Reoperations on the aortic root and ascending aorta

Aortic Root Surgery in Adults: An Unsolved Problem

Nowadays, despite the rapid advancements in interventional cardiology, open surgery still deals with aortic root diseases, to assure the best "ad hoc" treatment. In case of middle-aged adult patients, the optimal operation still represents a matter of debate. A review of the last 10-year literature was conducted, focusing on patients below 65 to 70 years of age. Because of the small sample and the heterogeneity of the papers, no metanalysis was possible. Bentall-de Bono procedure, valve sparing, and Ross operations are the surgical options currently available. The main issues in the Bentall - de Bono operation are lifelong anticoagulation therapy and cavitation in case of mechanical prosthesis implantation and structural valve degeneration in case of biological Bentall. As transcatheter procedures are currently performed as valve in valve, biological prosthesis may be preferable, if the diameter may prevent postoperative high gradients. Conservative techniques, such as remodeling and reimplantation, preferred in the young, guarantee physiologic aortic root dynamics and impose surgical analysis of the aortic root structures to get a durable result. The Ross operation, which shows excellent performance, involves autologous pulmonary valve implantation and is performed only in experienced and high-volume centers. Due to its technical difficulty, it requires a steep learning curve and presents some limitations in specific aortic valve diseases. All three have advantages and downsides, and no ideal solution has still been reported.

Mid-term outcomes of an alternative remodelling technique for aortic root replacement without coronary ostial mobilisation or reimplantation

BACKGROUND

We compare the early and late outcomes of a modified aortic root remodelling (ARR) technique for aortic root replacement without mobilisation or reimplantation of the coronary ostia, with those of the modified Bentall-de Bono procedure.

METHODS

A retrospective observational study was performed comprising 181 consecutive patients who underwent aortic root replacement with a modified Bentall-de Bono procedure (104 patients) or ARR (77 patients) between January 2013 and December 2019. Primary endpoints included hospital mortality and late survival. Secondary endpoints included incidence of post-operative complications and freedom from late re-operation.

RESULTS

ARR procedures were performed with shorter cross-clamp times and comparable cardiopulmonary bypass times to modified Bentall-de Bono procedures. The incidence of early post-complications was comparable between groups. 30-day mortality was numerically lower with ARR than the modified Bentall-de Bono procedure. Over 7-year follow-up, 4 patients (3.8%) required repeat aortic surgery after a modified Bentall-de Bono procedure, and none after ARR. Long-term mortality after ARR and after modified Bentall-de Bono procedures was 17.1% and 22.7%, respectively. The cumulative incidence of reintervention on the aortic root/valve was 3.2% after a modified Bentall-de Bono procedure and 0% after ARR. When adjusted for other independent risk factors, late mortality was not influenced by the procedure performed, although competing risk adjusted for age showed that the modified Bentall-de Bono procedure was associated with an increased risk of aortic root/aortic valve re-operation.

CONCLUSIONS

The modified ARR technique is associated with reduced myocardial ischaemia time, lower post-operative mortality and aortic re-intervention rates compared to a modified Bentall-de Bono procedure. It may be considered a safe and feasible procedure for aortic root/ascending aortic replacement offering good long-term outcomes.

Tips and tricks in redo aortic surgery

Redo aortic surgery is challenging, and the operative risk is higher than that in primary aortic surgery. Preoperative imaging is a crucial guide for a safe re-entry. Scrutinized preparing in cannulation and organ protection strategies have affected surgical outcomes. With comprehensive planning and meticulously executed surgery, mortality and morbidity can be acceptable.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-021-01322-x.

Closure of a Thoracic Aortic Graft Pseudoaneurysm With an Amplatzer Septal Occluder

We describe the case of a young man 7 weeks postoperative from repair of a Stanford type A aortic dissection who developed an expanding pseudoaneurysm of the proximal graft anastomosis. Owing to the morbidity and mortality associated with reoperation, an interdisciplinary team of interventional cardiologists and cardiothoracic surgeons implanted an Amplatzer septal occluder device in a hybrid operating room, successfully excluding the defect from the true lumen of the aorta. This case highlights the utility of a team approach and creative thinking for the treatment of a pseudoaneurysm in a high-risk, recently postoperative patient.

Trans-catheter closure of aortic anastomosis leak after aortic replacement: classifications and techniques

Background

Aortic anastomotic leak (AAL) is knotty complication after aortic replacement. We aimed to evaluate the feasibility and efficacy of the techniques of trans-catheter AAL closure as well as to evaluate the impact of the new classification on the interventional closure.

Methods

From October 2015 to November 2017, 20 consecutive high surgical risk patients (mean age 47±12 years, 13 males) were referred to our center for trans-catheter closure AALs. Due to the variation of leak, we therefore developed a new-classification based on transesophageal echocardiography (TEE) and computed tomography angiography (CTA) assessments: type I: aorta-to-right atrium fistula, n=6; type II: pseudoaneurysm induced by a suture line dehiscence, n=4; type III: patency of the false lumen in aortic dissection, n=10. Outcomes were analyzed by assessing TEE and CTA in different types of AALs.

Results

Successful closure was accomplished in 17 subjects (85%). The severity of AAL reduced significantly in 15 patients (88%); two patients required a second procedure. At follow-up, we found that in type I, the right atrium systolic pressure reduced (from 25.3±4.1 to 7.0±1.2 mmHg) with the improved NYHA (3.5±0.6 vs. 1.0±0.0), the diameter of pseudoaneurysm significantly decreased (5.0±1.8 to 2.0±1.8 mm) in type II, and complete thrombosis was achieved in all type III patients.

Conclusions

Trans-catheter closure of AAL displays satisfactory results even in those defined as high-risk patients, and it could be considered be a viable alternative approach. New classification is helpful in decision-making.

[Early results of various surgical approaches in reconstruction of ascending aortic aneurysms]

The study was aimed at analysing the immediate results of various surgical approaches to prosthetic repair of ascending aortic aneurysms. We analysed the data of 113 patients operated on for an ascending aortic aneurysm from 2008 to 2017. All patients were divided into two comparable groups. Group One patients (n=43) underwent prosthetic repair of the ascending portion of the aorta with formation of a distal anastomosis proximal to the level of the brachiocephalic trunk, Group Two patients (n=70) were subjected to reconstruction of the ascending aorta with aortic arch plasty ('hemiarch'). In the early postoperative period in Group One and Group Two patients, the frequency of adverse cardiac events amounted to 3 (7.0%) and 1 (1.5%) cases (p=0.339), with prolonged mechanical ventilation required in 12 (18.6%) and 6 (8.6%) cases and resternotomy required in 8 (18.6%) and 4 (5.7%) cases, respectively. The postoperative 30-day mortality in the group of isolated prosthetic repair of the ascending aorta amounted to 11.6% (5 cases) and in the group of patients with the hemiarch reconstruction to 3.0% (2 cases). No neurological complications were observed. Hemiarch prosthetic repair of the aorta is an effective and safe surgical method of treatment. This approach does not increase the risks for cardiac, neurological, pulmonary, haemorrhagic complications in the immediate postoperative period as compared with prosthetic repair of only the ascending portion of the aorta.

Perspective. Reoperative Bentall: choice of conduits

The Bentall procedure represents the gold standard in the treatment of patients requiring aortic root replacement. The most common indications for redo Bentall are structural degeneration or graft infection. Redo aortic root replacement can be performed with low perioperative morbidity and death. The choice of the best conduit is still up for debate but is mandatory to guarantee the best and most durable option for the patient. New options are available to reduce mortality in older or fragile patients and can modify the conduit choice.

Primary or secondary Bentall-De Bono procedure: are the outcomes worse?

BACKGROUND

The aim of this study was to compare the outcomes of a primary and secondary Bentall-De Bono procedure.

METHODS

From 2008 to 2015 (8-year period), 308 patients underwent a Bentall-De Bono procedure in our institute. The mean age was 43 ± 13 years and 80% were men. Twenty-eight patients had prior cardiac surgery through a median sternotomy (group 1) and 280 underwent a primary Bentall-De Bono procedure (group 2). Various preoperative and perioperative parameters were analyzed before and after propensity-score matching.

RESULTS

Before propensity-score matching, patients undergoing a secondary Bentall-De Bono procedure had a worse preoperative profile, as indicated by a higher EuroSCORE II ( p < 0.0001), with hospital mortality in group 1 of 14% (4/28) and 5% (14/280) in group 2 ( p = 0.069). After propensity-score matching, there was no significant difference in EuroSCORE II ( p = 0.922) or hospital mortality ( p = 0.729). After adjusting for the different variables, repeat sternotomy could not be identified as an independent predictor of postoperative mortality or morbidity. Survival at the end of 1 and 5 years in both groups showed no significant differences before or after propensity-score matching ( p = 0.328 and p = 0.356, respectively). In Cox multivariable regression analysis, reoperation was not identified as an independent factor for survival before ( p = 0.559) or after propensity-score matching ( p = 0.365).

CONCLUSION

A secondary Bentall-De Bono procedure can be performed with acceptable mortality and morbidity, and with midterm survival rates comparable to those of a primary Bentall-De Bono procedure.

Reoperation for composite valve graft failure: Operative results and midterm survival

BACKGROUND AND AIM OF THE STUDY

The replacement of a failed composite valve graft is technically more demanding and is associated with increased morbidity and mortality. We present our technique and outcomes for reoperations for composite graft failures.

METHODS

Between September 2011 and June 2017, 14 patients underwent a redo composite graft replacement. Twelve patients (85.7%) were male, and mean age was 58.4 years ± 12 standard deviation (SD). One patient had two previous root replacements. Indications for reoperation were endocarditis (8), aortic pseudoaneurysm (3), and aortic prosthesis thrombosis (3). Mean logistic EuroSCORE and EuroSCORE II were 30.8% and 14.7%, respectively.

RESULTS

A mechanical composite graft was used in 12 patients and biological composite grafts were used in two patients. Hospital mortality was 14.3% (n = 2). One patient (7.1%) required reoperation for bleeding, One patient (7.1%) had mechanical ventilation >24 h, and four patients (28.6%) required implantation of a permanent pacemaker. Median intensive care unit and hospital stays were 3 days (interquartile range [IQR] 1-5) and 10 days (IQR 6.5-38.5). One patient experienced recurrent prosthetic valve endocarditis 14 months after operation. On follow-up, 11 of 12 survivors were in New York Heart Association class I or II. Survival at 3 years was 85.7% ± 9.4% SD.

CONCLUSIONS

Composite valve graft replacement can be performed with acceptable morbidity and mortality with good mid-term survival.

Ascending aorta reinterventions

Ascending aorta reinterventions present a challenge for surgeons as the technical difficulties of the procedure and the complex strategic approach can complicate successful treatment. These patients should be treated by surgical teams with ample experience in aortic diseases as they can be at high risk of mortality. The number of interventions on the ascending aorta and aortic arch and the use of biological conducts (lung autograft, homograft, etc.) have increased in recent years; therefore, the number of reinterventions can also be expected to increase, representing 10% of aortic surgical procedures. This article reviews the current status of ascending aorta reinterventions, analyzing the principal aspects of indication and surgical strategy, as well as the results published in the largest studies.

Safe Reentry for False Aneurysm Operations in High-Risk Patients

BACKGROUND

In the absence of a standardized safe surgical reentry strategy for high-risk patients with large or anterior postoperative aortic false aneurysm (PAFA), we aimed to describe an effective and safe approach for such patients.

METHODS

We prospectively analyzed patients treated for PAFA between 2006 and 2015. According to the preoperative computed tomography scan examination, patients were divided into two groups according to the anatomy and extension of PAFA: in group A, high-risk PAFA (diameter ≥3 cm) developed in the anterior mediastinum; in group B, low-risk PAFA (diameter <3 cm) was situated posteriorly. For group A, a safe surgical strategy, including continuous cerebral, visceral, and coronary perfusion was adopted before resternotomy; group B patients underwent conventional surgery.

RESULTS

We treated 27 patients (safe reentry, n = 13; standard approach, n = 14). Mean age was 60 years (range, 29 to 80); 17 patients were male. Mean interval between the first operation and the last procedure was 4.3 years. Overall 30-day mortality rate was 7.4% (1 patient in each group). No aorta-related mortality was observed at 1 and 5 years in either group. The Kaplan-Meier overall survival estimates at 1 and 5 years were, respectively, 92.3% ± 7.4% and 73.4% ± 13.4% in group A, and 92.9% ± 6.9% and 72.2% ± 13.9% in group B (log rank test, p = 0.830). Freedom from reoperation for recurrent aortic disease was 100% at 1 year and 88% at 5 years.

CONCLUSIONS

The safe reentry technique with continuous cerebral, visceral, and coronary perfusion for high-risk patients resulted in early and midterm outcomes similar to those observed for low-risk patients undergoing conventional surgery.

Reoperative Aortic Root Replacement in Patients with Previous Aortic Root or Aortic Valve Procedures

Background

Generalization of standardized surgical techniques to treat aortic valve (AV) and aortic root diseases has benefited large numbers of patients. As a consequence of the proliferation of patients receiving aortic root surgeries, surgeons are more frequently challenged by reoperative aortic root procedures. The aim of this study was to evaluate the outcomes of redo-aortic root replacement (ARR).

Methods

We retrospectively reviewed 66 patients (36 male; mean age, 44.5±9.5 years) who underwent redo-ARR following AV or aortic root procedures between April 1995 and June 2015.

Results

Emergency surgeries comprised 43.9% (n=29). Indications for the redo-ARR were aneurysm (n=12), pseudoaneurysm (n=1), or dissection (n=6) of the residual native aortic sinus in 19 patients (28.8%), native AV dysfunction in 8 patients (12.1%), structural dysfunction of an implanted bioprosthetic AV in 19 patients (28.8%), and infection of previously replaced AV or proximal aortic grafts in 30 patients (45.5%). There were 3 early deaths (4.5%). During follow-up (median, 54.65 months; quartile 1–3, 17.93 to 95.71 months), there were 14 late deaths (21.2%), and 9 valve-related complications including reoperation of the aortic root in 1 patient, infective endocarditis in 3 patients, and hemorrhagic events in 5 patients. Overall survival and event-free survival rates at 5 years were 81.5%±5.1% and 76.4%±5.4%, respectively.

Conclusion

Despite technical challenges and a high rate of emergency conditions in patients requiring redo-ARR, early and late outcomes were acceptable in these patients.

Ascending Aorta or Arch Surgery: Is Previous Cardiac Surgery a Risk Factor?

Surgery on the ascending aorta ± arch is a challenge. The risks involved in such operations after previous cardiac surgery were assessed in elective and emergency settings in a single institution. Over a 10-year period, 29 patients underwent replacement of the ascending aorta ± arch following previous cardiac surgery. In 12 patients (41.4%), the procedure was carried out on an emergency basis. Thirteen had previous replacement of the ascending aorta and 16 had previous valve replacement with or without coronary artery bypass; 4 patients were undergoing a 3rd cardiac operation. Concomitant procedures included coronary artery bypass in 2, arch replacement in 4, and descending aortic replacement in one. The overall in-hospital mortality was 13.8% (4/29) vs. 12.4% (33/267) in primary procedures. Mortality in elective repeat surgery was 5.9% (1/17) vs. 25% (3/12) in emergency re-operations. The incidences of permanent stroke (3.4%) and renal failure (3.4%) were similar to first-time operations. Elective re-operation for ascending aorta ± arch repair can be accomplished with acceptable mortality and morbidity. Outcomes in emergency cases carry a higher early mortality but still conform to contemporary expectations and are similar to emergency first-time aortic surgery.

Outcomes of aortic root replacement after previous aortic root replacement: the "true" redo root

BACKGROUND

Aortic reoperations are technically challenging. This study evaluated outcomes after "true" redo root replacement (previous full root replacement) stratified by cause of prosthesis failure.

METHODS

Data were compared for 793 patients who underwent a first-time sternotomy (de novo group) and 120 patients who had previously undergone full aortic root replacement (redo group), of which 76 underwent reoperation due to structural valve deterioration (degenerative group), and 44 due to endocarditis (infection group).

RESULTS

Overall mortality was 4% (n = 28) in the de novo group and 5% (n = 6) in the redo group (p = 0.43) (degenerative group, 3%, infection group, 9%; p = 0.19). The infection group had an increased incidence of renal failure, sternal infection, prolonged ventilation, reoperation for bleeding, multisystem failure, and sepsis, and an increased hospital length of stay. The degenerative group and the de novo group had a similar risk of perioperative death and major complications. The 5-year survival was 86.3% ± 1.3% for the de novo group and 77.3% ± 4.6% for the redo group (p ≤ 0.01; degenerative, 86.3% ± 5%; infection, 65.3% ± 7.7%; p < 0.01; p = 0.98 for de novo vs degenerative). Multivariate analysis demonstrated that reoperation for degenerative failure did not increase the risk of perioperative or late death.

CONCLUSIONS

Redo aortic root replacement can be performed with low perioperative morbidity and death. The presence of infection increases the risk of complications and worsens survival. However, redo root replacement for degenerative failure can be performed with similar short-term complication risk and midterm survival as de novo root replacement.

Liverpool Aortic Surgery Symposium V: New Frontiers in Aortic Disease and Surgery

Aortic aneurysm disease is a complex condition that requires a multidisciplinary approach in management. The innovation and collaboration among vascular surgery, cardiothoracic surgery, interventional radiology, and other related specialties is essential for progress in the management of aortic aneurysms. The Fifth Liverpool Aortic Surgery Symposium that was held in May 2013 aimed at bringing national and international experts from across the United Kingdom and the globe to deliver their thoughts, applications, and advances in aortic and vascular surgery. In this report, we present a selected short synopsis of the key topics presented at this symposium.

Complete graft dehiscence 8 months after repair of acute type A aortic dissection

Acute type A aortic dissection is a dreaded differential diagnosis of acute chest pain. Long-term outcome mainly depends on pre-existing comorbidities and post-operative complications. We present a patient with aortic graft dehiscence and subsequent severe aortic regurgitation due to fungal graft infection 8 months after repair of acute type A aortic dissection. Redo aortic surgery had to be delayed for 28 days due to intracerebral haemorrhage caused by septic embolism and clipping of a mycotic left middle cerebral artery aneurysm. Surgery revealed a circumferentially detached graft at the site of the proximal anastomosis thereby forming a massive pseudoaneurysm. The patient underwent successful aortic root replacement using a Freestyle porcine root bioprosthesis (25 mm), followed by re-anastomosis of the coronary arteries and partial replacement of the ascending aorta with a 28 mm Dacron graft. The patient was discharged on day 67 in stable cardiac condition with persistent neurological deficits. This case highlights the challenging management of patients with aortic graft infection and neurological dysfunction after redissection of the ascending aorta who require redo cardiac surgery.

Outcomes of aortic arch replacement surgery after previous cardiac surgery

BACKGROUND

Aortic arch replacement is a potentially high-risk operation and in the re-operative setting has been found to be a risk factor for poor outcome, yet there is a dearth of published data specifically on this topic. The aim of the study was to review our unit's outcomes in this re-operative setting.

METHOD

Data were collated for all patients who underwent aortic arch replacement surgery after previous cardiac surgery from January 1988 to November 2011. The patients were divided based primarily on elective versus non-elective and also early (≤2005) and late (≥2006) series.

RESULTS

Twenty-seven eligible patients (22 male; median age: 53.0 years; elective: 14, non-elective: 13) were identified. There was a mean period of 14.5 years between the first operation and the subsequent aortic arch replacement. The overall 30-day mortality rate was 22.2% - 0% elective and 46.2% non-elective (P = 0.004). Overall permanent neurological dysfunction was 21.7% - 28.6% elective and 11.1% non-elective (P = 0.463). There were 11 early-series patients and 16 late-series patients. For early-series patients, 90.9% were non-elective versus 18.8% in the late-series patients. The 30-day mortality rate was 54.5% early series versus 0% late series.

CONCLUSION

Aortic arch replacement is high risk in the re-operative setting. These risks are even greater for non-elective procedures. This highlights the need for aggressive first-time surgery to reduce re-operative procedures and good long-term follow-up programmes to allow elective procedures if required.

Long-term results after proximal thoracic aortic redo surgery

OBJECTIVE

To evaluate early and mid-term results in patients undergoing proximal thoracic aortic redo surgery.

METHODS

We analyzed 60 patients (median age 60 years, median logistic EuroSCORE 40) who underwent proximal thoracic aortic redo surgery between January 2005 and April 2012. Outcome and risk factors were analyzed.

RESULTS

In hospital mortality was 13%, perioperative neurologic injury was 7%. Fifty percent of patients underwent redo surgery in an urgent or emergency setting. In 65%, partial or total arch replacement with or without conventional or frozen elephant trunk extension was performed. The preoperative logistic EuroSCORE I confirmed to be a reliable predictor of adverse outcome- (ROC 0.786, 95%CI 0.64-0.93) as did the new EuroSCORE II model: ROC 0.882 95%CI 0.78-0.98. Extensive individual logistic EuroSCORE I levels more than 67 showed an OR of 7.01, 95%CI 1.43-34.27. A EuroSCORE II larger than 28 showed an OR of 4.44 (95%CI 1.4-14.06). Multivariate logistic regression analysis identified a critical preoperative state (OR 7.96, 95%CI 1.51-38.79) but not advanced age (OR 2.46, 95%CI 0.48-12.66) as the strongest independent predictor of in-hospital mortality. Median follow-up was 23 months (1-52 months). One year and five year actuarial survival rates were 83% and 69% respectively. Freedom from reoperation during follow-up was 100%.

CONCLUSIONS

Despite a substantial early attrition rate in patients presenting with a critical preoperative state, proximal thoracic aortic redo surgery provides excellent early and mid-term results. Higher EuroSCORE I and II levels and a critical preoperative state but not advanced age are independent predictors of in-hospital mortality. As a consequence, age alone should no longer be regarded as a contraindication for surgical treatment in this particular group of patients.

Does additional aortic procedure carry a higher risk in patients undergoing aortic valve replacement?

Background

With growing attention to the aortopathy associated with aortic valve diseases, the number of candidates for accompanying ascending aorta and/or root replacement is increasing among the patients who require aortic valve replacement (AVR). However, such procedures have been considered more risky than AVR alone. This study aimed to compare the surgical outcome of isolated AVR and AVR combined with aortic procedures.

Materials and Methods

A total of 86 patients who underwent elective AVR between 2004 and June 2010 were divided into two groups: complex AVR (n=50, AVR with ascending aorta replacement in 24 and the Bentall procedure in 26) and simple AVR (n=36). Preoperative characteristics, surgical data, intra- and postoperative allogenic blood transfusion requirement, the postoperative clinical course, and major complications were retrospectively reviewed and compared.

Results

The preoperative mean logistic European System for Cardiac Operative Risk Evaluation (%) did not differ between the groups: 11.0±7.8% in the complex AVR group and 12.3±8.0% in the simple AVR group. Although complex AVR required longer cardiopulmonary bypass (152.4±52.6 minutes vs. 109.7±22.7 minutes, p=0.001), the quantity of allogenic blood products did not differ (13.4±14.7 units vs. 13.9±11.2 units). There was no mortality, mechanical circulatory support, stroke, or renal failure requiring hemodialysis/filtration. No difference was found in the incidence of bleeding (40% vs. 33.3%) which was defined as red blood cell transfusion ≥5 units, reoperation, or intentional delayed closure. The incidence of mediastinitis (2.0% vs. 0%), ventilator ≥24 hours (4.0% vs. 2.8%), atrial fibrillation (18.0% vs. 25.0%), mean intensive care unit stay (34.5 hours vs. 38.8 hours), and median hospital stay (8 days vs. 7 days) did not differ, either.

Conclusion

AVR combined with additional aortic or root replacement showed an excellent outcome and recovery course equivalent to that after isolated AVR.

Replacement of a stented biologic prosthesis within an aortic valved conduit

A 68-year-old man was referred for severe aortic regurgitation 10 years after aortic root replacement with a valved conduit containing a stented bioprosthesis that had been sutured inside of the vascular tube graft, rather than at its extremity. Because of this simple modification of the Bentall concept, replacing the prosthetic valve within the aortic conduit was easy and uneventful.

Device occlusion of pseudoaneurysm of ascending aorta

Pseudoaneurysm of ascending aorta is an infrequent but well-recognized and potentially fatal complication after cardiac surgeries. The complication can develop early, delayed or late, and the presentation is also varied. We are presenting here two cases of pseudoaneurysm of ascending aorta following cardiac surgery that were successfully managed by the transcatheter method. The first one occurred following coronary artery bypass surgery and the second one occurred following double-valve replacement surgery. The aortic openings of these aneurysms were occluded with 12 mm and 10 mm atrial septal occluders, respectively, with a good outcome. An immediate postprocedure angiogram showed no residual flow into the sac. Six months of follow-up of both cases also showed excellent results.

[Surgery of aortic coarctation with aneurysm of the ascending aorta and aortic coronary fistula]

Aortic coarctation is rarely associated with an aneurysm of the ascending aorta and an aortic coronary fistula. In this study, we report the case of a 52-year-old man undergoing surgery for an isthmic coarctation who also had an aneurysm of the initial portion of the aorta and an aortic coronary fistula. The diagnosis was clinically suspected and confirmed by vascular catheterism. The first operative stage consisted of treating the coarctation. The second stage was performed two months later to remove the aneurysm and replace the ascending aorta and the aortic valve with a prosthesis. The coronary arteries were then reimplanted. The postoperative results were quite favourable.

Outcome after the modified Bentall technique with a long interposed graft to the left coronary artery

BACKGROUND

The modified Bentall technique, which was reported by Svensson in 1992, is an aortic root composite valve graft replacement involving reimplantation of the left coronary ostium with a long interposed graft wrapping behind the composite graft. The technique is technically advantageous, particularly for complicated or redo aortic roots. To justify the technique, the midterm outcome needs to be evaluated.

METHODS

Since 1992, 40 patients (4 with Marfan syndrome) underwent the modified Bentall technique (Svensson's modification). The mean age was 54.7 +/- 13.6 years, and 32 patients (80.0%) were male. All hospital survivors have been consecutively followed with annual echocardiographic evaluations. Furthermore, in 2007, multislice computed tomography was performed at 4.7 +/- 3.5 years (maximum, 14.9 years) postoperatively in 30 patients who had preserved renal function.

RESULTS

No patients have experienced any complications regarding the technique at the follow-up of 5.7 +/- 4.0 years (maximum, 14.9 years), although there were 2 hospital deaths of emergency cases and 5 late deaths owing to noncardiac causes. In 35 patients (92.1% of hospital survivors), no structural complications were detected by multislice computed tomographies of the 30 patients or coronary angiograms of the remaining 5 patients. The consecutive echocardiographic follow-ups showed well-preserved left ventricular function with the most recent ejection fraction being 0.581 +/- 0.078.

CONCLUSIONS

This Svensson's modification technique was associated with favorable midterm outcomes by multislice computed tomography and consecutive echocardiographic evaluations, indicating long-lasting advantages as well as technical benefits. Thus, the technique can be considered as a helpful and justifiable alternative method.

Aortic Root Repair for Thoracic Aorta False Aneurysm Following Bentall Procedure

The Bentall procedure for aortic root replacement in Marfan's syndrome is safe and durable. We describe successful repair of periprosthetic valvular leak, 12 years following Bentall repair with composite graft. The aim of this report is to analyse and evaluate technical factors leading to this unusual occurrence.

Antegrade versus retrograde cerebral perfusion in relation to postoperative complications following aortic arch surgery for acute aortic dissection type A

BACKGROUND

Aortic arch surgery is impossible without the temporary interruption of brain perfusion and therefore is associated with high incidence of neurologic injury. The deep hypothermic circulatory arrest (HCA), in combination with antegrade or retrograde cerebral perfusion (RCP), is a well-established method of brain protection in aortic arch surgery. In this retrospective study, we compare the two methods of brain perfusion.

MATERIALS AND METHODS

From 1998 to 2006, 48 consecutive patients were urgently operated for acute type A aortic dissection and underwent arch replacement under deep hypothermic circulatory arrest (DHCA). All distal anastomoses were performed with open aorta, and the arch was replaced totally in 15 cases and partially in the remaining 33 cases. Our patient cohort is divided into those protected with antegrade cerebral perfusion (ACP) (group A, n = 23) and those protected with RCP (group B, n = 25).

RESULTS

No significant difference was found between groups A and B with respect to cardiopulmonary bypass-time, brain-ischemia time, cerebral-perfusion time, permanent neurologic dysfunction, and mortality. The incidence of temporary neurologic dysfunction was 16.0% for group A and 43.50% for group B (p = 0.04). The mean extubation time was 3.39 +/- 1.40 days for group A and 4.96 +/- 1.83 days for group B (p = 0.0018). The mean ICU-stay was 4.4 +/- 2.3 days for group A and 6.9 +/- 2.84 days for group B (p = 0.0017). The hospital-stay was 14.38 +/- 4.06 days for group A and 19.65 +/- 6.91 days for group B (p = 0.0026).

CONCLUSION

The antegrade perfusion seems to be related with significantly lower incidence of temporary neurological complications, earlier extubation, shorter ICU-stay, and hospitalization, and hence lower total cost.

Replacement of the Proximal Aorta Adds No Further Risk to Aortic Valve Procedures

BACKGROUND

Aortic valve pathology is often associated with proximal aortic dilatation. Even after valve surgery, the proximal aorta can continue to dilate and thus be at risk for rupture, dissection, or later aortic replacement. We hypothesized that the addition of proximal aortic intervention adds no further risk to aortic valve surgery, which may avoid subsequent proximal aortic procedures or catastrophes.

METHODS

Between 1996 and 2004, 430 aortic valve interventions alone and 146 aortic valves with proximal aortic replacements were identified in elective adult patients. The age in the valve-alone patients (68.8 years) was slightly higher than the valve-plus-aorta group (valve/aorta, 60.5 years; p < 0.01), but comorbidities were similar between groups. We compared groups based on hospital mortality and incidence of complications.

RESULTS

The 30-day mortality was similar between groups (valve-alone, 3.8% versus valve/aorta, 2.7%; p = 0.5), as were rates for bleeding and operative revision (valve-alone, 6.7% versus valve/aorta, 9.5%; p = 0.5). Pulmonary (valve-alone, 23.0% versus valve/aorta, 11.6%) and renal complications (valve-alone, 8.2% versus valve/aorta, 2.7%) were higher in the valve-alone group (p = 0.02). Logistic regression demonstrated no additional risk of death, neurologic, or cardiac event with replacement of the proximal aorta.

CONCLUSIONS

Proximal aortic replacement adds no risk to the patient beyond the aortic valve intervention alone. These findings suggest proximal aortic replacement is safe for patients undergoing valve operations. Patients with a moderately enlarged proximal aorta that may dilate further should also be considered for aortic replacement at the time of valve procedures.

Reoperations on the Ascending Aorta and Aortic Root in Patients With Previous Cardiac Surgery

BACKGROUND

First time operations on the ascending aorta are performed with low mortality, few complications, and excellent long-term results. Reoperations for aortic pathology in patients with previous cardiac surgery carry significantly more risk. Technical issues during the procedure, as well as age, preoperative New York Heart Association class, and perioperative renal dysfunction, have been shown to contribute heavily to worse outcomes. We analyzed our results with aortic reoperations with the intent of further reducing surgical risk through alterations in surgical technique or patient selection.

METHODS

From July 1997 until October 2005, 147 patients having previous cardiac surgery presented with aneurysm or dissection of the ascending aorta or root. Perioperative data were retrospectively analyzed. Morbidity, mortality, and risk factors for these events were calculated.

RESULTS

Eight patients expired (5.4%) after their reoperation. Significant (p < 0.05) univariate risk factors for mortality included age greater than 75 years (< 0.001), previous coronary artery bypass grafting (CABG) (< 0.008), cardiopulmonary bypass greater than 240 minutes (< 0.01), need for intraaortic balloon pump support (< 0.001), need for new CABG (< 0.007), postoperative cerebrovascular accident (< 0.032), and tracheostomy (< 0.003). Age 75 years or older (p < 0.025) was the only significant variable for death by multivariate analysis. A majority of patients (n = 87, 60%) required circulatory arrest to complete their procedure. However, neither arch involvement nor type of aortic root procedure was predictive of perioperative mortality.

CONCLUSIONS

Surgery on the ascending aorta and root in patients who have had previous cardiac surgery can be performed with low mortality. Advanced age and significant coronary disease may negatively influence surgical results.

Surgical treatment of pseudoaneurysm of the thoracic aorta

OBJECTIVES

To examine the clinical profiles, operative outcomes, and late results of patients with pseudoaneurysm of the thoracic aorta.

METHODS

From 1990 to 2002, 60 patients underwent repair of aortic pseudoaneurysm: ascending aorta in 70%, ascending aorta and arch in 15%, descending aorta in 10%, and arch alone in 5%. Mean age was 53 +/- 15 years, and 70% were men. Of these, 50 (83%) had undergone previous cardiac surgery, including 22 (37%) composite valve graft operations. The preferred cannulation site was femoral-femoral (n = 27, 45%), with deep hypothermic circulatory arrest in 62% and retrograde cerebral perfusion in 33%; more recently, however, axillary cannulation has been preferred.

RESULTS

Principal etiologies were graft infection in ascending aorta pseudoaneurysm and trauma in descending aorta pseudoaneurysm. Fifteen patients (25%) presented with chest pain, 13 (22%) with heart failure, and 20% with moderate or severe aortic regurgitation. The pseudoaneurysm was resected and the aorta replaced (n = 45, 75%) or repaired (n = 15, 25%) using various methods. Hospital mortality was 6.7% (n = 4). Reexploration for bleeding was required in 8.3%, and 3.3% had postoperative stroke. At 30 days, 5 years, and 10 years, survival was 94%, 74%, and 60% and freedom from reoperation was 95%, 77%, and 67%, respectively.

CONCLUSIONS

Most patients with aortic pseudoaneurysm require ascending aorta and/or arch replacement, which can be accomplished with low operative mortality and morbidity. Long-term survival and freedom from reoperation in these young patients parallel those expected for complex cardiac and aortic disease.

Thoracic Aorta False Aneurysm: What Surgical Strategy Should Be Recommended?

BACKGROUND

Thoracic aorta false aneurysms (TAFA) are a surgical challenge. The best technical approach remains uncertain.

METHODS

Between 1981 and 2004, 57 patients underwent operation for TAFA (mean age 57 +/- 18 years; 43 [75%] were male). Symptoms included dyspnea 25 (44%), chest pain 22 (39%), and fever 18 (32%). Twelve (21%) were asymptomatic. Thirty-seven (65%) had undergone previous operation with a mean interval between operations of 80 +/- 90 months. Fifteen (26%) had a mycotic etiology. The TAFA involved the aortic root in 10 (18%), ascending aorta in 28 (49%), arch in 6 (11%), and descending aorta in 13 (32%). Twenty-one (37%) required femorofemoral cannulation and 28 (49%), circulatory arrest. Surgical techniques included graft replacement in 27 (47%), composite root in 10 (18%), patch repair in 10 (18%), and direct suture in 10 (18%).

RESULTS

Operative mortality was 7% (4 patients). Four of 32 (13%) had massive hemorrhage during redo sternotomy, and all of these had planned extramediastinal cannulation (all survived). Follow-up was 100% for 349 patient-years. Actuarial survival was 77% +/- 6%, 63% +/- 8%, and freedom from recurrent TAFA was 87% +/- 5% and 83% +/- 7%, at 5 and 10 years, respectively. Univariate analysis identified TAFA greater than 55 mm, urgent operation, and NewYork Heart Association functional class III or IV as predictors of hemorrhage during redo sternotomy. Obesity and ejection fraction of 35% or less were predictors of operative death.

CONCLUSIONS

Thoracic aorta false aneurysm symptoms may be minimal, and consequently a high degree of suspicion plus serial imaging is warranted. Extramediastinal cannulation, deep hypothermia, and circulatory arrest are required for large mediastinal TAFA. Despite serious risks, TAFA correction is possible with good long-term results.

Aortic root replacement after previous surgical intervention on the aortic valve, aortic root, or ascending aorta

BACKGROUND

Aortic root replacement after a previous operation on the aortic valve, aortic root, or ascending aorta remains a major challenge.

METHODS

Records of 56 consecutive patients (44 men; mean age, 56.4 +/- 13.6 years) undergoing reoperative aortic root replacement between June 1994 and June 2005 were reviewed retrospectively.

RESULTS

Reoperation was performed 9.4 +/- 6.7 years after the last cardiac operation. Indications for reoperation were true aneurysm (n = 14 [25%]), false aneurysm (n = 10 [18%]), dissection or redissection (n = 9 [16%]), structural or nonstructural valve dysfunction (n = 10 [18%]), prosthetic valve-graft infection (n = 12 [21%]), and miscellaneous (n = 1 [2%]). Procedures performed were aortic root replacement (n = 47 [84%]), aortic root replacement plus mitral valve procedure (n = 5 [9%]), and aortic root replacement plus arch replacement (n = 4 [7%]). In 14 (25%) patients coronary artery bypass grafting had to be performed unexpectedly during the same procedure or immediately after the procedure to re-establish coronary perfusion. Hospital mortality reached 17.9% (n = 10). Multivariate logistic regression analysis revealed the need for unplanned perioperative coronary artery bypass grafting as the sole independent risk factor for hospital death (P = .005). Actuarial survival was 83.8% +/- 4.9% at 1 month, 73.0% +/- 6.3% at 1 year, and 65.7% +/- 9.0% at 5 years after the operation. One patient had recurrence of endocarditis 6.7 months after the operation and required repeated homograft aortic root replacement.

CONCLUSION

Reoperative aortic root replacement remains associated with a high postoperative mortality. The need to perform unplanned coronary artery bypass grafting during reoperative aortic root replacement is a major risk factor for hospital death. The optimal technique for coronary reconstruction in this setting remains to be debated.

Reoperation is not an independent predictor of mortality during aortic valve surgery

OBJECTIVE

Reoperations on aortic valves are associated with increased mortality, which may affect valve prosthesis selection at the time of initial aortic valve replacement. We analyzed our experience to determine whether reoperation itself independently predicts mortality during aortic valve surgery.

METHODS

Demographic, intraoperative, and outcome data were collected prospectively on patients undergoing primary or redo aortic valve replacement or Bentall procedures after previous aortic valve replacement with or without concomitant coronary bypass grafting at a single institution from 1990 through 2002. Logistic regression analyses validated by means of bootstrap methodology identified the predictors of hospital mortality and the independent effect of reoperation.

RESULTS

Of 2673 patients undergoing aortic valve surgery, 2375 were primary operations, 216 were reoperations, and 82 were Bentall-after-aortic valve replacement procedures. Of 298 reoperations, 32 were third and 5 were fourth procedures. Mortality was 2.3% for primary operations, 4.6% for redo aortic valve replacement, and 2.4% for Bentall-after-aortic valve replacement procedures. Most patients underwent elective procedures, with mortalities of 1.6%, 1.7%, and 2.5%, respectively. Hospital mortality was independently predicted by peripheral vascular disease (odds ratio, 3.6), active endocarditis (odds ratio, 2.9), worsening New York Heart Association class (odds ratio, 2.3), and need for annular enlargement (odds ratio, 2.1). Reoperation itself did not predict hospital mortality.

CONCLUSIONS

The risk of mortality during aortic valve surgery is due mostly to active endocarditis, New York Heart Association class, and comorbidity. We failed to find a significant effect of reoperation on perioperative mortality. Mechanical valves, with their attendant anticoagulation-related morbidity, should not be implanted solely because of anticipated high mortality associated with bioprosthetic rereplacement.

Novel use of the Amplatzer® septal occluder device in the percutaneous closure of ascending aortic pseudoaneurysms: A case series

Pseudoaneurysms of the ascending aorta are a potentially fatal condition that usually necessitates definitive surgical management. In this series of three cases, we describe the novel use of the Amplatzer septal occluder device in percutaneously managing this problem.

Long-term integrity of teflon felt-supported suture lines in aortic surgery

BACKGROUND

Although the ultimate success of aortic operations depends upon the integrity of graft-to-aorta anastomoses, little is known about different techniques used to assure their longevity. We report the incidence of reoperation for suture line disruptions arising from anastomoses using reinforcement with Teflon felt.

METHODS

Since 1987, 1475 patients underwent 2281 anastomoses in the thoracic aorta (mean 1.55/anastomoses per patient). All patients were followed with at least yearly computed tomographic scans, for a total follow-up of 6483.8 patient-years. Those requiring reoperation were reviewed retrospectively for evidence of suture line disruption.

RESULTS

Only 34 patients, with a mean age of 55.1 years old (range 26-85 years old) underwent reoperation for suture-line disruptions following vascular graft-to-aorta anastomosis using Teflon felt. The previous operation was a Bentall procedure in 15 (44%); ascending aorta replacement in 9 (26%); total arch replacement in 6 (18%); descending aorta replacement in 2 (6%); thoracoabdominal repair in 1 (3%); and sinus of Valsalva repair in 1 (3%). The incidence of suture line disruption was 0.0052 per patient-year, and 0.0034 per anastomosis-year. The mean interval between operations was 55.9 months (range 4-180 months). In 21%, the pseudoaneurysm originated from the proximal anastomosis; in 71% from the distal anastomosis; in 3% from both; in 3% from the innominate artery; and in 3% from a sinus of Valsalva repair. In only 1 patient was there evidence of infection. Reoperation involved ascending aorta replacement in 11 patients, and total arch replacement in 13 patients. Adverse outcome, such as hospital death or permanent stroke, occurred in 8% (3 patients).

CONCLUSIONS

Use of Teflon felt to support aortic suture lines yields a very low incidence of suture line disruptions: 1 per 191 patient-years, or 1 per 296 anastomosis-years. Teflon felt reinforcement provides a secure, long-lasting graft-to-aorta anastomosis with minimal risk of infection.