the fistula was accomplished , the wrapping procedure was processed over the revision with autologous or glutaraldehyde - preserved bovine pericardial patch ( figure 1a upper left ) .
from 2010 to 2015 , we performed the modified bentall procedure with internal shunt on 29 patients ( 23 male ) .
concomitant procedures were as follow : total aortic arch replacement with elephant trunk implantation in 18 cases , hybrid procedure in 2 cases , and mitral valve replacement in 1 case .
the mean postoperative blood transfusion was 3.5 2.2 u. three patients were free from homologous blood transfusion .
neither patent fistula nor new - onset arrhythmia due to the procedure was observed in follow - up .
the wrapping - shunt technique we currently employ is inspired by stepwise modifications of cabrol s shunt maneuver ( 3 , 4 ) .
it is appropriated for the cases of dilated aortic root with a good extent of cephalic end of coronary artery .
blindly punching between aorta and right atrium is dangerous . in that case , there is concerned about leakage between the two referred isolate parts .
besides , as the routine imaging techniques ( echocardiography or computer tomography ) are incompetent to detect this particular anatomic structure preoperatively , the intraoperative inspection appears necessary .
the thrombosis surrounding prosthesis was detected in the first ultrasound examination after the operation ( figure 2 ) , which was considered to be an indication of successful hemostasis .
as the innate fusion between aorta and right atrium appears no rare , the selective creation of left - to - right internal shunt is a valuable maneuver for controlling bleeding in appropriate cases .
yellow arrow indicates mechanical valve , red arrow indicates thrombosis surrounding prosthesis ; ( b ) and ( c ) pre- and postoperative enhanced computer tomography scan of the same patient .
 introduction : blindly punching between aorta and right atrium is dangerous . in that case , there is concerned about leakage between the two referred isolate parts . 
 besides , as the routine imaging techniques ( echocardiography or computer tomography ) are incompetent to detect this particular anatomic structure preoperatively , the intraoperative inspection appears necessary . 
 our method is useful for identifying this innate fusion plane.case report : the thrombosis surrounding prosthesis was detected in the first ultrasound examination after the operation , which was considered to be an indication of successful hemostasis . 
 as the innate fusion between aorta and right atrium appears no rare , the selective creation of left - to - right internal shunt is a valuable maneuver for controlling bleeding in appropriate cases . 
Introduction:
Case report:
1. INTRODUCTION
2. CASE REPORT
3. DISCUSSION