Composite aortic root replacement with direct coronary artery implantation

Long-term survival after composite mechanical aortic root replacement: a consecutive series of 448 cases

OBJECTIVE

To determine the effect of different etiologies on the outcome and mortality after mechanical composite aortic root/ascending replacement.

METHODS

From February 1998 to June 2011, 448 consecutive patients (358 men, age, 52.8 ± 12.3 years) underwent composite mechanical aortic root replacement. Of these 448 patients, 362 (80.8%) were treated for degenerative/atherosclerotic root/ascending aortic aneurysm (287 men, age, 53.0 ± 12.1 years), 65 (14.5%) for emergent acute type A aortic dissection (49 men, age, 51.0 ± 13.1 years), and 21 (4.7%) for active infective endocarditis (20 men, age, 46.5 ± 13.6 years); 15% (n = 68) were reoperative or redo procedures.

RESULTS

The overall hospital mortality after composite root/ascending replacement was 6.7% (n = 30). It was 3.9% (n = 14) after elective/urgent aneurysm replacement, 20.0% (n = 13) after emergency repair for acute type A aortic dissection, and 14.3% for active infective endocarditis (n = 3). The overall 1-year mortality--as a measure of operative success--was 5.2% (n = 19) after elective/urgent degenerative/atherosclerotic root/ascending aortic aneurysm repair, 21.5% (n = 14) after emergency repair for acute type A aortic dissection, and 14.3% (n = 3) after active infective endocarditis (degenerative/atherosclerotic root/ascending aortic aneurysm vs acute type A aortic dissection, P = .03; degenerative/atherosclerotic root/ascending aortic aneurysm vs active infective endocarditis, P = .08; acute type A aortic dissection vs active infective endocarditis, P = .8). Long-term survival was 88.3% at 5 years and 72.2% at 10 years, with a linearized mortality rate after 30 days of 2.5%/patient-year. Long-term survival after surgery for acute type A aortic dissection and active infective endocarditis was 72% and 72.3% at 5 years and 64.9% and 62% at 10 years, respectively, with a linearized mortality rate of 2.6%/patient-year for acute type A aortic dissection and 3.7% for active infective endocarditis. Survival after composite root replacement after the first year paralleled that of an age- and gender-matched population, regardless of the etiology. Women appeared to have less favorable longevity.

CONCLUSIONS

Composite root replacement remains a versatile choice for various pathologic features with excellent longevity and freedom from reoperation and should be strongly considered if conditions for valve-sparing repair are less than perfect.

Long-term mortality and morbidity after button Bentall operation

BACKGROUND AND AIM OF THE STUDY

The purpose of this study is to evaluate the long-term outcomes of the button Bentall procedure for the correction of aortic root disease.

METHODS

A total of 195 patients who underwent the button Bentall procedure between 1997 and 2010 were studied. The main pathology was annuloaortic ectasia. A mechanical valve was used in 163 patients (83.6%). The median duration of follow-up was 64 months (14133.0 patient-years).

RESULTS

There were five operative deaths (2.6%). Late overall mortality was 7.9%. The actuarial overall survival rate was 95.8 ± 1.5% at 5 years, 89.6 ± 3.4% at 10 years, and 75.9 ± 7.3% at 15 years. Multivariate logistic regression analysis identified preoperative poor mobility, cardiopulmonary bypass time, deep hypothermic circulatory arrest (DHCA) use, embolism, and bleeding event as significant independent risk factors for the late overall mortality. At 5, 10, and 15 years, actuarial composite valve graft-related event-free survival was 85.8 ± 2.8%, 75.5 ± 4.4%, and 69.3 ± 7.3%, respectively. Hypertension and concomitant coronary artery bypass graft (CABG) were independent predictors of composite valve graft-related events. Age, concomitant CABG, and DHCA use were associated with bleeding.

CONCLUSIONS

Valve-related morbidities, such as embolism and bleeding, determine the long-term overall mortality in aortic root replacement with button Bentall operation, similar to that in routine valve surgery.

Results of one-hundred and seventy patients after elective Bentall operation

The aim of this study was to evaluate the short and long-term operative results of patients who underwent a Bentall procedure in a 12-year period. We retrospectively analyzed the data of 170 patients who underwent an elective Bentall procedure between January 1998 and July 2010. All pre- and perioperative variable were entered into a multivariate regression model to identify significant predictors of early and late mortality. The early mortality rate was 11.2% (19/170 patients). Multivariate logistic regression analysis identified prior cardiac operation and cardiopulmonary bypass time as independent risk factors for early mortality, with odds ratios of 5.75 (95% confidence interval: 1.850–17.874; p = 0.003) and 1.011 (95% confidence interval: 1.003–1.019; p = 0.008), respectively. The Kaplan-Meier curve shows an overall survival of 78% ± 4% at 5 years and 66% ± 10% at 10 years. Cox regression analysis revealed no independent risk factors for late mortality. The Bentall procedure is still the procedure of choice for aortic root replacement. Improvements in perioperative management in recent years has improved the early outcome, and in our experience, the late results of this technique were satisfactory.

Long term results with the Cabrol aortic root replacement

Cabrol aortic root replacement is rarely performed in recent years because of potential coronary complications. The purpose of this study was to investigate its early and late results, including coronary complications, by evaluating our experience thus far. A retrospective lookup of patients who underwent Cabrol aortic root replacement between 1988 and 2001 found a total of 36 patients (24 men and 12 women) with a mean age of 45 years. Annuloaortic ectasia was the most frequent cause (n = 22), followed by chronic dissection (n = 5), acute dissection (n = 5), and aneurysm with prior aortic operation (n = 4). Early mortality occurred in one patient (2.8%). The mean follow-up period was 104 months. There were 7 late deaths, 4 of which were disease-related. The actuarial survival was 83.3% at 5 years and 72.9% at 10 years, and the freedom from reoperation was 87.9% at 5 years and 76.6% at 10 years. There were no reoperations on the ascending aorta. Coronary ostia were examined by angiography or 64-row multidetector computed tomography in 18 patients 43 to 189 months after the operation. Two patients developed stenosis or occlusion of the right coronary ostium. The early and late results of the Cabrol operation were favorable with the exception of coronary complications. The importance of careful follow-up for late coronary complications cannot be overemphasized.

Long-term follow-up, computed tomography, and computational fluid dynamics of the Cabrol procedure

OBJECTIVES

The Cabrol procedure is characterized by insertion of an ascending aortic composite graft with reimplantation of the coronary arteries by the interposition of a graft tube. Our purpose is to report the clinical long-term follow-up and computed tomographic findings in patients having undergone the Cabrol procedure and to determine blood flow in the Cabrol graft using computational fluid dynamics.

METHODS

Clinical follow-up (76.6 +/- 16.6 months) and dual-source computed tomographic angiography data of 7 patients (all men, mean age 54.9 +/- 9.6 years) with 12 Cabrol grafts (left main coronary artery, n = 7; right coronary artery, n = 5) were reviewed. In 2 patients, the right coronary artery was directly reattached to the aortic graft. Computational fluid dynamics were calculated using computed tomographic data of a patient with the Cabrol procedure and compared with those in a Valsalva graft and a healthy aortic root.

RESULTS

Computed tomography showed Cabrol graft occlusions to 1 of 7 (14%) left main and of 2 of 5 (40%) right coronary arteries. Six grafts to the left main and 3 to the right coronary artery were fully patent, similar to the 2 directly reattached right coronary arteries to the aortic graft. Computational fluid dynamics results show similar blood flow parameters into the coronaries for the healthy aortic root and Valsalva graft. In the Cabrol graft, a spiraling flow pattern with low flow into the right coronary artery was found (right coronary artery = 1 mL/min at both systole and diastole).

CONCLUSIONS

Our study indicates low flow rates particularly in the right Cabrol graft correlating with a higher incidence of occlusions of the right as compared with the left Cabrol graft at long-term follow-up.

Perioperative results of the aortic root replacement in strict graft inclusion technique

BACKGROUND AND AIM

Bleeding may sometimes be a serious problem after the termination of the aortic root replacement. Therefore, the strict graft inclusion technique has been developed to avoid major complications. We present the early results after aortic root replacement in strict graft inclusion technique.

MATERIALS AND METHODS

The strict graft inclusion technique was performed in 28 patients between April 2001 and June 2006 in St-Johannes-Hospital-Dortmund, Dortmund, Germany. There were nine female and 19 male patients. The mean age was 57.78 +/- 12.01 years (28 to 77 years). A type A aortic dissection and an ascending aortic aneurysm with aortic valve lesion were the indication to operation in patients.

RESULTS

There were no early mortality and postoperative rethoracotomy. The mean postoperative bleeding over mediastinal drains was 565 +/- 310 mL. (100-2250 mL). In exception of the patients with preoperative double thrombocyte aggregation inhibitors therapy and postoperative consumption coagulopathy, the mean postoperative bleeding over mediastinal drain was 443.04 +/- 171.59 mL (100-1100) in the first 24 hours, the transfusion rate was minimal, mean 0.39 +/- 0.64 packed red blood cells (RBC) (0-4) and mean 0.14 +/- 0.27 packed fresh frozen plasma (FFP) (0-4), whereas only in 18 patients (78.26%) out of 23 patients was a transfusion not necessary. The intraoperative and postoperative requirement for substitution of erythrocyte concentrate was mean 1 +/- 1.28 packed RBC (0-5) and FFP concentrate was mean 1.21 +/- 1.90 packed FFP (0-12).

CONCLUSIONS

The strict graft inclusion technique for aortic root replacement represents a safe and feasible method to avoid bleeding from coronary ostial anastomoses, from aortic annular suture lines, and annular leak.

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.

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.

Composite aortic root replacement with a bovine pericardial valve conduit

In order to offer selected patients undergoing composite aortic root replacement the advantages of a tissue valve, we have constructed conduits intraoperatively by suturing a stented bovine pericardial valve (Edwards Life-sciences LLC, Irvine, CA) inside of a Dacron tube graft (Boston Scientific Corp, Natick, MA). The conduit is quickly made from readily available materials, is easily implanted, and can accommodate any of the anatomic situations encountered in repair of aortic root aneurysms. It is particularly suitable for patients 65 years of age and older.

Composite grafts replacement of the aortic roots

Review of some of the techniques used for the replacement of aortic root grafts.

A long-term experience with the Cabrol root replacement technique for the management of ascending aortic aneurysms and dissections

BACKGROUND

Little information exists regarding the long-term results of the Cabrol technique. This study aimed at exploring, over a 16-year period, the results of aortic root replacements employing this procedure.

METHODS

Between 1986 and 2002 forty-five patients (mean age 58.7 +/- 13.8 years old, 84.4% male) underwent a Cabrol procedure. Aortic dissection was the most frequent cause of aortic disease in this series (n = 17), followed by annuloaortic ectasia (n = 10), atherosclerotic aneurysm (n = 5) and poststenotic dilatation (n = 5). Six patients (13.4%) had undergone a previous aortic operation, 8 (17.7%) had a Marfan syndrome and five (11.1%) underwent concomitant arch replacement. Mean clinical follow-up was 87.3 +/- 24.3 months. Twenty-eight patients (93.3% of survivors) had a transesophageal echocardiography (TEE) performed at a mean of 64 +/- 32 months postoperatively.

RESULTS

Early mortality was 20%. It was 9.1% for patients with an ascending aortic aneurysm and 41.2% for dissections (p = 0.026). Independent multivariate predictors of early mortality were: aortic dissection (p = 0.009), emergency operation (p < 0.001), operative year (p = 0.02), cross-clamp time (p = 0.001), and CPB duration (p < 0.001). Actuarial survival was 0.77 +/- 0.06, 0.72 +/- 0.06, 0.59 +/- 0.04 and 0.59 +/- 0.04 at 1, 5, 10, and 16 years, respectively. Multivariate analysis revealed age (p = 0.007), cross-clamp time (p = 0.0006) and CPB duration (p = 0.009) as strong predictors of poor late survival. A periprosthetic jet with significant valve regurgitation was detected by TEE in 3 patients. In one of them, an infected periprosthetic space-right ventricular fistula was demonstrated requiring reoperation. Altogether, freedom from reoperation and endocarditis at 16 years was 0.97 +/- 0.02 and 0.94 +/- 0.03, respectively.

CONCLUSIONS

The Cabrol technique demonstrated a nonnegligible incidence of early and long-term complications. It should be rarely used and only when a "button" technique is not feasible.

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.

Five-year experience in aortic root replacement with the flanged composite graft

BACKGROUND

Replacement of the aortic root with a composite graft containing a prosthetic mechanic valve is the preferred surgical procedure for tailoring the aortic root. The aim of this study is to determine the 5-year experience with the composite root replacement using our new modification of the Bentall technique.

METHODS

Between January 1996 and June 2001, 96 patients underwent aortic root replacement using a flanged composite graft. Eighty patients (83.3%) were male, and 16 patients (16.7%) were female with a mean age of 48.7 +/- 14.4 years. Indications for operation were a true or false aneurysm (65.6%), severe calcified aortic valve stenosis (4.2%) or severe aortic insufficiency (2.1%) with dilated ascending aorta, acute dissection (2.1%), or combination of indications (26%). Thirty-one patients (32.3%) received a concomitant cardiac procedure. Mean aortic cross-clamp time was 89.5 +/- 28.6 minutes, and mean cardiopulmonary bypass time was 146.2 +/- 45.6 minutes. Total follow-up was 253.9 patient-years.

RESULTS

Operative mortality was 8.3% (8 patients). The causes of hospital mortality were severe bleeding (3 patients), low cardiac output syndrome (2), acute respiratory distress syndrome (2) and cerebrovascular event (1). No patient died of flange-related complications. Univariate predictors of early mortality were low cardiac output syndrome (p < 0.001), neurologic complication (p = 0.03), and renal complication (p = 0.03). Multivariate analysis demonstrated only low cardiac output syndrome to be significant (p = 0.001) predictor for early mortality. There were five (5.7%) late deaths. Actuarial survival was 82.65% +/- 4.8% at 5 years (1.95% patient-year). Cox proportional hazards regression analysis demonstrated only low cardiac output syndrome to be significant (p = 0.032) predictor for late mortality. Actuarial freedom from prosthetic- and technique-related mortality was 100% at 5 years.

CONCLUSIONS

The flanged composite graft offers excellent long-term results, with very low prevalence of prosthetic-related complications. The new created sinuses and the flange are especially helpful to continue physiologic function of the aortic root.

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.

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.

Results of aortic arch repair with hypothermic circulatory arrest and retrograde cerebral perfusion

BACKGROUND

Repair of aortic arch pathology is reliably performed with hypothermic circulatory arrest, but the best method of brain protection is controversial.

METHODS

We reviewed a consecutive series of 67 patients who had aortic arch repair with hypothermic circulatory arrest. Retrograde perfusion of arterial blood into the superior vena cava (SVC) during systemic arrest was used in 87%. Average age was 65 years. Acute dissection was present in 25%. Average circulatory arrest time was 37 minutes, and average temperature 17.7 degrees C.

RESULTS

Hospital mortality was 1.5%. Strokes occurred in 4.5%. Temporary neurological dysfunction occurred in 16%. Multivariate logistic regression analysis showed that acute dissection was the only independent predictor of the combined risk of stroke and temporary neurological dysfunction (odds ratio 8.5). Duration of circulatory arrest and patient age were not risk factors for adverse neurological outcome.

CONCLUSION

Continuous arterial perfusion of the SVC during hypothermic circulatory arrest provides excellent cerebral protection for aortic arch repair. Acute dissection is an independent risk factor for adverse neurological outcome. Arrest time is not a predictor of neurological dysfunction.

Acute Dissection of Ascending Aorta after Aortic Valve Replacement

A 57-year-old man who had aortic insufficiency with mild dilatation (36 mm) of the ascending aorta but no evidence of aortic wall degeneration, developed acute dissection of the ascending aorta 6 months after aortic valve replacement. He underwent successful Dacron graft replacement of the ascending aorta.

Combined grafting of thoracic aortic aneurysm and cardiac repair using continuous cold-blood coronary perfusion

OBJECTIVE

For patients diagnosed with combined thoracic aortic aneurysms and cardiac lesions, we conduct a 1-stage operation for ascending and aortic arch grafting. We studied surgical outcome comparatively with patients undergoing aortic grafting alone. For descending and thoracoabdominal aortic grafting, we choose a 2-stage operation.

SUBJECTS AND METHODS

Subjects were 80 patients undergoing ascending and aortic arch aneurysm repair between June 1994 and March 1999. Group 1 consisted of 30 undergoing simultaneous cardiac repair. Concomitant cardiac procedures involved 21 valvular, 5 coronary arterial, and 4 valvular and coronary arterial surgeries. Group 2 consisted of 50 undergoing aortic grafting alone. We used crystalloid cardioplegia and additional antegrade continuous cold-blood coronary perfusion in Group 1, and crystalloid cardioplegia alone in Group 2.

RESULTS

Hospital mortality was 10% in Group 1 and 2% in Group 2. Surgery length, cardiopulmonary bypass time, and aortic cross-clamping time in Group 1 were significantly longer than Group 2. Myocardial ischemic time did not differ significantly. Postoperative ICU stay, mechanical ventilation time and catecholamine support time did not differ significantly. Actuarial survival was 66.9 +/- 13.1% at 52 months in Group 1 and 87.2 +/- 4.8% at 57 months in Group 2 (p = 0.2918).

CONCLUSION

Simultaneous cardiac repair and ascending and aortic arch aneurysm repair were conducted using continuous cold-blood coronary perfusion. Hospital mortality and mid-term survival did not differ significantly between groups.

Management of aortic valve disease during aortic surgery

BACKGROUND

Alternative management strategies for aortic valve disease and aortic operation include valve preservation and aortic repair (VPR), composite valve graft (CVG), or separate valve and aortic repair (SVR). We evaluated these approaches.

METHODS

Of 250 ascending/arch operations, 151 patients had aortic valvular disease and dissection (n = 56, 37%) or aneurysms operated between November 1990 and January 1998. Sixty-seven patients underwent CVG insertion, 50 SVR, 13 VPR, and 21 only aortic repair alone (RA). Sixty (40%) patients also had aortic arch repairs and 53 (35%) coronary artery bypasses.

RESULTS

The early 30-day survival and stroke rates were 99% (150 of 151) and 0% (0 of 151), respectively: CVG 100% (67 of 67), 0%; VPR 100% (13 of 13), 0%; SVR 98% (49 of 50), 0%; RA 100% (21 of 21), 0% (p = not significant [NS]). On late follow-up of all patients (5 to 92 months; 96% complete 1998), 3 CVG, 2 VPR, 6 SVR, and 0 RA patients died with respective 5-year Kaplan-Meier survival rates of 88.4%, 70%, 69%, and 100% (p = 0.07, log-rank test). The respective linear rates for stroke were 0%, 5.5% (n = 1), 0%, and 0%; for hemorrhage were 0%, 0%, 0%, and 0%; and for endocarditis were 2.2% (n = 3), 0%, 0%, and 0% (p = NS). There were 11 late deaths and no patient required reoperation or ruptured the ascending aorta or the aortic arch.

CONCLUSIONS

With careful selection of the appropriate method excellent early and late results can be achieved.

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.

Twenty-four year experience with reoperations after ascending aortic or aortic root replacement

OBJECTIVE

A retrospective analysis of early and late outcome for late (>4 weeks) reoperations on the ascending aorta or aortic root.

MATERIALS AND METHODS

During a 24-year interval, starting in 1974, 834 patients underwent replacement of the ascending aorta (39.2%) or aortic root (60.8%). During the same period, 56 patients with a mean age of 51.1 +/- 14.4 years underwent reoperation after ascending aortic or aortic root replacement. Predominant indications for reoperation were false aneurysm in 25 (44.6%) patients and true aneurysm in 18 (32.1%) patients. Most frequent surgical procedures were redo aortic root replacement in 30 (53.6%) patients and closure of a false aneurysm in 14 (25.0%) patients. Median interval between the operations was 51 months. Eighteen (32.2%) patients underwent concomitant partial or total aortic arch replacement.

RESULTS

Hospital mortality was 5.4% (n = 3; 70% CL: 2.4-8.4%). Cause of death was low cardiac output in two patients and rupture of the aorta at the distal suture line in one patient. Univariate analysis identified two or more previous operations (P = 0.038) and the interval between initial operation and reoperation for complication of less than 8 months (P = 0.005) as risk factors for hospital death. Multivariate analysis indicated operation for active endocarditis or vascular graft infection as an independent risk factor for hospital death (P = 0.038, odds 14.6). Follow-up was complete, median 3.1 years. Nine (16.9%; 70% CL: 11.7-22.1%) patients died during that period. Estimated survival at 1, 5 and 10 years was 91.2, 84.0 and 76.4%. One patient underwent another reoperation. Estimated event-free survival at 1, 5 and 10 year is 84.3, 72.2 and 65.6%.

CONCLUSION

False aneurysm formation and progression of aneurysmatic disease are the predominant causes for late reoperations after aortic root or ascending aortic replacement. Reoperations can be performed with low hospital mortality and good late results.

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.

Conservative treatment of the aortic root in acute type A dissection

OBJECTIVE

In acute type A dissection long-term results of conservative aortic root surgery were compared with the outcome of primary valve and/or root replacement.

METHODS

Between 1985 and 1995, 199 patients (mean age 59 years, 154 men) were operated on. The aortic root was involved in the dissection process and valve incompetence of varying degree was present without exception. Replacement of a proximal aortic segment was standard procedure in all patients. The aortic valve was preserved in 126 patients: commissural suture resuspension (12 patients), root reconstruction with GRF-glue (gelatine-resorcin-formaldehyde/glutaraldehyde-glue) (114 patients). Valve replacement was performed in 73 patients (50 composite grafts, 23 valve prostheses with separate supracoronary grafts). Preoperative risk factors (valve replacement vs. preservation): coronary artery disease (11 vs. 8%, NS), tamponade (18 vs. 17%, NS), unstable hemodynamics (22 vs. 15%, NS), renal failure (4 vs. 6%, NS), neurologic disorder (19 vs. 32%, NS).

RESULTS

The overall early mortality was 23.6% (47/199 patients) and increased after commissural suture resuspension compared with GRF-glue reconstruction (P = NS). Parameters of the early postoperative period did not differ between conservative treatment and root/valve replacement: low cardiac output, 34 versus 38% (P = NS); myocardial infarction, 10 versus 11% (P = NS); hemorrhage, 25 versus 23% (P = NS); duration of intensive care (P = NS). Survival was 61% after 8 years without difference between the two principal treatment groups (P = NS) and between the two conservative subgroups (P = NS). At 2 years, GRF-glue reconstruction had an increased freedom from reoperation on the aortic root (92 vs. 70%, P = 0.0253) and event free survival (77 vs. 41%, P = 0.0224) compared with suture resuspension. Commissural suture resuspension was an independent, significant predictor for reoperation (P = 0.0221, relative risk = 4.7130).

CONCLUSION

Surgery for acute type A dissection still carries a considerable early risk. Preservation of the aortic root is safe in the absence of Marfan or annuloaortic ectasia, but a certain incidence of reoperations on the aortic valve and the aortic root has to be accepted. Root reconstruction using GRF-glue is the method of choice and is superior to suture resuspension, with a significantly better reoperation-free and event-free survival.

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.

Repeat aortic root replacement

BACKGROUND

Aortic root replacement in patients who have undergone previous aortic root replacement presents a formidable technical challenge, which may lead to increased surgical mortality.

METHODS

We reviewed our experience from January 1989 through November 1995. Seven consecutive patients (6 men and 1 woman) underwent eight repeat aortic root replacements. Mean follow-up was 19 months. Previous root replacement had been performed with homograft in 1 patient, with a bioprosthetic valve composite graft in 1 patient, and with a mechanical valve composite graft in 6 patients. The techniques used at the previous procedures were the Cabrol technique (2 patients), Bentall technique (3 patients), and the coronary button technique (3 patients). Reoperation was indicated for pseudoaneurysm formation in 4 patients and for endocarditis in the others.

RESULTS

Aortic homografts were implanted in all patients with endocarditis and mechanical valve composite grafts were used in the others. In all reoperations, the coronary button technique was used. No procedures were done emergently. Concomitant procedures were performed in 2 patients, including mitral valve replacement and aortic arch aneurysm repair. One patient had recurrence of his endocarditis 36 months after operation because of continued intravenous drug use requiring a second successful homograft root replacement. There were no early deaths and one late death at 16 months after operation.

CONCLUSIONS

Repeat aortic root replacement, even in the setting of endocarditis, can be done with low mortality.

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.