MATERIAL AND METHODS
From 2015 to 2019 FAP was used for wrapping of the AA in 10 patients. In all of them the AA dimensions were below 50 mm. As none of them had bicuspid aortic valve or Marfan’s syndrome, current guidelines did not advise AA replacement9. Preoperative clinical transthoracic echocardiographic data, with particular regards to aortic root at Valsalva sinuses level, sinotubular junction (STJ), AA and proximal arch dimensions, were collected in all patients using the parasternal long axis projection. Retrospective analysis of our database was approved by the Local Institutional Review Board, which waived patient consent.
Surgical technique . The pericardium was carefully dissected toward both pleuras. A piece large in general 16 cm and as long as the AA, from the origin of the brachiocephalic trunk to the STJ, was harvested. The pericardium was trimmed to fit the concavity and the convexity of the AA and was then kept in a bowl with saline. At the end of the procedure, after protamine, the AA was dissected for its whole length and surrounded by the pericardium. It was then sutured proximally and distally to the STJ and to the aorta close to the proximal arch with 4/0 Prolene, trying not to go through the full thickness of the aorta. The pericardium was then sutured around the aorta with 4/0 Prolene and the excess of tissue cut (fig. 1A). Another suture (4/0 Prolene) is then passed parallel to the previous one, from the proximal to the distal AA (fig. 1B). This suture, after pressure reduction, either pharmacological or by means of intermittent closure of inferior vena cava, is put in tension to allow the pericardium to fit properly to the AA (fig. 1C). The final result is an AA with a size more or less similar to the preoperative one, but wrapped completely with pericardium from the STJ junction to the proximal arch (fig. 1D). In all patients who underwent myocardial revascularization, we used anaortic grafting, using as blood source the left, the right or both internal thoracic arteries.
Follow up . All patients were clinically followed at our outpatient clinic. The follow up ended on November 2021 and was 100% complete. All the patients had an intermediate echocardiography after a mean of 16±4 months. The final postoperative echocardiogram was performed between June and October 2021. Mean clinical and echocardiographic follow up was 53±14 months.
Statistical analysis . Categorical variables are expressed as counts and percentages. Distribution of continuous variables was assessed using the Shapiro‐Wilk test. Continuous variables are expressed as mean ± standard deviation if normally distributed, as median with the 25th and 75th percentiles if not normally distributed. Pre‐ and postoperative data of each group were compared by paired t‐test for normally distributed. variables, or Wilkinson test for non‐normally distributed variables. The ANOVA test for repeated measures was applied for repeated echocardiographic data. If not otherwise indicated definition of the variables follows the definition reported in the EuroSCORE II model10. For all tests, a P‐value <0.05 was considered statistically significant. The SPSS software (SPSS Inc, Chicago, IL) was used.