Reoperative Aortic Root Replacement in Patients With Previous Aortic Surgery

The impact of reoperative surgery on aortic root replacement in the United States

OBJECTIVE

Reoperative sternotomy is associated with poor outcomes after cardiac surgery. We aimed to investigate the impact of reoperative sternotomy on the outcomes after aortic root replacement.

METHODS

All patients who underwent aortic root replacement from January 2011 to June 2020 were identified using the Society of Thoracic Surgeons Adult Cardiac Surgery Database. We compared outcomes between patients who underwent first-time aortic root replacement with those with a history of sternotomy undergoing reoperative sternotomy aortic root replacement using propensity score matching. Subgroup analysis was performed among the reoperative sternotomy aortic root replacement group.

RESULTS

A total of 56,447 patients underwent aortic root replacement. Among them, 14,935 (26.5%) underwent reoperative sternotomy aortic root replacement. The annual incidence of reoperative sternotomy aortic root replacement increased from 542 in 2011 to 2300 in 2019. Aneurysm and dissection were more frequently observed in the first-time aortic root replacement group, whereas infective endocarditis was more common in the reoperative sternotomy aortic root replacement group. Propensity score matching yielded 9568 pairs in each group. Cardiopulmonary bypass time was longer in the reoperative sternotomy aortic root replacement group (215 vs 179 minutes, standardized mean difference = 0.43). Operative mortality was higher in the reoperative sternotomy aortic root replacement group (10.8% vs 6.2%, standardized mean difference = 0.17). In the subgroup analysis, logistic regression demonstrated that individual patient repetition of (second or more resternotomy) surgery and annual institutional volume of aortic root replacement were independently associated with operative mortality.

CONCLUSIONS

The incidence of reoperative sternotomy aortic root replacement might have increased over time. Reoperative sternotomy is a significant risk factor for morbidity and mortality in aortic root replacement. Referral to high-volume aortic centers should be considered in patients undergoing reoperative sternotomy aortic root replacement.

True redo-aortic root replacement versus root replacement after any previous surgery

Objective

The impact of previous aortic root replacement (True-Redo) versus any previous operation (Any-Redo) on outcomes after reoperative aortic root replacement (redo-ROOT) is largely unknown. In this first multi-institutional study, the clinical impact True-Redo versus Any-Redo in the setting of redo-ROOT was reviewed.

Methods

From 2004 to 2021, 822 patients underwent redo-ROOT at 2 major academic centers: 638 Any-Redo and 184 True-Redo. Matching based on preoperative demographics and concomitant operations resulted in 174 matched pairs. An independent risk factor analysis was performed to determine risk factors for early and late mortality.

Results

Patients in the True-Redo group were younger, at 49.9 ± 15.1 versus 55.3 ± 14.7 years, P < .001. Concomitant operations were largely similar between the 2 groups, P > .05. Median cardiopulmonary bypass time (P < .001) and aortic crossclamp time (P = .03) were longer for True-Redo group. In-hospital mortality was 13% (109) and was without significant difference between groups, P = .41. Ten-year survival was 78% versus 76% for True-Redo versus Any-Redo groups respectively, P = .7. Landmark survival analysis at 4 years' postoperatively on the matched groups found that patients in the True-Redo group had improved survival outcomes (P = .046). Risk factors of in-hospital mortality consisted of older age (P < .0001), lower ejection fraction (P = .02), and male patient (P = .0003).

Conclusions

Clinical outcomes following redo-ROOT are excellent. Performance of a True-Redo-ROOT does not result in worse in-hospital morbidity or mortality and has improved survival benefit at midterm follow-up when compared with patients in the Any-Redo group. The decision to perform a redo-ROOT must be taken seriously and must be individualized in a patient-specific manner for optimal outcomes.

Redo aortic surgery: Does one versus multiple affect outcomes?

Objective

Redo aortic surgery has a higher risk of morbidity and mortality because it is technically complex due to mediastinal adhesions, infection, and previously implanted prostheses. In this study, we sought to benchmark our single-center experience comparing outcomes in patients undergoing aortic surgery after 1 versus multiple previous cardiac operations.

Methods

Between 2004 and 2019, 429 patients underwent redo aortic surgery. They were classified as aortic surgery after 1 previous surgery (first redo surgery, n = 360) and aortic surgery after 2 or more (multiple) previous surgeries (multiple redo surgery, n = 69). Postoperative outcomes and long-term survival were compared, and risk factors for mortality were identified.

Results

Thirty-day mortality was lower in first redo surgery compared with multiple redo surgery (12.3% vs 21.7%, P = .03). Age, cardiopulmonary bypass time, intra-aortic balloon pump use, postoperative cerebrovascular accident, absence of postoperative atrial fibrillation, intra-aortic balloon pump, and multiple redo surgery were independent predictors of 30-day mortality. Long-term survival was similar at 15 years. Patients who received first redo surgery were older (57.9 ± 14.0 years vs 50.3 ± 15.8 years, P = .0001) and had a higher incidence of hypertension (84.7% vs 73.9%, P = .02), whereas patients who received multiple redo surgery had a higher incidence of cerebrovascular disease (31.9% vs 20.3%, P = .03). Aortic valve replacement was the most common previous operation with higher incidence in multiple redo surgery. Incidence of previous aortic surgery was similar. Cardiopulmonary bypass (246 ± 67.3 minutes vs 219.9 ± 57.5 minutes, P = .009) and crossclamp times (208.2 ± 51.8 vs 181.9 ± 50.8 minutes, P = .004) were longer in multiple redo surgery. Incidence of reentry injury and balloon pump insertion were similar. Extracorporeal membrane oxygenation use was higher in multiple redo surgery. Postoperative complications occurred at similar rates, except for higher incidence of dialysis in multiple redo surgery (14.5% vs 7.2%, P = .04).

Conclusions

Multiple redo aortic procedures have a higher morbidity and mortality compared with first redo aortic procedures, with linearly increasing short-term mortality risk but similar long-term survival with the number of redo procedures.

Outcomes of reoperative aortic root surgery

OBJECTIVE

The study objective was to determine the impact of reoperative aortic root replacement on short-term outcomes and survival.

METHODS

This was a retrospective study of aortic root operations from 2010 to 2018. All patients with a complete aortic root replacement were included, and patients undergoing valve-sparing root replacements were excluded. Patients were dichotomized by first-time sternotomy versus redo sternotomy, which was defined as having had a prior sternotomy for whatever reason. Within the redo sternotomy group, reoperative aortic root replacements were identified, being defined as a complete aortic root replacement in patients with a prior aortic root replacement; 1:1 nearest neighbor propensity matching was used to compare outcomes across groups. Kaplan-Meier survival estimates were generated and compared using log-rank statistics.

RESULTS

A total of 893 patients undergoing complete ARR were identified, of whom 595 (67%) underwent first-time sternotomy and 298 (33%) underwent redo sternotomy. After matching, postoperative outcomes were similar for the first-time and redo sternotomy groups, including operative mortality. Redo sternotomy was not associated with reduced survival after aortic root replacement compared with first-time sternotomy (P = .084), with 5-year survival of 73.7% for first-time sternotomy and 72.9% for redo sternotomy. In the redo sternotomy group (n = 298), 69 (23%) were reoperative aortic root replacements and 229 (77%) were first-time aortic root replacements. After matching, postoperative outcomes were similar for the first-time and reoperative aortic root replacement groups, including operative mortality. Reoperative aortic root replacement was not associated with reduced survival, compared with first-time aortic root replacement (P = .870), with 5-year survival of 67.9% for first-time aortic root replacement and 72.1% for reoperative aortic root replacement.

CONCLUSIONS

Reoperative aortic root replacement can be performed safely and provides similar survival to first-time aortic root replacement.

Outcomes of Reoperative Aortic Root Replacement After Previous Acute Type A Dissection Repair

Limited aortic root repair for acute type A dissection is associated with greater risk of proximal reoperations compared to full aortic root replacement. Surgical outcomes for patients undergoing reoperative root replacement after previous dissection repair are unknown. This study seeks to determine outcomes for these patients to further inform the debate surrounding optimal upfront management of the aortic root in acute dissection. Retrospective record review of all patients who underwent full aortic root replacement after a previous type A dissection repair operation at a tertiary academic referral center from 2004-2020 was performed. Among 57 cases of reoperative root replacement after type A repair, 35 cases included concomitant aortic arch replacements, and 21 cases involved coronary reconstruction (unilateral or bilateral modified Cabrol grafts). There were 3 acute postoperative strokes and 4 operative mortalities (composite 30-day and in-hospital deaths, 7.0%). Mid-term outcomes were equivalent for patients who required arch replacement compared to isolated proximal repairs (81.8% vs 80.6% estimated 5-year survival, median follow-up 5.53 years. Reoperative root replacement after index type A dissection repairs, including those with concomitant aortic arch replacement and/or coronary reconstruction is achievable with acceptable outcomes at an experienced aortic center.

Assessment of valve implantation in the descending aorta as an alternative for aortic regurgitation patients not treatable with conventional procedures

BACKGROUND

Aortic Regurgitation (AR) produces the entrance of an abnormal amount of blood in the left ventricle. This disease is responsible for high morbidity and mortality worldwide and may be caused by an aortic valve dysfunction. Surgical and transcatheter aortic valve replacement (TAVR) are the current options for treating AR. They have replaced older procedures such as Hufnagel's one. However, some physicians have reconsidered this procedure as a less aggressive alternative for patients not eligible for surgical or TAVR. Although Hufnagel suggested a 75% regurgitation reduction when a valve is placed in the descending aorta, a quantification of this value has not been reported.

METHODS

In this paper, CFD/FSI numerical simulation is conducted on an idealized geometry. We quantify the effect of placing a bileaflet mechanical heart valve in the descending aorta on a moderate-severe AR case. A three-element Windkessel model is employed to prescribe pressure outlet boundary conditions. We calculate the resulting flow rates and pressures at the aorta and first-generation vessels. Moreover, we evaluate several indices to assess the improvement due to the valve introduction.

RESULTS AND CONCLUSIONS

Regurgitation fraction (RF) is reduced from 37.5% (without valve) to 18.0% (with valve) in a single cardiac cycle. This reduction clearly shows the remarkable efficacy of the rescued technique. It will further ameliorate the left ventricle function in the long-term. Moreover, the calculations show that the implantation in that location introduces fewer incompatibilities' risks than a conventional one. The proposed methodology can be extended to any particular conditions (pressure waveforms/geometry) and is designed to assess usual clinical parameters employed by physicians.

Computed tomography follow-up after elective proximal aortic surgery: Less is more?

STUDY OBJECTIVE

The added value of computed tomography (CT) follow-up after elective proximal aortic surgery is unclear. We evaluated the benefit of CT follow-up by assessing the incidence of aorta-related complications and reinterventions detected during routine CT follow-up.

METHODS

Data on 314 patients undergoing first time elective proximal aortic surgery between 2000 and 2015 were collected. The primary study end points were aorta-related complications and reinterventions, detected during routine CT follow-up. Secondary study endpoints included all aorta-related complications and reinterventions, irrespective of the mode of detection and survival.

RESULTS

Median CT follow-up time was 6.8 (IQR 4.1-9.8) years, during which a total of 1303 routine follow-up CT-scans (median 4, IQR 3-5) were performed. During CT follow-up, aorta-related complications were detected in 18 (5.7%) patients, of which 6 (1.6%) underwent reintervention. In total, 28 aorta-related complications were observed in 23 (7.3%) patients, of which 9 led to reintervention. In order to detect 1 aorta-related complication leading to reintervention, 218 routine follow-up CT-scans were required. The unadjusted and EuroSCORE II adjusted hazard ratios of not undergoing CT follow-up on mortality were 1.260 (95% CI 0.705-2.251) and 0.830 (95% CI 0.430-1.605), respectively.

CONCLUSIONS

Following first time elective proximal aortic surgery, aorta-related complications are uncommon, are not always detected during CT follow-up and, if detected, often do not result in reintervention. Therefore, a more conservative CT follow-up protocol could be considered in selected patients to reduce lifetime radiation burden and health care costs.

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.

Geometric changes in aortic root replacement using Freestyle prosthesis

Background

The Medtronic Freestyle prosthesis has proven to be a promising recourse for aortic root replacement in various indications. The present study aims to evaluate clinical outcomes and geometric changes of the aorta after Freestyle implantation.

Methods

Between October 2005 and November 2020, the computed tomography angiography (CTA) data of 32 patients were analyzed in a cohort of 68 patients that underwent aortic root replacement using Freestyle prosthesis. The minimum and maximum diameters and areas of the aortic annulus, aortic root, ascending aorta, and the proximal aortic arch were measured at a plane perpendicular to the long axis of the aorta using 3D multiplanar reconstruction in both the preoperative (n = 32) and postoperative (n = 10) CTAs. Moreover, volumetric changes of the aortic root and ascending aorta were quantified.

Results

Mean age was 64.6 ± 10.6 years. Indications for surgery using Freestyle prosthesis were combined aortic valve pathologies, aortic aneurysm or dissection, and endocarditis, with concomitant surgery occurring in 28 out of 32 patients. In-hospital mortality was 18.6%.

Preoperative diameter and area measurements of the aortic annulus strongly correlated with the implanted valve size (p < 0.001). Bicuspid valve was present in 28.1% of the patients. Diameter and areas of the aortic root decreased after freestyle implantation, resulting in a reduction of the aortic root volume (45.6 ± 26.3 cm³ to 18.7 ± 4.5 cm³, p = 0.029). Volume of the aortic root and the ascending aorta decreased from 137.3 ± 65.2 cm³ to 54.5 ± 21.1 cm³ after Freestyle implantation (p = 0.023).

Conclusion

Implantation of the Freestyle prosthesis presents excellent results in restoring the aortic geometry. Preoperative CTA measurements are beneficial to the surgical procedure and valve selection and therefore, if available, should be considered in pre-operative planning.

Repeat aortic valve surgery: contemporary outcomes and risk stratification

OBJECTIVES

Redo aortic valve surgery (rAVS) is performed with increasing frequency, but operative mortality is usually higher compared to that associated with primary aortic valve surgery. We analysed our patients who had rAVS to determine the current outcomes of rAVS as a surgical benchmark in view of the growing interest in transcatheter valve techniques.

METHODS

We retrospectively reviewed 148 consecutive patients [median age 67.7 years (interquartile range 54.9-77.6); 68.2% men] who underwent rAVS following aortic valve replacement (81.6%), aortic root replacement (15%) or aortic valve repair (3.4%) between 2000 and 2018.

RESULTS

Indications for rAVS were structural valve dysfunction (42.7%), endocarditis (37.8%), non-structural valve dysfunction (17.7%) and aortic aneurysm (2.1%). Valve replacement was performed in 69.7%, and 34 new root procedures were necessary in 23%. Early mortality was 9.5% (n = 14). Female gender [odds ratio (OR) 6.16], coronary disease (OR 4.26) and lower creatinine clearance (OR 0.95) were independent predictors of early mortality. Follow-up was 98.6% complete [median 5.9 (interquartile range 1.7-10.9) years]. Survival was 74.1 ± 3.7%, 57.9 ± 5.1% and 43.8 ± 6.1% at 5, 10 and 14 years, respectively. Cox regression analysis revealed female gender [hazard ratio (HR) 1.73], diabetes (HR 1.73), coronary disease (HR 1.62) and peripheral vascular disease (HR 1.98) as independent determinants of late survival.

CONCLUSIONS

Despite many urgent situations and advanced New York Heart Association functional class at presentation, rAVS could be performed with acceptable early and late outcomes. Risk factors for survival were female gender, coronary disease and urgency. In this all-comers patient cohort needing rAVS, only a minority would eventually qualify for transcatheter valve-in-valve procedures.

Long-term outcomes of aortic root replacement for endocarditis

BACKGROUND

Infective endocarditis (IE) involving the aortic valve and root is associated with high risk requiring thoughtful surgical decision-making. The impact of valve and conduit choices and patient factors on long-term outcomes in this patient population is poorly documented.

METHODS

From January 1976 to December 2013, 485 patients underwent aortic root and valve replacement at a single institution. Cox's proportional hazard model identified predictors of long-term survival and cumulative incidence functions were compared to assess need for reoperation with death as a competing risk.

RESULTS

Median age at time of operation was 56.6 years (interquartile range: 23.1) with the indication for operation being endocarditis in 14.6% (n = 71). Stentless root replacement was used in 70% IE versus 34% non-IE (p < .001). Endocarditis at time of root replacement did not have a significant impact on survival through 15 years (IE: 37.3% vs. non-IE: 42.5%; log-rank; p = .13). After multivariable adjustment, survival was similar between patients with and without endocarditis (hazard ratio: 1.1; 95% confidence interval: [0.77, 1.62]; p = .57). Freedom from reoperation at 15 years did not vary significantly by endocarditis status (IE: 95.9% vs. non-IE: 73.6%; p = .07). Among endocarditis patients, freedom from reoperation at 10 years was similar between homograft and stentless bioprosthetic conduits (95.3% vs. 88.5%; log-rank; K-sample; p = .46).

CONCLUSIONS

In a sample with frequent use of stentless prostheses, aortic root replacement for infective endocarditis had acceptable risk and long-term survival similar to root replacement for other indications. In the setting of endocarditis, root replacement with homograft or stentless bioprosthetic root has excellent durability through 15 years.

Outcome of reoperative aortic root or ascending aorta replacement after prior aortic valve replacement

Background

There are limited data regarding the clinical outcomes of reoperative aortic root or ascending aorta replacement after prior aortic valve replacement (AVR). We aimed to analyze outcomes of reoperative aortic root or ascending aorta replacement after prior AVR.

Methods

Eighty patients with prior AVR underwent reoperative aortic root or ascending aorta replacement in our hospital. The indications were root or ascending aortic aneurysm in 36 patients, root or ascending aortic dissection in 37, root false aneurysm in 2, prosthesis valve endocarditis (PVE) with root abscess in 2, Behçet’s disease (BD) with root destruction in 3 patients. An elective surgery was performed in 63 patients and an emergent surgery in 17. The survival and freedom from aortic events during the follow-up were evaluated with the Kaplan-Meier survival curve and the log-rank test.

Results

The operative techniques included ascending aorta replacement in 14 patients, ascending aorta replacement with AVR in 3, prosthesis-sparing root replacement (PSRR) in 35, Bentall procedure in 24, and Cabrol procedure in 4 patients. Operative mortality was 1.3% (1/80). A composite of adverse events occurred in 5 patients, including 1 operative death, 2 stroke and 3 renal failure necessitating hemodialysis. The mean follow-up was 35.5±22.1 months. Five late deaths occurred. The Kaplan-Meier survival at 1 year, 3 years and 6 years were 97.5%, 91.1% and 84.1%, respectively. Aortic events developed in 3 patients. The freedom from aortic events at 1-year, 3-year, and 6-year were 100%, 96.3% and 88.9%, respectively. There were no differences in survival and freedom from aortic events between the elective group and the emergent group.

Conclusions

Reoperative aortic root or ascending aorta replacement after prior AVR could be performed to treat the root or ascending pathologies after AVR, with satisfactory early and midterm outcomes.

Tissue "valve-over-valve" implantation in previous mechanical Bentall

Multiple studies have reported the adverse impact of audible clicks from mechanical heart valves on the quality of life. Sadly, this can become a lifelong liability in younger patients necessitating explantation. Bioprosthetic valve replacement is the treatment for this distressing condition associated with an isolated mechanical valve. However, patients who have undergone a mechanical Bentall's procedure represent a unique surgical challenge. In view of the significant complications associated with a redo aortic root operation, the alternative of a "valve-over-valve" implantation is an attractive option that might present reduced morbidity. We report a unique case of valve noise intolerance in a patient who underwent a bioprosthetic valve-over-valve replacement following previous Bentall's procedure with a mechanical valved conduit.

Redo Aortic Valve Replacement Following Bio-Bentall's Procedure

BACKGROUND

Structural valve degeneration is a known sequel of aortic valve replacement with bioprosthetic valves, not infrequently leading to redo valve replacement. Reoperation on the aortic valve is associated with an incumbent increase in perioperative risk, and this risk is further increased when reoperation is performed on an already replaced aortic root.

METHODS

We present a technique of opening the aortic graft and explanting the bioprosthesis by dividing the plane between the stent frame and the sewing ring of the bioprosthesis, followed by re-implantation of a bioprosthesis using simple sutures incorporating the remaining valve seat.

RESULTS

The patient experienced an uneventful postoperative course and was discharged on the fifth day postoperatively.

CONCLUSIONS

The author presents a simple and reproducible technique to replace a degenerated bioprosthetic aortic valve while preserving the previous aortic root replacement.

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.

Hemi-Cabrol Aortic Root Replacement in Complex Aortic Reconstructions

The Cabrol aortic root replacement with subsequent modifications remains an extremely useful technique within the armamentarium of the aortic surgeon. The technical considerations detailed here allow for the uncompromised creation of a hemi-Cabrol anastomosis in complex aortic reconstructions.

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.

A History of Thoracic Aortic Surgery

Ancient historical texts describe the presence of aortic pathology conditions, although the surgical treatment of thoracic aortic disease remained insurmountable until the 19th century. Surgical treatment of thoracic aortic disease then progressed along with advances in surgical technique, conduit production, cardiopulmonary bypass, and endovascular technology. Despite radical advances in aortic surgery, principles established by surgical pioneers of the 19th century hold firm to this day.

Imaging Surveillance After Proximal Aortic Operations: Is it Necessary?

BACKGROUND

Current guidelines for imaging surveillance after proximal aortic repair are not evidence based. This study sought to characterize the incidence and causes of reintervention after proximal aortic operations to provide data to guide the frequency and duration of postoperative surveillance.

METHODS

Data on all patients undergoing proximal aortic operations (ascending, with or without root, with or without aortic valve replacement, or with or without arch) during a 9-year period (n = 869) at a single institution were prospectively collected. Patients who required reintervention on the proximal or distal aorta were identified and causes for reintervention determined. Planned two-stage repairs and index procedures done at other hospitals were excluded. The primary end point was the time to the first reintervention, and competing-risk Cox regression was used to model reintervention risk.

RESULTS

Reinterventions occurred in 4.3% of patients (n = 37), with 48.6% (n = 18) involving the proximal aorta and 51.4% (n = 19) the distal. Median time to reintervention was 2.8 years (interquartile range, 1.5 to 3.6 years). For index aneurysm cases, reintervention for aneurysm of the descending/thoracoabdominal aorta and root were most common. Of the 6 root aneurysms/pseudoaneurysms, 5 (83%) were due to degeneration of a stentless porcine aortic root. For index type A dissections, reintervention for aneurysm of the descending/thoracoabdominal aorta and arch were most common. The mean duration of follow up was 4.2 ± 2.5 years. The 9-year actuarial freedom from reintervention was 92.9%. Cox regression showed index type A dissection was a significant predictor of time to aortic reintervention (hazard ratio, 2.01; 95% confidence interval, 1.04 to 3.9; p = 0.038).

CONCLUSIONS

Reinterventions after proximal aortic operations are uncommon; most occur within 3 years of the index operation and involve the proximal and distal aorta nearly equally. Patients with type A dissection or stentless porcine roots require aggressive surveillance, whereas a more liberal approach is suitable for patients without such risk factors. This strategy may reduce the lifetime radiation burden and health care costs.

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.

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.

Clinical outcome of redo operation on aortic root

BACKGROUND

With the increasing use of biologic conduits or bioprosthetic valve, the number of patients who require redo operation on aortic root increased.

METHODS

In the past 22 years, 14 patients underwent redo operation on aortic root. The mean age was 61.9 ± 14.8 years. Previous operations were full root replacement with stentless valve (n = 4), aortic root replacement with subcoronary technique (n = 3) and Bentall operation (n = 7). The operation interval was 5.4 ± 6.4 years. Indication for redo operation included structural valve deterioration (n = 6), prosthetic valve endocarditis (n = 4), perivalvular leakage (n = 2), dilatation of sinus of Valsalva (n = 1) and dehiscence of proximal anastomosis line (n = 1). Mean follow-up period was 5.3 ± 5.2 years.

RESULTS

Present operations were full root replacement with stentless valve (n = 5) and Bentall operation (n = 9). There was one in-hospital death (7.1 %) caused by arrhythmia. Postoperative complications included implantation of permanent pacemaker (n = 3), arrhythmia (n = 2) and re-intubation (n = 1). The 5-year survival was 92.9 ± 6.9%. Freedom from redo aortic operation at 5 years was 100%.

CONCLUSION

Redo operation on aortic root can be performed with acceptable in-hospital mortality and good late survival.

Comparing aortic root replacements: porcine bioroots versus pericardial versus mechanical composite roots: hemodynamic and ventricular remodeling at greater than one-year follow-up

BACKGROUND

Stentless porcine bioroots and pericardial composite roots were developed as prostheses that avoid the anticoagulation necessary for mechanical composite roots. Data on the hemodynamics of all root replacements are lacking and questions remain regarding comparative performance.

METHODS

This study evaluated patients receiving a stentless porcine bioroot, a pericardial, or a mechanical composite root at a single institution from January 2000 to December 2008. All patients underwent preoperative, postoperative and greater than 1-year echocardiograms. All root replacements were performed for aortic insufficiency or aneurysm. Median follow-up was 3.3 years (1 to 8 years).

RESULTS

There were no significant differences in preoperative left ventricular ejection fraction, aortic valve peak gradient, mean gradient, left ventricular end diastolic diameter, and left ventricular end systolic diameter. Postoperative peak and mean gradients in mechanical composite roots were significantly higher than stentless porcine bioroots. At greater than 1 year, stentless porcine bioroots had significantly lower peak and mean gradients than both mechanical composite roots and pericardial composite roots. The end diastolic diameter was also significantly smaller in stentless porcine bioroots at greater than 1 year than mechanical composite roots.

CONCLUSIONS

All prostheses resulted in favorable hemodynamic and ventricular remodeling. Stentless porcine bioroots had the lowest gradients at greater than 1 year of all root replacements, with significantly better ventricular remodeling when compared with mechanical composite roots. Pericardial roots also had favorable hemodynamics and ventricular remodeling, suggesting that they are a viable alternative.

Indirect re-implantation of the left coronary artery during aortic surgery

OBJECTIVE

Indirect re-implantation of the left coronary artery (LCA) via an interposition graft simplifies difficult LCA re-implantation during aortic root replacement. Little information exists regarding the results of this technique. In this study, we report our experience.

METHODS

Between January 2001 and July 2008, of 82 aortic root replacements, 24 (mean age 48.2 years, 83% male) used the indirect re-implantation technique. All case notes were retrospectively analyzed. Indications for operation were; aortic root aneurysm (n = 16), acute dissection (n = 6), existent homograft calcification (n = 1), failed Ross procedure (n = 1). Reasons for indirect re-implantation were: difficult LCA mobilization secondary to previous cardiac surgery (n = 7), short left main stem (n = 6), acute dissection (n = 6), adherence to surrounding tissues (n = 5). All patients had yearly CT or MRI follow-up.

RESULTS

Mechanical and tissue valved conduits were implanted in 22 and two patients, respectively. Ten millimeters (n = 17) or 8 mm (n = 7) Dacron grafts were used for LCA re-implantation. Thirty-day mortality was 12.5%. Postoperative complications were: re-opening for bleeding (n = 2), pericardial effusion (n = 4), renal failure (n = 1). Over a median follow-up of 26 months (range 4 to 81), one developed a false aneurysm at the right coronary artery anastomosis five months postoperatively, which was subsequently repaired. All interposition grafts remained patent on MRI or CT. There were six late deaths. At median follow-up survival rate was 71%.

CONCLUSIONS

The indirect re-implantation of the LCA during aortic root replacements is a reliable, safe, and effective method in dealing with the LCA in difficult circumstances. Survival at 26 months is equivalent to other series of similar patients.

Early and long-term results of reoperative total aortic root replacement with reimplantation of the coronary arteries

BACKGROUND

Total root replacement with biologic valves and reimplantation of the coronaries gives good early and midterm results. There is continuing concern, however, regarding the risks and long-term results for reoperation after total replacement of the aortic root with reimplantation of the coronaries.

METHODS

Between June 1981 and July 2010, a total of 84 patients underwent reoperative aortic root replacement with reimplantation of the coronaries (60 male, mean age 38 ± 15 years). All patients had undergone first-time total aortic root replacement with homografts (82 patients) or autografts (2 patients). Indication for reoperation was structural valve deterioration in 72 patients (85%) and infective endocarditis in 12 patients (15%). Mean interval between first operation and reoperation was 11.1 ± 4.7 years (range, 1 month-24.7 years). Median length of follow-up was 9.7 ± 5.6 years (range, 1 month-24.4 years).

RESULTS

Thirty-day mortality was 2.4% (n = 2 patients). Both patients died postoperatively of low-output syndromes with multiorgan failure. At reoperation, 74 patients received homografts (87%), 7 patients underwent a Ross procedure (9%), and 3 received stentless porcine roots (4%). One patient required pacemaker implantation (1%). Actuarial survivals were 89% ± 4% and 81% ± 5% at 5 and 10 years, respectively. Nine patients underwent a successful third root replacement during follow-up. Freedom from third-time aortic root operation was 97% ± 3% at 10 years.

CONCLUSIONS

Reoperative aortic root replacement can be performed safely with good short-term and midterm outcomes in a young patient cohort.

Re-operations for aortic allograft root failure: experience from a 21-year single-center prospective follow-up study

OBJECTIVE

The study aims to report results of re-operations after aortic allograft root implantation.

METHODS

All consecutive patients in our prospective allograft database, who underwent aortic allograft root implantation, were selected for analysis, and additional information for patients who subsequently underwent re-operation was obtained from hospital records.

RESULTS

From 1989 to 2009, 262 aortic allograft root implantations were performed. Thirty-day mortality was 5.7%. During follow-up, 69 patients died. The actuarial survival was 77.0% (95% confidence interval (CI) 71-83%) after 10 years, and 65.1% (95% CI 57-74%) after 14 years. A total of 52 patients required re-operation. The actuarial freedom from allograft re-operation was 82.9% (Standard Error (SE) 2.9%) after 10 years and 55.7% (SE 5.7%) after 14 years. The actuarial median time to re-operation was 14.8 years. The indications for re-operation were structural valve dysfunction in 46 patients, endocarditis in two patients and non-structural valve dysfunction in four patients. The re-operations included 23 aortic valve replacements (mechanical prostheses 20 and bioprostheses 3), 27 aortic root replacements (mechanical conduits 21, aortic allografts five, and biological conduit one), one trans-apical valve implantation and one primary closure of a false aneurysm. The additional procedures were mitral valve repair (N = 5), mitral valve replacement (N = 1), ascending aortic replacement (N = 5), and coronary artery bypass grafting (CABG) (N = 4; in two patients unforeseen). Thirty-day mortality after re-operation occurred in two patients (3.9%). Five patients died during follow-up. The survival after re-operation was 87.1% (SE 5.5%) after 1 year and 79.3% (SE 7.4%) after 9 years.

CONCLUSIONS

Re-operations after aortic allograft root implantation will be required in a substantial and growing number of patients. These re-operations, although technically demanding, can be performed with satisfying results.

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.