Surgical repair of aortic root aneurysms in 280 patients

Is valve-sparing aortic root replacement better than total aortic root replacement? An overview of reviews

Background

Total aortic root replacement (TRR) is certainly beneficial for aortic root disease, but does it still have an advantageous prognosis for patients compared to valve-sparing aortic root replacement (VSRR)? An overview of reviews was conducted to assess each of their clinical efficacy/effectiveness.

Review methods

Systematic reviews (SRs)/Meta-analyses comparing the prognosis of TRR and VSRR in aortic root surgery were collected from 4 databases, all searched from the time of database creation to October 2022. Two evaluators independently screened the literature, extracted information and applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2) tool, Grading of Recommendations, Assessment, Development and Evaluations (GRADE), and Risk of Bias in Systematic Reviews (ROBIS) to evaluate the quality of reporting, methodological quality, risk of bias, and level of evidence of the included studies.

Main results

A total of 9 SRs/Meta-analyses were ultimately included. In terms of the reporting quality of the included studies, PRISMA scores ranged from 14 to 22.5, with issues mainly in reporting bias assessment, risk of study bias, credibility of evidence, protocol and registration, and funding sources. The methodological quality of the included SRs/Meta-analyses was generally low, with key items 2, 7, and 13 having major flaws and non-key items 10, 12, and 16. In terms of risk of bias assessment, the overall assessment of the included 9 studies was high-risk. The quality of the evidence was rated as low to very low quality for the three outcome indicators selected for the GRADE quality of evidence rating: early (within 30 days postoperatively or during hospitalization) mortality, late mortality, and valve reintervention rate.

Conclusions

VSRR has many benefits including reduced early and late mortality after aortic root surgery and reduced rates of valve-related adverse events, but the methodological quality of the relevant studies is low, and there is a lack of high-quality evidence to support this.

Systematic Review Registration

https://www.PROSPERO, identifier: CRD42022381330.

Percutaneous Coronary Intervention for Iatrogenic Right Coronary Artery Dissection Post Bentall Procedure: A Case Report and Minireview

Iatrogenic coronary artery dissection is a potentially life-threatening complication of cardiovascular interventions. The optimal management of iatrogenic coronary artery dissection is not clear; however, both conservative management and percutaneous or surgical revascularization have been performed depending on the patient's clinical status and the extent of dissection. We present the first reported case of right coronary artery dissection after Bentall procedure performed for ascending aortic aneurysm. Urgent percutaneous intervention using adjunctive coronary imaging was performed with excellent clinical recovery. In this article, we highlight coronary artery dissection after Bentall procedure as a possible complication, provide an insight into various options in its management, and review published data on iatrogenic coronary artery dissection. We also discuss the challenges in percutaneous treatment of coronary artery dissection with special focus on intracoronary imaging for accurate diagnosis and guidance in the management of this complex lesion.

Is Transesophageal Echocardiography Needed before Hospital Discharge in Patients after Bentall Surgery?

BACKGOUND

Whether transesophageal echocardiography (TEE) should be routinely performed before hospital discharge after Bentall surgery remains unclear. The investigators took advantage of this practice at their institution to evaluate its benefit.

METHODS

All patients who had undergone the Bentall procedure at Bichat Hospital from January 2010 to March 2014 were included. For each patient, transthoracic echocardiographic and transesophageal echocardiographic data and clinical events were retrospectively collected from the various reports.

RESULTS

One hundred ninety-eight patients underwent the Bentall procedure during the study period. Postoperative TEE was performed in 117 patients (59.1%), including nine with abnormalities observed on transthoracic echocardiography (a vibrating element on the new prosthetic valve, suspicion of peritubular complications in two patients, and aortic regurgitation in six patients). In 108 patients, routine TEE was performed (i.e., without clinical indication beyond baseline postoperative imaging). Patients with and those without routine TEE were identical, except for more frequent endocarditis as an indication for surgery in patients with routine TEE. Routine TEE did not reveal any new findings that prior transthoracic echocardiography had not shown. The most frequent finding on transthoracic echocardiography or TEE was periaortic hematoma, which sometimes led to the performance of computed tomography. This imaging did not change the care of the patients in this population.

CONCLUSIONS

This study does not support the performance of TEE after Bentall surgery during the in-hospital course in the absence of a specific indication. Baseline postoperative imaging using TEE or computed tomography should preferably be recommended beyond the early postoperative period after periaortic hematoma has resolved.

A simple modified Bentall technique for surgical reconstruction of the aortic root - short and long term outcomes

Background

Since the first introduction of the Bentall technique, several modifications have been proposed to improve patient outcomes and decrease intra- and post-operative complications. We describe a simplified modification of the technique that tries to lessen the intra-operative time, improve homeostasis and miminize early and late complications. Our experience with the technique and short- and long-term patient outcomes are reported.

Methods

From August 1996 to October 2013, 110 consecutive patients underwent this modified technique. The procedure used Dacron composite graft with a mechanical valve (St. Jude Medical®) for aortic root replacement. To avoid intra-operative complications, no mobilization of coronary ostia was done. Additionally, the tubular aorta was kept minimally unchanged.

Results

Total bleeding after the operation was 450 ± 105 mL. The mean duration of intensive care unit and hospital stay were 2 ± 1 and 5 ± 2 days, respectively. Sixty-six patients (60 %) were discharged from the surgical intensive care unit on the first postoperative day, 34 patients (30.9 %) were discharged on the second day and ten patients (9.1 %) needed more time to stay in the intensive care unit due to haemodynamic or respiratory problems. At 5-years follow up, survival rate was 97 %. In the three deceased patients, causes of death were mediastinitis, sepsis and myocardial infarction. No operation-related complications such as anticoagulant-related hemorrhage, valve or graft thrombosis, or coronary pseudoaneurysm were occurred during follow-up.

Conclusions

The proposed modification of the Bentall technique seems to minimize late intra-operative blood loss, improves homeostasis, shortens the operation time and is associated with excellent long-term outcomes in patients undergoing composite graft replacement of the aortic root.

Long term outcomes of aortic root replacement: 18 years' experience

Background

We reviewed the long-term outcomes of aortic root replacement at Asan Medical Center and investigated the predictors affecting mortality.

Materials and Methods

A retrospective analysis was performed on 225 consecutive adult patients undergoing aortic root replacement with mechanical conduits (n=169), porcine aortic root prosthesis (n=23), or aortic homografts (n=33) from January 1992 to September 2009. The median follow-up duration was 6.1 years (range, 0 to 18.0 years).

Results

The porcine root group was older than the other groups (freestyle 55.9±14.3 years vs. mechanical 46.3±14.6 years, homograft 48.1±14.7 years; p=0.02). The mechanical group had the highest incidence of the Marfan syndrome (mechanical 22%, freestyle 4%, homograft 3%; p=0.01). Surgery performed for infective endocarditis was more frequent in the homograft group (mechanical 10%, freestyle 10%, homograft 40%; p<0.001). The overall 30-day mortality was 5.3% (12/225). Actuarial survival rates in the mechanical, porcine root, and homograft groups were 79.4%, 81.5%, and 83.5% at 5 years and 67%, 61.9%, and 61.1% at 10 years, respectively (p=0.73). By multivariate analysis, preoperative diabetes mellitus, older age, and longer cardiopulmonary bypass time were independent predictors of mortality. Incidence of postoperative complications, including infective endocarditis and thromboembolism were comparable in all of the groups.

Conclusion

Aortic root replacement can be safely performed with different types of prostheses as the outcome was not affected by the choice of prosthesis. Further studies are required to assess the long-term durability of biological prostheses.

Revival of Continuous Suture Technique in Aortic Valve Replacement in Patient with Aortic Valve Stenosis a Novel Modified Technique

Objective

The continuous suture technique has numerous advantages as simple, quick, and effective for aortic valve replacement; however, it is technically difficult. We have modified the continuous suture technique and evaluated our new technique in patients with aortic stenosis.

Methods

Between July 2007 and May 2010, 86 patients with aortic valve stenosis underwent aortic valve replacement alone or with other concomitant cardiac procedures including mitral valve surgery in our hospital. The patients were randomly divided into two groups: group A (n = 43) in which the continuous suture technique with some modifications was used and group B (n = 43) in which the conventional interrupted suture technique was used. There were no statistical differences between two groups in age, sex, body surface area, concomitant cardiac procedures, blood loss, and postoperative extubation time.

Results

The aortic cross-clamp time, cardiopulmonary bypass time, operation time, and hospital stay were significantly shorter in group A than that in group B, and the valve size was significantly larger in group A. No perivalvular leak was detected in postoperative echocardiograms. All patients recovered satisfactorily without complications associated with suture technique or prosthesis. During follow-up of 4 to 38 months, there were no clinically significant complications in group A, while one patient in group B developed perivalvular leakage requiring reoperation 3 months after surgery.

Conclusions

Our modified continuous suture method is useful for aortic valve replacement in patients with aortic stenosis and beneficial for the patients because the procedure is less invasive and a larger valve can be implanted.

A refined flanged Bentall technique using Valsalva tube graft for proximal reinforcement

Bleeding from the proximal suture line during aortic root replacement using a composite valve graft is a crucial and catastrophic problem. We present a simple flanged Bentall technique using a Valsalva tube graft to eliminate bleeding from the proximal suture line. The method is to wrap the proximal anastomosis completely by sewing the Valsalva flange to the residual aortic wall. The wrapping is facilitated by the use of part of a horizontally stretching Valsalva graft. This refined technique is effective and reproducible to prevent bleeding from the proximal suture line after the Bentall procedure.

Ten years experience of aortic root replacement using a modified bentall procedure with a carrel patch and inclusion technique

OBJECTIVE

A modified Bentall procedure with a Carrel patch and inclusion technique (Modified Bentall Procedure) has been used to treat combined disease of the aortic valve and aortic root. The current study examined the outcomes of this surgical technique.

MATERIALS AND METHODS

Between April 1999 and March 2009, 16 patients (10 males, 6 females; 63.3 ± 9.4 years) underwent elective surgery involving the Modified Bentall Procedure and no additional surgery, so they were included in the study.

RESULTS

The mean cardiopulmonary bypass time was 140.2 ± 34.4 min (range: 97-232 min), and aortic cross-clamp time was 97.3 ± 16.6 min (range: 76-132 min). There were no hospital deaths. No patients required additional surgery to correct excessive bleeding. The follow-up rate was 100% (16/16). The mean follow-up period was 5.6 ± 2.8 years (range: 0.7-9.9 years). One of the 16 patients died (6.3%) due to lung cancer, and 1 of the 15 surviving patients required additional surgery (6.7%) for a thoracic aortic aneurysm. Kaplan-Meier analysis found that 1-year and 5-year survival and event-free survival rates were all 100%.

CONCLUSIONS

The Modified Bentall Procedure provided satisfactory results over both the short term and long term.

Aortic root surgery in septuagenarians: impact of different surgical techniques

Background

To evaluate the impact and safety of different surgical techniques for aortic root replacement (ARR) on early and late morbidity and mortality in septuagenarians undergoing ARR.

Methods

Ninety-five patients (73.8 ± 3.2 years) were operated and divided into three groups according to the aortic root procedure; MECH-group (n = 51) patients with a mechanical composite graft, BIO-group (n = 22) patients with a customized biological composite graft, and REIMPL-group (n = 22) patients with a valve sparing aortic root reimplantation (David I). In 42.1% (40/95) of these patients the aortic arch was replaced. Follow-up was completed in 95.2% (79/83) of in-hospital survivors.

Results

Hospital mortality was 12.6% (12/95) in the entire population (MECH. 15.7% (8/51), BIO 19.7% (4/22), REIMPL 0% (0/22); p = 0.004). Two patients died intraoperatively. The most frequent postoperative complications were prolonged mechanical ventilation ((>48 h) in 16.8% (16/93) (MECH. 7% (7/51), BIO 36.4% (8/22), REIMPL 4.5% (1/22); p = 0.013) and rethoracotomy for postoperative bleeding in 12.6% (12/95) (MECH. 12% (6/51), BIO 22.7% (5/22), REIMPL 4.5% (1/22); p = 0.19). Nineteen late deaths (22.9%) (19/83) (MECH 34.8% (15/43), BIO 16.7% (3/18), REIMPL 4.5% (1/22); p = 0.012) occurred during a mean follow-up of 41 ± 42 months (MECH 48 ± 48 months, BIO 25 ± 37 months, REIMPL 40 ± 28 months, p = 0.028). Postoperative NYHA class decreased significantly (p = 0.017) and performance status (p = 0.027) increased for the entire group compared to preoperative values.

Conclusion

Our data indicate that valve sparing aortic root reimplantation is safe and effective in septuagenarians, and is associated with low early and late morbidity and mortality.

Composite aortic valve graft replacement: mortality outcomes in a national registry

BACKGROUND

Composite aortic valve and root replacement (CVG) is a complex surgical procedure, but excellent center-specific outcomes are reported. We sought to report outcomes in a national cohort.

METHODS AND RESULTS

The United Kingdom Heart Valve Registry was interrogated for 1962 first-time CVG (and 37,102 aortic valve replacements [AVR] as a reference group) procedures from 1986 to 2004. We analyzed 30-day mortality, long-term survival (97.2% complete follow-up), and examined available risk factors for mortality using univariate and multivariate logistic regression analysis and causes of death. CVG patients were younger, received larger valve sizes and were more likely to be emergent than AVR patients. Overall 30-day mortality was 10.7% (CVG) and 3.6% (AVR). For CVG, multivariate analysis identified advanced age (> 70 years), concomitant coronary artery surgery, impaired left ventricular function, urgent or emergency status, prosthetic valve size < or = 23 mm and hospital activity volume < or = 8 procedures per annum as significant factors for 30-day mortality. Kaplan-Meier, 1-year, 5-year, 10-year and 20-year survival were 85.2%, 77.1%, 70% and 59.3%, respectively. The conditional (post-30-day) survival was similar to the AVR cohort.

CONCLUSIONS

These Registry data provide a unique national insight into CVG outcomes. After a higher initial mortality risk, CVG has equivalent conditional longer-term survival to AVR.

Composite aortic root replacement using the classic or modified Cabrol coronary artery implantation technique

BACKGROUND

We report in this study our results with composite aortic root replacement (CVR) using the classic or modified Cabrol coronary implantation technique.

MATERIAL AND METHODS

From October 2001 to March 2005, 25 patients underwent aortic root replacement. In all cases, the indication for surgery was a degenerative aneurysm with a diameter of more than 6 cm. Seven patients had undergone a previous aortic operation on the ascending aorta. Mean age was 53+/-13 years and 22 patients were male. Mean Euroscore was 5.2+/-2.4. Aortic insufficiency was present in all patients. Two patients had Marfan syndrome.

RESULTS

The 30-day mortality was 0%. Two patients required profound hypothermic circulatory arrest. Mean aortic cross-clamp time was 91+/-24 minutes and the mean circulatory arrest time was 24+/-15 minutes. No patients developed a pseudoaneurysm after the operation.

CONCLUSION

We conclude that composite aortic root replacement with the classic or modified Cabrol technique results in a low operative mortality. However, it should be only used when a "button" technique is not feasible.

Short-Term and Intermediate-Term Outcomes of Aortic Root Replacement with St. Jude Mechanical Conduits and Aortic Allografts

BACKGROUND

Few studies have directly evaluated outcomes in patients undergoing aortic root replacement with St. Jude mechanical conduits or aortic allografts (ALLO), yet both approaches have been advocated. The purpose of this study was to provide a detailed description of outcomes in a large series of aortic root replacements performed with either St. Jude mechanical conduits or aortic allografts.

METHODS

A retrospective analysis was performed on 172 consecutive adult patients undergoing aortic root replacement with either St. Jude mechanical conduits (n = 73) or aortic allografts (n = 99) from January 1990 to December 2002. Maximal follow-up was 15 years, and median follow-up was 5 years.

RESULTS

Both groups were similar with regard to median age, preoperative ejection fraction, and New York Heart Association class. The aortic allograft patient group had a higher proportion (p < 0.05) of women (43% versus 18%), prior sternotomies (52% versus 26%), preoperative renal failure (9% versus 1%), and cerebrovascular disease (16% versus 4%). Operative indications for the aortic allograft group were more frequently endocarditis (29% versus 3%; p < 0.0001) and prosthetic valve dysfunction (13% versus 1%; p < 0.01), and less frequently annuloaortic ectasia (34% versus 60%; p < 0.001) or aortic dissection (3% versus 26%; p < 0.0001). Concomitant coronary artery bypass grafting or other valve surgery was performed in 30% of patients in both groups. Incidence of early postoperative complications, including bleeding, stroke, renal failure, and respiratory failure, was similar in both groups. Thirty-day mortality was 5.5% in the St. Jude mechanical conduit group and 8.1% in the aortic allograft group (p = 0.4). Unadjusted actuarial survival at 1, 5, and 10 years was 90%, 81%, 67%, and 86%, 70%, 67%, for the St. Jude mechanical conduit and aortic allograft groups, respectively (p = 0.09). Event-free survival at 1 and 5 years was similar for both groups (p = 0.4). By multivariate analysis, New York Heart Association class III or IV, emergently performed aortic root replacement, and postoperative respiratory failure, but not valve conduit type (p = 0.3), were independent predictors of mortality.

CONCLUSIONS

Aortic root replacement can be safely performed with either allograft or mechanical conduits, even in the setting of acute dissection, redo sternotomy, or endocarditis.

Aortic root replacement surgery: indications, techniques and outcomes

Aortic root pathology is a common cause of aortic insufficiency. Aortic root aneurysm and aortic dissection, if left untreated, carry significant risk of mortality and morbidity. Surgical treatment involves replacement of the aortic valve, sinuses and ascending aorta. A number of prosthetic options have been developed including composite valve-synthetic graft, xenograft, homograft and pulmonary autograft. The current review describes the two main indications for aortic root replacement surgery, aortic dissection and root aneurysm, and discusses the various operative strategies and outcomes.

Surgery for Aneurysms of the Aortic Root

BACKGROUND

This study evaluated long-term results of aortic root replacement and valve-preserving aortic root reconstruction for patients with aneurysms involving the aortic root.

METHODS AND RESULTS

Two-hundred three patients aged 53+/-16 years (mean+/-SD; 153 male, 50 female) underwent elective or urgent aortic root surgery from 1971 to 2000 for an aortic root aneurysm: 149 patients underwent a composite valve conduit reconstruction, and 54 patients underwent valve-preserving aortic root reconstruction. Fifty patients had Marfan syndrome. In-hospital and 30-day mortality was 4.0% (8/203) overall: for a composite valve conduit procedure, the corresponding value was 4.0% (6/149) and for valve-preserving procedure, 3.7% (2/54) (P=NS). Morbidity included 3 strokes (1%), 10 perioperative myocardial infarctions (5%), and 8 reoperations for bleeding (4%). Actuarial survival at 5, 10, 15, and 20 years was 93% (95% confidence interval [CI] = 88% to 97%), 79% (95% CI = 71% to 87%), 67% (95% CI = 57% to 79%), and 52% (95% CI = 36% to 69%), respectively. Freedom from reoperation was 72% (95% CI = 54% to 86%) at 20 years. Complications with anticoagulation occurred in 29 patients; with valve thrombosis, in 2; and with hemorrhage, in 27 (4 life threatening and 23 minor). Freedom from thromboembolism was 91% (95% CI = 77% to 98%) at 20 years. Freedom from endocarditis was 99% (95% CI = 92% to 100%) at 20 years. Multivariate analysis revealed preoperative mitral valve regurgitation (+3 to 4) and older age to be significant predictors of late death (P< or =0.005), and Marfan syndrome, initial valve-preserving aortic root reconstruction, and need for a concomitant procedure at initial operation to be significant predictors of the need for reoperation (P< or =0.01).

CONCLUSIONS

Aortic root replacement for aortic root aneurysms can be done with low morbidity and mortality. Composite valve conduit reconstruction resulted in a durable result. There were few serious complications related to the need for long-term anticoagulation or a prosthetic valve. Reoperation was most commonly required because of failure of the aortic valve when a valve-preserving aortic root reconstruction was performed or for other cardiac or aortic disease elsewhere.

Late reoperation for proximal aortic and arch complications after previous composite graft replacement in marfan patients

BACKGROUND

Marfan patients who received composite graft replacement for proximal aortic disease frequently require late reoperation. The initial surgical technique for this lesion remains controversial.

METHODS

Fourteen Marfan patients who received composite graft replacement for annuloaortic ectasia with or without aortic dissection required late reoperation thorough re-median sternotomy. The techniques used for an initial composite graft replacement were the original Bentall procedure in 11 patients, the Cabrol procedure in 2, and coronary button technique in 1. Reoperation was indicated for prosthesis-related complications in 10 patients, distal aortic lesion in 13, or for both lesions in 8. Reoperations were performed, on average, 8.4 years after an initial operation. Reoperative procedures included re-composite graft replacement in 1 patient, total arch replacement in 5, and re-composite graft replacement with total arch replacement in 8.

RESULTS

There were two in-hospital deaths (14.3%). Although pseudoaneurysms of the coronary artery or distal aorta occurred in the original Bentall or Cabrol procedures, true aneurysms of the coronary artery were noted even in the coronary button technique. Six patients required a total of eight subsequent descending or thoracoabdominal aortic replacements for an aneurysmal formation of a distal false lumen.

CONCLUSIONS

The coronary button technique, with a small side hole for coronary anastomosis, is the procedure of choice for annuloaortic ectasia because it reduces the risk of coronary artery-related complications. Concomitant total arch replacement may be recommended for annuloaortic ectasia with DeBakey type I aortic dissection in selected patients to avoid the risk of reoperation on the aortic arch.

Aortic root replacement with composite valve graft

BACKGROUND

Composite valve graft replacement is currently the treatment of choice for a wide variety of lesions of the aortic root and the ascending aorta. In this study we report our experience with aortic root replacement using a composite graft.

METHODS

Between October 1978 and May 2001, 274 patients (79.6% male and 20.4% female) with a mean age of 53.5 years underwent composite graft replacement of the aortic root. One hundred sixty-one patients (70.8%) had annuloaortic ectasia and 46 (16.8%) aortic dissection. The classic Bentall technique was used in 94 patients (34.3%), the "button technique" in 172 patients (62.8%), and the Cabrol technique in 8 patients (2.9%).

RESULTS

The early mortality rate was 6.9% (19 of 274 patients). Cardiopulmonary bypass time longer than 180 minutes and associated coronary artery bypass grafting were found to be independent risk factors of early mortality. The actuarial survival rate was 77.7% at 5 years and 63% at 10 years. The independent risk factors for late mortality were coronary artery disease, chronic renal failure, and postoperative dialysis. The actuarial freedom from reoperation on the remaining aorta was higher among patients without Marfan syndrome (94.6% versus 79.6% at 10 years, p = 0.008).

CONCLUSIONS

Composite valve graft replacement can be performed with low hospital mortality and morbidity. The button technique offers some advantages and should be used whenever possible. In case of acute aortic dissection root replacement is usually not necessary. Marfan patients should be treated with early root replacement before dissection occurs.

Fate of coronary ostial anastomoses after the modified Bentall procedure

BACKGROUND

Introduction of the modified Bentall procedure with the button technique has reduced but not eliminated anastomotic complications in patients receiving a composite aortic conduit. Particularly the true incidence of coronary ostial complications such as stenosis, kinking or pseudoaneurysm formation needs to be assessed.

METHODS

We reviewed 71 patients receiving a composite aortic conduit from November 1993 to November 1999 for chronic aneurysms (n = 51) or aortic dissection (n = 20), 12 of whom had Marfan syndrome. Patients were divided into two groups according to variations in the surgical technique. In group 1 (30 patients; 42%) the classic modified Bentall operation with the button technique was employed whereas in group 2 (41 patients; 58%) some technical modifications were added mainly consisting of a reinforcement suture joining the cut edge of the aortic wall and the prosthetic sewing ring and suture of the coronary buttons with an "endo-button" technique. To detect potential procedure-related complications particularly at the coronary ostia anastomoses follow-up included transthoracic two-dimensional echocardiography every 6 months and computerized tomographic angiography at 12 months or whenever indicated; in 20 patients a magnetic resonance imaging angiography and standard aortography with selective coronary angiography were also added.

RESULTS

At a mean follow-up of 49 +/- 19 months anastomotic complications occurred in 4 patients (6%): in 2 a pseudoaneurysm developed at the distal aortic suture line and in 1 a pseudoaneurysm developed at the right coronary ostium after repair of acute aortic dissection; in 1 Marfan patient an aneurysm of the left coronary ostium developed. Such complications were unrelated to the two surgical techniques used in this series for reimplantaion of the coronary ostia.

CONCLUSIONS

The modified Bentall operation is associated with an extremely low incidence of anastomotic complications particularly at the coronary ostia. More extensive use of new imaging techniques is desirable to assess the true incidence of such complications in patients receiving a composite aortic conduit.

Proximal aortic reoperations in patients with composite valve grafts

BACKGROUND

The purpose of this study was to examine our experience with proximal aortic reoperations in patients with composite valve grafts (CVGs) and assess postoperative survival and morbidity.

METHODS

Since 1991, 33 patients with CVGs underwent reoperation for one or more of the following indications: aneurysms distal to the CVG (n = 20, 61%), false aneurysms (n = 13, 39%) and graft infection (n = 7, 21%). Operations included false aneurysm repair (n = 13, 39%), graft replacement of distal ascending aortic or transverse aortic arch aneurysm (n = 20, 61%) and aortic root re-replacement with a new CVG (n = 6, 18%) or homograft (n = 4, 12%).

RESULTS

Operative mortality was 15% (n = 5), including 2 of the 7 patients who had infected CVGs (29%). All 4 patients who had infected CVGs replaced with aortic root homografts survived. Complications included vocal cord paralysis (n = 4, 12%), bleeding requiring reoperation (n = 3, 9%) and stroke (n = 2, 6%). Actuarial 3-year survival was 74.4% +/- 7.9%.

CONCLUSIONS

Reoperations in patients with CVGs remain challenging procedures with high associated morbidity and mortality, especially in the setting of graft infection. The results of homograft aortic root re-replacement for infected CVGs are encouraging.

Aortic root replacement using composite valve graft in patients with aortic valve disease and aneurysm of the ascending aorta: twenty years' experience of late results

The purpose of this study was to evaluate the clinical outcome of composite valve graft replacement in 193 patients with aortic valve disease and aneurysm of the ascending aorta from January 1980 to June 1999. The clinical outcome was compared between the patients diagnosed with Marfan syndrome (M group) and those without Marfan syndrome (non-M group), between those with aortic dissection (AD group) and without dissection (non-AD group), between 2 different techniques for coronary artery reattachment (modified Bentall [mB] and modified Piehler [mP]), and between the time of operation (1980-1989 and 1990-1999). Long-term outcome of this procedure was almost satisfactory with actuarial survival of 71.5 +/- 4.4% at 10 years and freedom from reoperation of 76.5 +/- 4.4% at 10 years. Freedom from cardiovascular events and freedom from reoperation were significantly lower in the M group and AD group than in the non-M and non-AD groups. Also, actuarial survival was significantly higher in the latter 10 years compared with the former 10 years. It was concluded that the improvement of perioperative management and proper selection of the technique for coronary artery reattachment could have improved the clinical outcome. In patients with Marfan syndrome or aortic dissection, there still remains a higher risk of cardiovascular event and future reoperation. Extensive aortic reconstruction or staged operation should be performed in such patients.

Thymectomy by thoracoscopic approach in myasthenia gravis

BACKGROUND

A series of 25 thoracoscopic thymectomies performed in the Department of General Surgery and Liver Transplantation of the Fundeni Clinical Institute between April 1999 and April 2000 is analyzed.

METHODS

Thoroscopic thymectomies were performed on 4 male patients (16%) and 21 female patients (84%), aged between 8 and 60 years.

RESULTS

The mean operative time was 90 (+/-15) min. There were no conversions to open thymectomy. Mortality was nil, and morbidity consisted of one minor postoperative right pneumothorax probably related to a injury to right mediastinal pleura that was not observed intraoperatively. Hospital stay ranged from 2 to 4 days, with a mean of 2.28 days. The patients were transferred to the neurological department and they were usually discharged after 1 more day.

CONCLUSIONS

Postoperatively, all patients had clinical improvement of their disease both in symptoms and medication requirements, but a longer follow-up is necessary. The results are edifying regarding the very low morbidity, the lack of mortality, the acceptance of the patients, and the short hospitalization.

Analysis of perioperative risk factors in mortality and morbidity after modified Bentall operation

The objective of the present study was to determine the risk factors for operative and short-term mortality, and morbidity after a Bentall operation. Between July 1994 and February 2001, 86 consecutive patients (70 males) underwent a modified Bentall operation at our hospital. The aortic pathology was acute aortic dissection in 12 (14%), chronic dissection in 9 (10.5%) and degenerative aneurysm in 65 (75.6%). Mean age was 48 +/- 15 years. Eleven preoperative, 8 intraoperative and 6 postoperative variables of these patients were retrospectively analyzed using univariate and multivariate logistic regression analysis. Six patients died in the hospital (6.9%) and 2 died within four months after being discharged from the hospital. Mean follow-up time was 33 +/- 23 months (2 months to 8 years). The survival rate among hospital survivors was 88% at 3 years and 77% at 6 years. Univariate predictors of in-hospital and short-term mortality were the presence of aortic valve calcification, stenotic aortic valves, renal failure, and cardiac failure after the operation. Multivariate analysis revealed no independent risk factors. Risk factors for morbidity were etiology of acute dissection, use of circulatory arrest, transfusion of blood and fresh frozen plasma more than 2 units each, cross clamp and cardiopulmonary bypass times (exceeding 90 and 140 minutes, respectively), and performing concomitant procedures. Modified Bentall procedures are safe in general. Meticulous dissection, careful handling and positioning of the coronary buttons are of paramount importance in patients with stiff aortic root since technical errors are more likely to occur.

Influence of technique of coronary artery implantation on long-term results in composite aortic root replacement

BACKGROUND

Long-term results after composite graft aortic root replacement may depend on the insertion technique. The aim of this study is to assess the influence of the technique of coronary artery implantation on long-term results in composite aortic root replacement.

METHODS

One hundred fifty consecutive patients (mean age, 55 years; 119 men) with different disorders of the ascending aorta who underwent aortic root replacement with a composite graft prosthesis between January 1985 and December 1999 were retrospectively studied. Thirteen patients had previously undergone cardiovascular surgery. The open button technique was performed in 65 patients (43.3%, group 1) and the inclusion technique in 85 patients (56.7%, group 2). Mean follow-up was 70.5 months. Surgery was elective in 110 procedures (73%).

RESULTS

Global actuarial survival was 76.1% +/- 4.3% for group 1 and 73.7% +/- 3.9% for group 2 at 10 years (p = 0.22). Freedom from reoperation excluding early deaths was 81% +/- 3% for group 1 and 86% +/- 2.2% for group 2 at 10 years (p = 0.62). Group 2 demonstrated a statistically significantly higher occurrence of pseudoaneurysm formation versus group 1 (p = 0.04).

CONCLUSIONS

Composite graft aortic root replacement is a safe and effective therapy for proximal aortic aneurysm and dissection, resulting in good early and long-term results irrespective of the anastomotic technique. However, the open button technique seems to avoid late false aneurysm formation at the anastomotic sites.

Modified button-Bentall operation for aortic root replacement: the miniskirt technique

BACKGROUND

The aim of this study was to evaluate the midterm results of a modified button-Bentall operation (modified-bB) specifically designed to incorporate any type of prosthetic valve in composite conduit aortic root replacement.

METHODS

Between 1991 and 2000, a total of 135 patients underwent modified-bB for annuloaortic ectasia (74 patients), type A dissection (31), or aortic aneurysm without dissection (30). Of these, 34 were emergencies (25.2%). A total of 50 bioprostheses (study group 1) and 85 bileaflet mechanical prostheses (study group 2) were implanted. Group 1 mean age was 66.9 +/- 7.4 years versus 51.5 +/- 12.1 years in group 2 (p < 0.001). Composite-conduit creation occurred during proximal suture line construction as a single-step maneuver. Interrupted extracardiac polyester mattress sutures sequentially entered the aortic annulus, the prosthetic valve ring, and the vascular graft 7 mm from its free edge (miniskirt). Running monofilament suture line secured proximal hemostasis, buttressing aortic remnants and graft edge. Coronary reimplantation was accomplished in all cases by the button technique. Concomitant procedures were performed in 51 patients (37.8%).

RESULTS

The 30-day mortality was 5.18% (7/135 patients). Eight patients (5.9%) required revision for proximal (1 patient), coronary button (3), or distal (4) anastomosis leakage. Three patients (2.2%) perioperatively developed nonfatal inferior myocardial infarction. Kaplan-Meier 9-year survival is 91.8% +/- 0.026 SE with 88.1% (95% confidence limits 71.7% to 95.5%) reoperation freedom. According to the Cox proportional hazard method, stratification of the risk for death according to prosthesis type indicates previous operation (p = 0.001) and emergency (p = 0.0465) as independent predictors of hospital mortality. Associated procedures to modified-bB increased risk of reoperation (p = 0.031).

CONCLUSIONS

Modified-bB was associated with low mortality, excellent midterm survival, and freedom from reoperation. Absence of valve-to-graft tapering, reduced coronary button anastomosis tension, and prosthesis selection according to patient profile, are apparent advantages of modified-bB.

CT findings following the cabrol composite graft procedure

PURPOSE

Insertion of a composite graft and reimplantation of the coronary arteries through an intermediate Dacron tube (Cabrol composite graft procedure) has been used to treat ascending aortic aneurysms and dissections. The CT findings after the Cabrol composite graft procedure have not been previously described.

METHOD

Retrospective review of 12 postoperative CT and CT angiography (CTA) studies both in the immediate postoperative period as well as during long-term follow-up was conducted.

RESULTS

The Cabrol composite graft procedure produces typical CT findings consisting of a coronary conduit separate from the aortic graft. The presence of perigraft flow can be normal or abnormal depending on the time point of its occurrence and the extent of its hemodynamic consequences.

CONCLUSION

Knowledge of the typical CT and CTA findings following a Cabrol composite graft procedure is essential for the correct interpretation of these studies.

Redo composite valve graft replacement

BACKGROUND

Redo composite valve graft replacement remains a challenging problem, that may lead to increased surgical mortality.

METHODS

In our experience from September 1976 through December 1999, eight consecutive patients (seven men and 1 woman) underwent eight redo composite valve graft replacements. The mean age at reoperation was 43.1 years (range 31 to 51 years). Seven patients had stigmata of Marfan's syndrome. Reoperation was indicated for pseudoaneurysm formation in five patients, coronary ostial aneurysms in two patients, and active fungal endocarditis in one patient. Previous root replacement had been performed in all eight patients using a composite mechanical valve. The techniques used at previous procedures were the Bentall technique in seven and Carrel's button technique in one. The mean interval between primary root replacement and redo root replacement was 10 years (range 2 to 18 years). The patient with active fungal endocarditis having a stuck valve was subjected to emergency operation.

RESULTS

The techniques used at the reoperations included Carrel's button technique in five patients, the interposition technique (Phieler) in two patients, and Cabrol's technique in one patient. Aortic arch aneurysm repair was performed in five patients. There were two hospital deaths (2 [25%] of 8). One patient died on postoperative day 1 with low cardiac output and the other suffered a sudden cardiac arrest on postoperative day 14. The mean follow-up was 34.6 months (range 1 to 85 months). There was one late death. The cause of death was multiple organ failure due to recurrence of fungal endocarditis 6 months after redo composite and total arch replacement.

CONCLUSION

Redo composite graft replacement can be accomplished with lower early mortality, and therefore, this operation should not be delayed given the appropriate clinical circumstances. Many causes of failure of composite valve graft replacement can be avoided if the appropriate surgical technique is chosen.

Favorable outcome after composite valve-graft replacement in patients older than 65 years

BACKGROUND

Concomitant surgical replacement of the aortic valve and ascending aorta is an ideal treatment for aortic root aneurysms, but there may be hesitation in its use in older patients, despite their known increased risk of rupture. This study was conducted to examine our results in 84 patients older than 65 years undergoing elective aortic root resection with composite valve-graft replacement.

METHODS

Eighty-four patients older than 65 years were operated on between June 1987 and August 1998. Median age was 74 years (range, 66 to 89 years), and 57 patients were men. Seventeen patients were undergoing reoperation. Aortic insufficiency was present in 70 patients. Forty-seven patients received a conduit using a bioprosthesis, whereas in 37 a mechanical valved conduit (St. Jude) was used. The ascending aorta alone was replaced in 23 patients; 50 had hemi-arch replacement, and in 11 the entire aortic arch was replaced.

RESULTS

Hospital mortality was 8.3% (7 of 84). Sixteen late deaths (19%) were noted during a median follow-up of 3.2 years (range, 0 to 10 years). Only one late death was aorta-related. The incidence of thrombotic or hemorrhagic complications was 2.1/100 patient-years, with equal frequency for both mechanical and bioprosthetic valves.

CONCLUSIONS

We conclude that composite valve-graft replacement in elderly patients results in a low operative mortality, yields excellent long-term survival, and averts fatal aneurysm rupture in this high-risk population.

A continuous murmur after surgery for dissecting ascending aortic aneurysm

We report a case of a subcutaneous arteriovenous fistula that developed after aortic surgery. A careful physical examination and the selective use of imaging tests can differentiate this relatively benign complication from the more serious causes of a continuous murmur in this setting.

Predicting outcome after reoperative procedures on the aortic root and ascending aorta

OBJECTIVE

Reoperations on the ascending aorta after prior aortic procedures are formidable challenges. In order to identify factors predictive of clinical outcome using a uniform surgical approach, results of a 15-year experience were reviewed.

METHODS

Between 1983 and 1998, 78 reoperations on the ascending aorta were performed in 71 consecutive patients. There were 56 males and 15 females, aged 54+/-13 years (10-73 years), with a mean interval to first reoperation of 60+/-76 months (5-223 months). The original operation was replacement of ascending aorta (23), aortic valve (25), aortic root (7), ascending aorta with valve preservation (9), ascending aorta and aortic valve (7). Surgical approach included femoral vessels dissection and repeat sternotomy, with femoro-femoral bypass limited to cases of traumatic reentry. Reoperation consisted in replacement of the aortic root (48), ascending aorta (15), ascending aorta and aortic valve (6), aortic root with ascending aorta and arch (6), ascending aorta and aortic arch (3). Average aortic crossclamp and cardiopulmonary bypass times were 122+/-86 and 188+/-60 min, respectively.

RESULTS

Early deaths were five (7%), due to low output syndrome (3), hemorrhage (1) and sepsis (1). Mortality for emergent reoperation was significantly higher (38 vs. 3%, P=0.001). A total of 39 early complications were observed in 78 reinterventions (50%), including: traumatic reentry requiring emergent femoro-femoral bypass (4), reexploration for bleeding (4), respiratory failure (12), sepsis (5), transient neurologic dysfunction (4), renal failure (3), myocardial infarction (3), circulatory insufficiency requiring mechanical life support (2), and wound infection (2). Average intensive care unit stay was 4.5+/-9.7 days (0.5-40 days). Survival was 92+/-4%, 78+/-10% and 78+/-10% at 1, 5, and 10 years, respectively. At follow-up (mean 34+/-36 months, 1-170), survivors were in satisfactory clinical conditions (1.6+/-0. 8 mean NYHA class, 1-3) with no evidence of renal, respiratory or neurologic dysfunction. Multivariable analysis showed emergent reoperation (P=0.001), prior aortic valve replacement (P=0.005) and need for arch replacement (P=0.03) to be predictive of higher operative mortality. Longer duration of bypass (P=0.01) and aortic arch replacement (P=0.04) were predictive of higher prevalence of postoperative complications.

CONCLUSIONS

Reoperations on the ascending aorta via repeat sternotomy without preventive femoral bypass are associated with low operative risk and high prevalence early complications. Emergent reintervention due to aortic dissection, particularly in patients with prior aortic valve replacement, and need for arch repair are predictive of poorer perioperative outcome. Long-term outlook of hospital survivors is satisfactory.

Aortic root replacement with coronary button re-implantation: low risk and predictable outcome

OBJECTIVE

Cardiac morbidity in aortic root replacement often occurs through myocardial ischaemia. We analyzed a 10 year experience of all root replacement operations by one surgeon to determine the incidence of coronary complications and risk factors for early mortality.

METHODS

The study included 140 aortic root replacement patients (aged from 2 to 77 years; median 53 years) operated between 1988 and 1999. Thirty-four had Marfan's syndrome. Eleven had root infection requiring homograft replacement. Nineteen were reoperations (14%). Concomitant procedures were arch replacement (16), mitral replacement (five), and coronary bypass (22). Mobilization and reimplantation of the coronary ostia was performed in 139 patients. We performed the distal graft anastomosis before right coronary reimplantation.

RESULTS

There were eight hospital deaths (5.7%). Risk factors for hospital mortality were: preoperative NYHA class IV, shock, LVEF < or =30%, acute dissection, concomitant mitral valve replacement, pump time > or = 60 min, reentry for bleeding, and postoperative renal failure. Neither myocardial ischaemia nor right ventricular dysfunction contribute to mortality. There were 18 late deaths with an actuarial survival of 79% at 5 years. There were no late coronary false aneurysms.

CONCLUSIONS

Button reimplantation with the sequence described is predictable and safe. Wrap-around is unnecessary. Coronary aneurysms have been eliminated.

Preoperative MRA assessment of the coronary arteries in an ascending aortic aneurysm

We present a patient with an aneurysm that included both the aortic root and the ascending aorta. Visualization of the coronary arteries by x-ray angiography was not technically feasible. Magnetic resonance angiography (MRA) was thus performed and allowed an accurate evaluation of the involvement of the coronary arteries in the aneurysm and the patency of the proximal coronaries, as well as visualization of the aneurysm itself.

Aortic root replacement with the Carboseal composite graft: 7-year experience with the first 100 implants

BACKGROUND

Aortic root replacement remains a challenging surgical procedure. A variety of techniques and prosthetic devices have thus far been used. In order to assess the performance of the Carboseal (Sultzer Carbomedics, Inc, Austin TX) composite graft, review of the experience with composite root replacement was undertaken.

METHODS

Between January 1979 and December 1998, 273 patients underwent composite aortic root replacement. One-hundred-six received the Carboseal composite prosthesis (group 1) and 84 other types of composite grafts (group 2). Demographic and operative variables were similar in the 2 patient groups, except for an older mean age in group 1 (58+/-12 versus 50+/-12 years, p = 0.001).

RESULTS

Operative mortality was lower in group 1 patients (3 of 106, 3% versus 10 of 84, 12%, p = 0.04). Follow-up of survivors was longer in group 2 due to more recent adoption of the Carboseal grafts (93+/-57 versus 36+/-23 months, p = 0.01). Late mortality was higher in group 2 (3 of 103, 3% versus 13 of 74, 18%, p = 0.04), with higher prevalence of prosthetic-related complications (2 of 103, 2% versus 12 of 74, 15%, p = 0.002). Reoperation was more prevalent in group 2 (1 of 103, 1% versus 5 of 74, 8%, p = 0.04), and limited to patients having root replacement using the inclusion technique. Functional status of survivors was comparable in the 2 groups (83 of 103, 80% versus 45 of 74, 61% of patients in New York Heart Association class I, p = 0.1).

CONCLUSIONS

Aortic root replacement using the Carboseal composite graft offers excellent long-term results, with negligible prevalence of prosthetic-related complications. Superior performance compared to other available composite grafts in the present series may be influenced by more recent adoption of the Carboseal conduit and concomitant uniform adoption of coronary button technique.

Replacement of the proximal aorta and aortic valve using a composite bileaflet prosthesis and gelatin-impregnated polyester graft (Carbo-Seal): early results in 143 patients

OBJECTIVE

We report the combined early results from two centers in the United Kingdom using a composite conduit consisting of a bileaflet mechanical valve incorporated into a gelatin-impregnated, ultra-low porosity, woven polyester graft (Carbo-Seal; Sulzer Carbomedics, Inc, Austin, Tex).

METHODS

Between August 1992 and March 1997, 143 patients underwent aortic root replacement with the Carbo-Seal composite prosthesis. The indication for surgery was acute type A dissection in 31 (22%), chronic type A dissection in 9 (6%), ascending aortic aneurysm without dissection in 100 (70%), and false aneurysm of the ascending aorta in 3 (2%). Twenty-seven patients (19%) had undergone previous sternotomy, and 40 (28%) were seen as emergencies. Concomitant procedures were performed in 38 (27%), including 18 aortic arch or hemiarch replacements. Total follow-up is 270 patient-years. Follow-up is 100% complete.

RESULTS

The early (30-day) mortality was 7% (10 patients). Permanent neurologic events occurred in 2%. At a mean follow-up of 23 months, 94% of survivors were in New York Heart Association functional class I. Freedom from reoperation was 97.2% +/- 1.6% (1 standard error [1 SE]) at 12 months and 95.7% +/- 2.2% at 48 months. Including early mortality, survival was 90.1% +/- 2.6% at 12 months and 83.1% +/- 3. 5% at 48 months.

CONCLUSIONS

Aortic root replacement with use of the Carbo-Seal prosthesis can be undertaken with a relatively low early mortality and morbidity. A low reoperation rate and high intermediate-term survival can be expected, but continued follow-up is needed to determine the long-term efficacy of this prosthesis.

Coronary ostial aneurysms after composite graft replacement

Coronary ostial aneurysms after composite graft replacement of the ascending aorta and aortic valve is a rare complication. We report two patients with Marfan syndrome who developed coronary ostial aneurysms at the sites of the coronary anastomosis, presumably because of oversized windows made in the graft. They were successfully treated by redo composite graft replacement. To prevent this complication, it is important to consider that the hole made in the tube graft should not be larger than the diameter of the respective coronary ostium to avoid exposure of the diseased aortic wall to the circulating blood as much as possible, and that the suture used to anastomose the coronary buttons should pass through the rim of the ostium rather than through the aortic wall surrounding it.

A 23-year experience with composite valve graft replacement of the aortic root

BACKGROUND

This is a retrospective study of early and long-term results of composite valve graft replacement of the aortic root.

METHODS AND RESULTS

Between July 1974 and July 1997, 244 patients underwent aortic root replacement with a composite valve graft. Mean age was 54+/-15 years. The inclusion technique was used in 178 patients (73.0%), the open technique in 65 (26.5%), and the Cabrol II technique in 1 patient (0.5%). Hospital mortality was 7.8% (70% confidence limit, 6.1% to 9.5%). Independent determinants of hospital mortality were preoperative creatinine level more than 150 micromol/L (p = 0.04), prolonged cardiopulmonary bypass time (p = 0.006), intraoperative technical problems (p = 0.048), and year of operation (p = 0.015). Follow-up was 99.6% complete, median 96 months (range, 2 to 256 months). Fifty-seven patients (25.3%; 70% confidence limit, 22.4% to 28.2%) died during follow-up. Cumulative survival at 5, 10, and 20 years was 76%, 62%, and 33%. Independent risk factors for late death were postoperative complications (p = 0.027), technique for coronary reattachment (p = 0.028), and concomitant aortic arch operation (p = 0.01). Twenty patients (8.8%; 70% confidence limit, 7.0% to 10.6%) underwent reoperation on the aortic root. Estimated freedom from reoperation for pseudoaneurysms at 3 years was 96% in the inclusion group and 94% in the open group (p = 0.236).

CONCLUSIONS

Aortic root replacement with a composite valve graft can be performed with low hospital mortality and morbidity. Pseudoaneurysms did occur in the inclusion group, but also in the open group.

Intimal tear without hematoma: an important variant of aortic dissection that can elude current imaging techniques

BACKGROUND

The modern imaging techniques of transesophageal echocardiography, CT, and MRI are reported to have up to 100% sensitivity in detecting the classic class of aortic dissection; however, anecdotal reports of patient deaths from a missed diagnosis of subtle classes of variants are increasingly being noted.

METHODS AND RESULTS

In a series of 181 consecutive patients who had ascending or aortic arch repairs, 9 patients (5%) had subtle aortic dissection not diagnosed preoperatively. All preoperative studies in patients with missed aortic dissection were reviewed in detail. All 9 patients (2 with Marfan syndrome, 1 with Takayasu's disease) with undiagnosed aortic dissection had undergone >/=3 imaging techniques, with the finding of ascending aortic dilatation (4.7 to 9 cm) in all 9 and significant aortic valve regurgitation in 7. In 6 patients, an eccentric ascending aortic bulge was present but not diagnostic of aortic dissection on aortography. At operation, aortic dissection tears were limited in extent and involved the intima without extensive undermining of the intima or an intimal "flap." Eight had composite valve grafts inserted, and all survived. Of the larger series of 181 patients, 98% (179 of 181) were 30-day survivors.

CONCLUSIONS

In patients with suspected aortic dissection not proven by modern noninvasive imaging techniques, further study should be performed, including multiple views of the ascending aorta by aortography. If patients have an ascending aneurysm, particularly if eccentric on aortography and associated with aortic valve regurgitation, an urgent surgical repair should be considered, with excellent results expected.

Replacing the atherosclerotic ascending aorta is a high-risk procedure

BACKGROUND

Improved techniques in cerebral and myocardial protection have made replacement of the chronically aneurysmal ascending thoracic aorta a safe and effective procedure. We hypothesized that patients with severe ascending or aortic arch atherosclerosis were at greater risk for operative complications during ascending aortic replacement because of the diffuse nature of their atherosclerotic process.

METHODS

We retrospectively analyzed the records of 17 patients who received ascending aortic replacement during elective coronary artery bypass grafting (CABG) because of the intraoperative finding of severe atherosclerosis. All 17 patients underwent tube graft replacement of the ascending aorta under hypothermic circulatory arrest and retrograde cerebral perfusion before coronary artery bypass grafting. The outcomes for these patients were compared with those of a control group of 89 consecutive patients who underwent replacement for ascending thoracic aortic aneurysm.

RESULTS

The hospital mortality rate for replacement of the ascending thoracic aorta for severe atherosclerosis was 23.5% (4/17) versus 2.25% (2 of 89) for the control group (p=0.006). The incidence of cerebrovascular accident in the atherosclerotic group was 17.6% (3/17) and 3.37% (3/89) for the control group (p=0.051). Nine of 17 atherosclerotic patients (52.9%) had operative morbidity. Only 20.2% (18 of 89) of the control patients had nonfatal postoperative complications.

CONCLUSIONS

The severely atherosclerotic ascending aorta is a marker of diffuse atherosclerosis. Despite improved techniques of myocardial and cerebral protection, we have been unable to duplicate our success with ascending thoracic aneurysm repair. Preoperative screening of the ascending aorta by chest computed tomography may be appropriate in select high-risk patients to determine operability.

Management of the patient with aortic root disease and aortic insufficiency

There is no single standardized method of repair for the anatomic variations in aortic root pathology, which may include dissection, aneurysmal dilation, and valve disease and can occur at the annulus, sinuses of Valsalva, or the sinotubular junction. Composite valve/graft replacement, valve resuspension, and allograft each play a significant role in aortic root therapy, but none is applicable in all cases. Patient age, Marfan's syndrome, endocarditis, and previous valve replacement are examples of some of the wide variations in delineating factors.

Hypothermic circulatory arrest does not increase the risk of ascending thoracic aortic aneurysm resection

OBJECTIVE

The purpose of this study was to investigate the safety and efficacy of a period of deep hypothermic circulatory arrest (DHCA) during elective replacement of the ascending thoracic aorta.

SUMMARY BACKGROUND DATA

DHCA has been implemented in ascending thoracic aortic aneurysm resection whenever the anatomy or pathology of the aorta or arch vessels prevents safe or adequate cross-clamping. Profound hypothermia and retrograde cerebral perfusion have been shown to be neurologically protective during ascending aortic replacement under circulatory arrest.

METHODS

The authors conducted a retrospective analysis of 91 consecutive patients who underwent repair of chronic ascending thoracic aortic aneurysms from 1986 to present. The authors hypothesized that patients undergoing DHCA with or without retrograde cerebral perfusion during aneurysm repair were at no greater operative risk than patients who received aneurysm resection while on standard cardiopulmonary bypass.

RESULTS

There were no significant differences in hospital mortality, stroke rate, or operative morbidity between patients repaired on DHCA when compared to those repaired on cardiopulmonary bypass.

CONCLUSIONS

DHCA with or without retrograde cerebral perfusion does not result in increased morbidity or mortality during the resection of ascending thoracic aortic aneurysms. In fact, this technique may prevent damage to the arch vessels in select cases and avoid the possible complications associated with cross-clamping a friable or atherosclerotic aorta.

Reduction aortoplasty for moderately sized ascending aortic aneurysms

Enlargement of the ascending aorta may coexist with concomitant valvular, coronary, or other cardiac diseases. If dilation is moderate (i.e., <6 cm diameter) and another cardiac procedure is being performed, we have reduced the diameter of the ascending aorta with an S-shaped incision and excision of the curves of the "S" as a modified Z-plasty. We have performed the procedure in 23 patients with concomitant procedures including aortic valve replacement in 21 (1 as a pulmonary autograft), coronary bypass in 1, and resection of subaortic stenosis in 1. There were 15 males and 8 females with a mean age of 53 years (range 8-67 years). The mean maximal preoperative diameter on transesophageal echocardiography was 5.0+/-0.7 cm (range 3.2-6.6 cm). The mean intraoperative postreduction diameter was 3.1+/-0.6 cm (range 2.1-4.1) (p<0.01). All patients tolerated their procedures well. Sixteen patients were studied by transthoracic echocardiography postoperatively. These patients had a mean intraoperative postreduction diameter of 2.9+/-0.65 cm that increased to 3.1+/-0.45 cm (p = NS) after a mean follow-up of 9.9+/-12.6 months. Of these, seven patients were studied >1 year postoperatively. Their mean intraoperative postreduction diameter of 2.9+/-0.5 cm increased to 3.1+/-0.35 cm (p = NS) after a mean follow-up of 22.1+/-9.2 months. No known recurrences of the aneurysms have occurred. We feel this technique is valid in patients with moderate aortic dilation undergoing concomitant cardiac procedures and in whom more aggressive aortic interventions are not warranted.

Composite graft replacement of the aortic root in acute dissection

OBJECTIVE

In acute type A dissection the indication for composite graft replacement of the aortic root and the optimal implantation technique are a matter of debate. In this study early and late results of root replacement in acute dissection are determined and compared with supracoronary graft replacement. Two implantation techniques (open vs. inclusion) are evaluated.

METHODS

Between 1985 and 1995, 207 consecutive patients (mean age 58 +/- 12 years, 78% men) were operated for acute type A dissection of the aorta. Root replacement in 50 patients (inclusion technique in 34/50 patients with Cabrol shunt in 15/34 patients, open technique in 16/50 patients) was compared with more conservative procedures in 157 patients: supracoronary graft replacement in 143 patients (with aortic valve replacement in 23 patients) and local repair without graft interposition in 14 patients. Preoperative risk factors, like hemodynamic instability, renal failure, neurologic disorder and coronary artery disease did not differ in the two treatment groups.

RESULTS

Early results, survival and reoperation-free survival after 5 years were insignificantly better after root replacement: mortality 10/50 (20%) vs. 38/157 (24%) P = n.s.; hemorrhage 10/50 (20%) vs. 39/157 (25%) P = n.s.; stroke 5/50 (10%) vs. 27/157 (17%) P = n.s.; survival 70 +/- 7% vs. 63 +/- 4%, reoperation free survival 92 +/- 6% vs. 78 +/- 5% P = 0.0815). For the open technique, early mortality was 18.8 vs. 20.6%, P = n.s. and reoperation free survival at 5 years was 80.7 vs. 65.2%, P = n.s. Perioperative complications did not differ in the two technical groups and a single pseudoaneurysm occurred in the Bentall group.

CONCLUSION

In acute dissection composite graft replacement of the aortic root can be carried out with good early and late results not inferior to more conservative procedures. The open technique is the implantation method of choice and the modified Bentall technique is indicated in situations with increased risk of bleeding.

Aortic root replacement: results using the St. Jude Medical/Hemashield composite graft

BACKGROUND

Aortic root replacement remains a formidable operation. Although perioperative mortality has declined steadily, there is no consensus regarding the preferred method of reconstruction or type of composite to be used. We present our last 2 years' experience with aortic root replacement using the St. Jude Medical/Hemashield composite valve conduit.

METHODS

A retrospective review of 52 consecutive patients undergoing aortic root replacement from February 1994 through October 1996 is presented. Both the open/exclusion and Cabrol methods of reconstruction were used.

RESULTS

Thirty-one percent of the patients had undergone previous procedures of the aortic root. Thirty-seven percent required aortic arch replacement and 35% required concomitant cardiac or vascular procedures. Perioperative morbidity was low, as was perioperative mortality (3.8%). Both of the deaths that occurred were related to complications with the management of remaining thoracoabdominal aneurysms.

CONCLUSIONS

Using meticulous surgical technique and the St. Jude Medical/Hemashield composite valve conduit, one can expect low mortality and complication rates for complex aortic root reconstruction.

Composite aortic root replacement with direct coronary artery implantation

BACKGROUND

Composite aortic root replacement is accepted treatment for aneurysms of the ascending aorta involving the root with aortic valve regurgitation, but controversy continues regarding the best technique of operation. We excise the aneurysm, implant a composite valve graft, directly attach the coronary arteries to the aortic graft, and make the distal anastomosis to the divided aorta.

METHODS

We reviewed the records and collected complete follow-up data on 110 consecutive patients having composite aortic root replacement with this technique from 1979 to 1995.

RESULTS

Average age was 54 years. Marfan's syndrome was present in 22 patients, acute dissections in 26, chronic dissections in 11, and active endocarditis in 13. Operative characteristics were: 25 emergency procedures, 33 urgent procedures, 52 elective procedures, 24 reoperations, and 19 with coronary artery bypass grafting. Hospital death occurred in 8 patients (7.3%). Multivariate predictors of hospital death were postoperative renal failure and acute dissection. Actuarial survival was 70% at 10 years (standard error, 5%). Multivariate predictors of total mortality were porcine valve, Björk-Shiley valve, preoperative stroke, reoperation on a composite valve graft, and coronary artery bypass grafting. Only 3 patients required late reoperation, all for valve dysfunction. Actuarial freedom from reoperation on the aortic root was 97.3% (standard error, 1.9%) at 10 years. Late echocardiograms in 47 patients showed no anastomotic aneurysms.

CONCLUSIONS

Composite aortic root replacement with direct coronary implantation is effective and durable treatment for a variety of aortic pathologic conditions in elective and emergency situations.