Modified bio-Bentall procedure: 10-year experience

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.

The David Operation Offers Shorter Hemostasis Time Than the Bentall in Case of Acute Aortic Dissection Type A

Background

The aim of the present study was to compare the clinical outcome of the David operation and the Bentall operation in patients with Stanford type A acute aortic dissection (AADA) from the viewpoint of hemostasis.

Methods

Between April 2016 and April 2020, 235 patients underwent emergent surgery for AADA. Of them, 38 patients required aortic root replacement (ARR: The David operation 17, the Bentall operation 21). The mean age was 59.3±12.6 years. In the present series, the David operation was the first choice for relatively young people, and the Bentall operation was performed for relatively elderly patients and cases in which valve-sparing seemed impossible.

Results

Between the David and the Bentall group, the 30-day mortality rate did not differ significantly. However, hemostasis time (144.6±50.3 vs. 212.5±138.1 min, p=0.047), defined as the interval from the cessation of cardio-pulmonary bypass (CPB) to the end of the operation, and total operation time (477.8±85.7 vs. 578.3±173.6 min, p=0.027) were significantly shorter in the David group than in the Bentall group, and the amount of blood transfusion was less in the David group than in the Bentall group (red blood cells: 3.5±3.6 vs. 9.2±5.9 units, p=0.013; fresh frozen plasma: 4.1±4.7 vs 9.4±5.1 units, p=0.002; platelet concentrate: 33.2±11.3 vs 42.2±12.0 units, p=0.025).

Conclusion

David operation offers a shorter hemostasis time and consequently shorter operation time than the Bentall operation in the setting of AADA, probably due to double suture lines, despite its surgical complexity.

Clinical Outcomes Using Freestyle Valve/Valsalva Graft Composite Conduit for Aortic Root Replacement

BACKGROUND

We review the clinical outcomes with a novel method of aortic root replacement using a self-constructed tissue valve-conduit comprised of a Freestyle subcoronary valve sewn into a Valsalva graft.

METHODS

From 2005 to 2020, 523 patients had aortic root replacement operations using a self-constructed Freestyle Subcoronary-Valsalva graft tissue valve-conduit. Median age was 62 years (IQR 54-70) and 430 (82%) were male patients. Primary outcomes were mortality and the need for reoperation. Multivariable regression analyses were performed to identify risk factors for mortality and reoperation.

RESULTS

Urgent procedures comprised 48.37% of the cases and 29.26% were reoperative procedures. Concomitant ascending aorta replacement, hemi-arch replacement, and total arch replacement were required in 348 (67%), 227 (44%), and 40 (8%) patients, respectively. Cardiopulmonary bypass and cross-clamp times were 189 minutes (IQR 164-218) and 166 minutes (IQR 145-191). Early mortality was 7.7% (40), five and ten-year survival was 83% and 71% respectively. At last echo follow-up, LVEF, LV end diastolic diameter, degree of AI, and mean aortic valve gradient were significantly improved from baseline, p<0.001. Increasing age, peripheral artery disease, tobacco use, increased preoperative creatinine, and prior aortic valve surgery were risk factors for both mortality and the composite outcome (p<0.02).

CONCLUSIONS

In a complex patient population, aortic root replacement using a self-constructed composite tissue valve-conduit comprised of a Freestyle Subcoronary Valve/Valsalva Graft can be performed with excellent operative and 10-year outcomes. Mid-term survival is acceptable and valve durability was outstanding with an exceedingly low incidence for valve reintervention.

Long-term results of modified bentall procedures: 18-year experience of the flanged technique

OBJECTIVES

To evaluate the early and late outcomes of the modified Bentall procedure with the flanged technique.

METHODS

We reviewed the medical records of 63 patients who had undergone root replacement by the modified Bentall procedure at our institute between January 2001 and December 2018. In most cases, we adopted a composite graft constructed with a mechanical valve or bioprosthesis and a Dacron graft by the flanged technique. Since 2011, we have used Valsalva grafts.

RESULTS

Mean age 57 ± 16 years, range 16-80, male 43 cases. The mean follow-up was 75 ± 56 months (range 0-216). Through April 1, 2020, we could follow up on 61 cases (97%) within a six-month period. Hospital mortality was 7.9% (4.8% in elective cases). In late follow-up, eight deaths were observed. In the bio-Bentall group (n=26), no deaths or major adverse valve-related events (MARVEs) occurred. In the mechanical Bentall group (n=37), seven cases of MARVEs, including two cerebral hemorrhages and one cerebral embolism, were observed. All patients were free from MARVEs at 5 years post procedure in the bio-Bentall group, and 93.8% and 76.8% were event-free at 5 years and 10 years, respectively, in the mechanical Bentall group.

CONCLUSIONS

The 18-year results of the modified Bentall procedure were acceptable, providing excellent outcomes in the bio-Bentall group. The flanged technique enabled the use of a larger prosthesis, which may have resulted in good durability with the bio-Bentall procedure.

Midterm Outcomes of Stented Versus Stentless Bioprosthetic Valves After Aortic Root Replacement

To determine the impact of aortic root replacement (ARR) with a stentless bioprosthetic valve on midterm outcomes compared to a stented bioprosthetic valve-graft conduit. This was an observational study of aortic root operations from 2010 to 2018. All patients with a complete ARR for nonendocarditis reasons were included, while patients undergoing valve-sparing root replacements or primary aortic valve replacement or repair were excluded. Of the patients with a complete ARR, bioprosthetic valve implants were included, while mechanical valve implants were excluded. Patients were dichotomized into the stented ARR group and the stentless ARR group. A total of 1:1 nearest neighbor propensity matching was employed to assess the association of stentless valves with short-term and midterm outcomes. A total of 455 patients underwent a complete ARR with a bioprosthetic valve implant for nonendocarditis reasons, of which 212 (46.6%) received a stented valve, while 243 (53.4%) received a stentless valve. After matching, postoperative outcomes were similar across each group (P > 0.05), including operative mortality and adverse neurologic events. Median follow-up for the entire cohort was 4.41 years (95% CI: 4.01, 4.95). At 1 year follow-up, aortic regurgitation ≥ 2+ and ejection fraction were similar across each group (P > 0.05); however, the stentless valve group had lower aortic valve velocity and transvalvular pressure gradient. Finally, reoperations and survival were similar for each group over the study's follow-up (P > 0.05). Stentless valves may provide hemodynamic benefits after ARR; however, the clinical impact of those benefits for survival and reoperation may not yet be evident in the midterm.

Incidence, Cause, and Outcome of Reinterventions after Aortic Root Replacement

BACKGROUND

This study aims to comprehensively characterize the details of the aortic and aortic valve reinterventions after aortic root replacement (ARR).

METHODS

Between 2005 and 2019, 882 patients underwent ARR. The indication was for aneurysm in 666, aortic valve-related in 116, aortic dissection in 64, and infective endocarditis (IE) in 36. Valve-sparing root replacement was performed in 290 while Bio-Bentall was done in 528. Among them, 52 (5.9%) patients required reintervention. The incidence, cause, and time to reintervention, as well as outcomes after reintervention were investigated. Cause-Specific Cox hazard model was performed to identify predictors for reintervention after ARR.

RESULTS

The 10-year cumulative incidence of aortic and aortic valve reintervention after ARR was 10.3% [95%CI, 7.3%-14.0%]. Age per year decrease was the only independent predictor for reintervention [sHR, 0.97; 95%CI, 0.95-0.99]. The causes for 52 reinterventions were: 29 (55.8%) for aortic valve causes including aortic stenosis/insufficiency, and prosthetic valve dysfunction; 15 (28.9%) for IE; 7 (13.5%) for aortic-related causes including pseudoaneurysm, development of aneurysm, and residual dissection; and 1 (1.9%) for coronary button pseudoaneurysm. Median times to reintervention were 11.0 [IQR, 2.0-20.5] months for IE, 24.0 [IQR, 3.7-46.1] months for aortic-related causes, 77.0 [IQR, 28.4-97.6] months for aortic valve-related causes (p=.005). Overall in-hospital mortality after the reinterventions was 7.7% (4/52) with 20.0% with IE (3/15) .

CONCLUSIONS

Reintervention for IE occurs relatively early after ARR while aortic valve- and aortic-related reinterventions gradually increase over time. In-hospital mortality after the reintervention is low, unless it is for IE.

Long-term follow-up of Bentall procedure using the Perimount bioprosthesis and the Valsalva graft

OBJECTIVES

Bentall procedure is the gold standard for aortic root pathologies when valve repair is not feasible. The development of durable bioprosthetic valves and improved vascular conduits allowed the implementation of bioprosthetic composite grafts; hereby, we performed a retrospective analysis of long-term follow-up of Bentall procedure using the Valsalva graft and the Perimount Magna Ease prosthesis.

METHODS

From June 2000 to March 2019, 309 patients received an aortic root and valve replacement with a bioprosthetic composite graft. The mean age was 69 ± 6.9 years, and the majority were men (88%); most of them were affected by aortic stenosis (86%) and the mean aortic root diameter was 48.6 ± 5.5 mm.

RESULTS

Freedom from cardiac death was 76.8% [confidence interval (CI) 32.5-94.0] at 16 years. Freedom from thromboembolism, haemorrhage, structural valve deterioration and infective endocarditis was 98.2% (CI 96.0-98.9), 95.2% (CI 87.1-98.2), 87.5% (CI 63.2-97.1) and 79.6% (CI 45.3-95.6) at 16 years, respectively. Freedom from reoperation was 74.7% (CI 41.9-90.6).

CONCLUSIONS

These data indicate that, in experienced centres, the Bentall procedure is a safe and effective intervention. This is the first long-term follow-up that analyses the results after implantation of a composite graft made with the Perimount Magna Ease aortic valve and the Valsalva graft.

First-in-Human Endo-Bentall Procedure for Simultaneous Treatment of the Ascending Aorta and Aortic Valve

We describe the endovascular management of a middle-aged woman who developed a bleeding suprasternal fistula after conventional aortic valve replacement. The patient's condition was considered inoperable. A customized stent attached to a transcatheter valve was successfully used to treat the individual, this being the first-in-human case of the promising Endo-Bentall procedure. (Level of Difficulty: Advanced.).

Acute aortic dissection involving the root: operative and long-term outcome after curative proximal repair

OBJECTIVES

The aim of the study was to evaluate operative and long-term results after surgery of acute aortic dissection involving the root, in which the proximal repair consisted of curative resection of all dissected aortic sinuses and was performed using either valve-sparing root repair or complete root replacement with a valve conduit.

METHODS

Between August 2002 and March 2013, 162 consecutive patients (mean age 63 ± 14 years) underwent surgery for acute type A aortic dissection. Eighty-six patients with an involvement of the aortic root underwent curative surgery of the proximal aorta consisting of valve-sparing root repair (n = 54, 62.8%) or complete valve and root replacement using composite valve grafts (n = 32, 37.2%). In patients with root repair, all dissected aortic walls were resected and root remodelling using the single patch technique (n = 53) or root repair with valve reimplantation (n = 1) was performed without the use of any glue. All perioperative data were collected prospectively and retrospective statistical examination was performed using univariate and multivariate analyses.

RESULTS

The mean follow-up was 5.2 ± 3.5 years for all patients (range 0-12 years) and 6.1 ± 3.3 years for survivors. The 30-day mortality rate was 5.8% (5 patients), being considerably lower in the repair sub-cohort (1.9 vs 12.5%). The estimated survival rate at 5 and 10 years was 80.0 ± 4.5 and 69.1 ± 6.7%, respectively. No patient required reoperation on the proximal aorta and/or aortic valve during the follow-up time and there were only two valve-related events (both embolic, one in each group). Among those patients with repaired valves, the last echocardiography available showed no insufficiency in 40 and an irrelevant insufficiency (1+) in 14.

CONCLUSIONS

Curative repair of the proximal aorta in acute dissection involving the root provides favourable operative and long-term outcome with very low risk of aortic complications and/or reoperations, regardless if a valve-sparing procedure or replacement with a valve conduit is used. Valve-sparing surgery is frequently suitable, providing excellent outcome and very high durability.

Impact of sinuses of Valsalva on prosthesis durability in patients undergoing ascending aorta and aortic valve replacement with Carpentier-Edwards bioprosthesis: a propensity score-based study

OBJECTIVES

The effect of sinuses of Valsalva on aortic bioprosthesis durability has not been investigated so far. The aim of this study was to compare durability of the Carpentier-Edwards aortic bioprosthesis in patients undergoing aortic valve and ascending aorta replacement as a composite bioconduit (Group A, case group) versus patients undergoing separate replacement of the aortic valve and ascending aorta, with preservation of the aortic root (Group B, control group), between January 2000 and January 2014.

METHODS

Records of Group A (n = 133) and Group B (n = 162) patients were retrospectively reviewed. End-points were evaluated among groups in three ways: before and after propensity score 1:1 matching (Group A, n = 94; Group B, n = 94 patients) and after patient stratification through quintiles of propensity scores.

RESULTS

There was no difference among groups regarding mean and maximal trans-prosthetic pressure gradients at discharge (P = 0.07 and 0.45, respectively). Maximal trans-prosthetic gradients were lower in Group A patients at last control (P = 0.03). Structural valve deterioration (SVD) was due to prosthesis regurgitation (Group A, n = 5; Group B, n = 1), stenosis (Group A, n = 2; Group B, n = 5) or combined (Group A, n = 4; Group B, n = 2). After a mean follow-up of 68 ± 42 months, there was no difference among groups, at 5 and 12 years, regarding mortality, freedom from SVD, from redo aortic valve replacement for SVD and cardiac redo of any type, before and after matching and after stratification according to quintiles of propensity scores.

CONCLUSIONS

Within the 12-year follow-up, the absence of the sinuses of Valsalva seems to have no influence on durability of Carpentier Edwards aortic bioprosthesis. Longer follow-up may be warranted.

Long-term results after aortic root replacement using self-assembled valve composite grafts in patients with small aortic annulus

OBJECTIVES

The study was aimed to evaluate operative and long-term results after complete root replacement using self-assembled valve composite grafts in patients with a small aortic annulus.

METHODS

Among 547 consecutive patients who received the Bentall procedure between 2000 and 2012, a total of 29 patients (61 ± 10; range 42-79 years) had an annulus of ≤20 mm (mean 19.0 ± 0.9). Patients with a native aortic valve (22) suffered from stenosis, insufficiency or mixed defect in 10, 10 and 2 cases, respectively. Among the remaining 7 patients with an artificial aortic valve, there were 3 symptomatic prosthesis-patient mismatches, 3 valve prosthesis deteriorations (1 structural and 2 none-structural) and 1 paravalvular leak. Indication for aortic root replacement was true or false aneurysm, porcelain aorta and intraoperative aortic wall injury in 17, 6 and 6 patients, respectively.

RESULTS

The composite graft for complete aortic root replacement was assembled using a mechanical (26) or biological (3) valve prosthesis placed inside a vascular graft with a median size of 24 (range 22-26) mm. The margin of the tube beneath the valve was anastomosed to the aortic annulus, and coronary ostia were implanted in the usual manner. The mean transvalvular gradient at discharge was 10.8 ± 3.9 mmHg and remained virtually unchanged at the follow-up completed for all patients. Early mortality was 0. During the mean follow-up of 95.8 ± 43.7 months, 2 patients died (54 and 146 months after surgery) due to pulmonary embolism and myocardial infarction, respectively.

CONCLUSIONS

In patients with a small aortic annulus who need complete aortic root replacement, an oversizing of the valve can be easily achieved using modified, self-assembled composite grafts. Offering excellent haemodynamic characteristics, these grafts lead to prevention of prosthesis-patient mismatch and result in very good and durable functional and clinical results.

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.

Cardiac surgery in patients with a porcelain aorta in the era of transcatheter valve implantation

OBJECTIVES

New surgical and perfusion techniques allow the avoidance of deep hypothermia during open aortic arch surgery, which is generally necessary in patients with an unclampable porcelain aorta. The aim of the study was to evaluate operative and long-term results in patients with a porcelain aorta who underwent conventional cardiac surgery using current surgical and perfusion techniques.

METHODS

Between November 2003 and February 2012, 30 consecutive patients (mean age 68 ± 11 years, 10 patients had previous cardiac surgery with use of glue in 5 of them) with porcelain aorta diagnosed by computed tomography and defined as a severe circular calcification of the proximal thoracic aorta were referred for cardiac surgery. All patients underwent conventional surgery with arterial cannulation of the innominate (8) or a carotid artery (22) for arterial return. During mild hypothermic circulatory arrest, unilateral cerebral perfusion through the arterial line was performed for cerebral protection. The valve surgery consisted of aortic, mitral or double valve repair in 23, 3 and 4 cases, respectively. Aortic surgery (17 complete root replacements with valve composite grafts and 22 arch replacements) and coronary revascularization due to coronary heart disease (15) were the most frequent concomitant procedures.

RESULTS

Thirty-day mortality was 3.3% (1 patient died of bowel ischaemia caused by severe stenosis of the celiac and upper mesenteric arteries) and the rate of permanent neurological deficit was 3.3% as well. Two further patients died during the follow-up at age 91 and 82 years, respectively; however, no death was cardiac or valve related. The actuarial survival at 5 years was 87.3 ± 7.2%. There were no cardiac reoperations, new interventions or aortic- or valve-related events noted during the median follow-up of 45 months (range 0.1-106.0).

CONCLUSIONS

Conventional cardiac and aortic surgery offers definitive repair and can be performed safely using current perfusion and operative techniques. Although more invasive, this surgical technique provides mortality and morbidity rates that do not exceed those reported for transcatheter valve implantation. The curative replacement of the pathological proximal aorta, which is one of the most main sources of cerebral embolism, leads to excellent neurological outcome during mid- to long-term follow-up.

Modified Bentall procedure using two short grafts for coronary reimplantation: long-term results

BACKGROUND

The modified Bentall procedure remains a gold standard of aortic root surgery. We present in this study the early and late outcomes of a particular modification using 2 separated grafts for the coronary reimplantation.

METHODS

From 1995 to 2009, 153 patients aged 57±12 (mean±standard deviation [SD]) underwent elective (n=113) or urgent (n=40) aortic root replacement with a composite mechanical valve conduit reconstruction using 2 short, separated 8-mm Dacron grafts for the coronary reimplantation and were retrospectively reviewed.

RESULTS

Aortic disease etiologies were annuloaortic ectasia (n=108), type A aortic dissection (n=38), aortic false aneurysm, or Valsalva aneurysm evolution after previous cardiac surgery (n=7). The overall early mortality was 8.5% (20% for urgent procedure and 4.4% for elective procedure). For the whole group, actuarial survival at 5 and 10 years was 86.3%±2.78 and 73.7%±4.23, respectively. Among the 23 late deaths, 9 were valve-related deaths (stroke, n=3; endocarditis, n=1; unknown, n=5). During the follow-up, linearized rates of major bleeding, thromboembolism, and endocarditic evolution were, respectively, 1.3 %/patient-years, 0.42 %/patient-years, and 0.22 %/patient-years. One patient presented a nonseptic false aneurysm of the right coronary anastomosis and no structural valve dysfunction has been diagnosed. In total, only 2 patients required an aortic root reoperation.

CONCLUSIONS

The modified Bentall procedure using 2 separated grafts for the coronary reimplantation is a feasible, safe, easy, and reproducible operative technique for aortic root surgery.