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

True Aneurysm of the Common Coronary Button in a Marfan Patient with an Anomalous Right Coronary Artery after a Bentall Procedure: A Case Report

True aneurysms of the coronary artery after aortic root replacement in Marfan syndrome patients are very rare. An anomalous origin of the right coronary artery (RCA) from the left sinus of Valsalva adds complexity during aortic root surgery. We present a case of a 37-year-old male patient with Marfan syndrome who had an RCA anomaly and a 4.5-cm true aneurysm of the common coronary button 14 years after a previous Bentall procedure. A redo Bentall operation and hemi-arch replacement were successfully performed. The anomalous origin of the RCA from the left sinus of Valsalva was safely divided and anastomosed as separate coronary buttons to the prosthetic composite valve graft. To prevent coronary button aneurysms after aortic root surgery in Marfan patients, the coronary buttons and the corresponding side holes on the prosthetic graft must be reduced to the maximum possible extent.

Short-segment coronary artery bypass grafting using radial artery to repair bilateral coronary ostial aneurysms after aortic root replacement in a patient with Marfan syndrome

Coronary ostial aneurysm is a complication of aortic root replacement, particularly in Marfan syndrome. Reconstructing the coronary artery is an important problem during reoperation. Herein, we report a case of coronary artery bypass grafting using radial artery to repair bilateral coronary ostial aneurysms after aortic root replacement in a patient with Marfan syndrome.

A 10-year study of surgical results of descending aorta aneurysm repair following chronic aortic dissection

BACKGROUND

Patients presenting with descending aortic aneurysms developing after aortic dissection often undergo continued aortic expansion which may require operative interventions to address the risk of aortic rupture. In light of the current advances in various treatment options, including endovascular approaches, we analyzed our experience with open surgical repair (OSR) of aneurysms of the descending aorta following aortic dissection.

METHODS

Patients who underwent open repair for aneurysmal changes of the descending aorta after chronic dissection were retrospectively studied. The 30-day operative mortality rate, midterm survival, and major complications were analyzed. Patients were divided into two categories; primary chronic type B aortic dissection and remnant repaired type A aortic dissection (RTAAD).

RESULTS

There were 149 patients with enlargement of the descending thoracic aorta developing after aortic dissection. Of these, 49 patients had medical management, while the remaining 100 patients received OSR. These patients were included in the present analysis. The 30-day mortality and permanent paraplegia rates were 9% and 4%, respectively. The 1-, 3-, and 5-year survival rates were 83%, 80.9%, and 76.1%, respectively. The 1- and 5-year survival rates between the primary chronic type B aortic dissection and remnant RTAAD groups showed no significant between-group differences at 86.7% and 84.3%, and 80% and 71.3%, respectively (P = .289). The overall outcomes of other complications such as renal injury, bleeding reoperation, and extracorporeal membrane oxygenation support showed no significant between-group differences, including an insignificantly higher neurologic complication rate in the remnant RTAAD group. The survival rate in patients with Marfan syndrome was significantly higher than in the patients without Marfan syndrome (P = .033).

CONCLUSIONS

OSR for descending aortic aneurysms developing after chronic aortic dissection showed good early and mid- to long-term outcomes, with acceptably low complication rates. OSR for descending aortic aneurysm after chronic aortic dissection associated with Marfan syndrome also showed good early and mid- to long-term outcomes.

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.

Late complications after Cabrol technique in a case with Marfan syndrome

A patient with Marfan syndrome underwent aortic root replacement with the Cabrol technique at 37 years of age. She underwent a surgical repair for an aneurysm in the right coronary at 58 years of age, followed by a surgical repair for a pseudoaneurysm of the left coronary artery at 64 years of age.

Ascending aorta reinterventions

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

Bentall procedure: quarter century of clinical experiences of a single surgeon

Background

We retrospectively analyzed 25 years of experiences with the button Bentall procedure in patients with aortic root pathologies. Even though this procedure has become widespread, there are only a few very long term follow-ups available in the clinical literature, especially regarding single surgeon results.

Methods

Between 1988 and 2013, a total of 147 patients underwent the Bentall procedure by the same surgeon. Among them there were 62 patients with Marfan syndrome. At the time of the surgery the mean age was 46.5 ± 17.6 years. The impact of surgical experience on long-term survival was evaluated using a cumulative sum analysis chart.

Results

The Kaplan-Meier estimated overall survival rates for the 147 patients were 91.8 ± 2.3 %, 84.3 ± 3.1 %, 76.3 ± 4.9 % and 59.5 ± 10.7 % at 1,5,10 and 20 years, respectively. Multivariate Cox regression analysis identified EuroSCORE II over 3 % (OR 4.245, 95 % CI, 1.739–10.364, p = 0.002), acute indication (OR 2.942, 95 % CI, 1.158–7.480, p = 0.023), use of deep hypothermic circulatory arrest (OR 3.267, 95 % CI, 1.283–8.323, p = 0.013), chronic kidney disease (OR 6.865, 95 % CI, 1.339–35.189, p = 0.021) and early complication (OR 3.134, 95 % CI, 1.246–7.883, p = 0.015) as significant risk factors for the late overall death. The survival rate for freedom from early complication was 94.3 ± 2.2 %, 88.0 ± 3.3 %, 82.9 ± 4.7 % and 69.2 ± 8.4 % at 1,5,10 and 20 years. The main pathological findings of the aortic wall were cystic medial degeneration in 75 %, fibrosis in 6 %, atherosclerosis in 13 % and no pathological alteration in 6 % of the samples. The overall survival rate was significantly lower in patients operated in first 15 years compared to patients operated in the last decade (log-rank p = 0.011).

Conclusion

According to our long-term follow-up the Bentall operation provides an appropriate functional result by resolving the lesions of the ascending aorta. Based on our results, 25–30 operations done is necessary to gain such a level of confidence and experince to aquire better results on long-term survival. In addition, we discussed that there were no co-morbidities affecting on the survival of Marfan patients and prophylactic aortic root replacement ensures a longer survival among patients with Marfan syndrome.

Late reoperations after acute aortic dissection repair: Single-center experience

Background

After repair of acute type A aortic dissection, aortic complications can develop, and reoperations might be necessary. In our retrospective study, we wanted to assess early and late outcomes in this cohort of patients.

Methods

From September 2005 to July 2012, 21 consecutive patients previously operated on for acute type A aortic dissection underwent 27 redo aortic surgical procedures. Indications for redo procedures were: enlargement of the false lumen in the residual aorta (18 events), severe aortic regurgitation with or without aortic root dilatation (8 events), suture dehiscence and pseudoaneurysm at the proximal or distal aortic graft anastomosis (5 events) or at the coronary button anastomosis in patients who previously underwent a Bentall procedure (1 patient). In all cases, total or partial cardiopulmonary bypass was used. Hypothermic cardiocirculatory arrest was needed in 22 (81%) procedures.

Results

Hospital mortality was 3.7% (1/27), reexploration for bleeding and paraplegia rates were 7.4% and 7.4%, respectively. Marfan patients received 3.2 procedures per patient vs. 1.5 in non-Marfan patients ( p < 0.01). At a mean follow-up of 6.5 years, 2 aortic events occurred: 1 aortic death, and 1 additional aortic redo surgery.

Conclusions

When procedures are carried out on elective basis, redo aortic surgery can be performed in all segments of the aorta with good early and late outcomes. Close lifelong clinical and radiological follow-up is mandatory. After repair of acute type A aortic dissection, Marfan patients are more prone to develop late complications, with a more rapid evolution.

[Exceptional association of bilateral popliteal aneurysm with an abdominal aortic aneurysm in Marfan syndrome]

Marfan syndrome is an autosomal dominant disorder with rheumatoid, ophthalmological, neurological, cutaneous and cardiovascular manifestations. Aneurysmal lesions affecting both the abdominal aorta and the peripheral arteries are not often described in the literature. We report a case associating a bilateral popliteal aneurysm and an aneurysm of the infra-renal abdominal aorta.

Rescue surgery 19 years after composite root and hemiarch replacement

A 59-year-old male patient with Marfan's syndrome was referred to our clinic due to acute chest pain. His medical history contains complex surgery for type A aortic dissection 19 years ago including composite root replacement using a mechanical aortic valve. Immediate computed tomography indicated perforation at the distal ascending aortic anastomosis plus complete avulsion of both coronary ostia. The patient underwent successful rescue surgery with ascending aortic and arch replacement using a modified Cabrol technique.

Clinical experience with the Bentall procedure: 28 years

PURPOSE

We retrospectively analyzed 28 years of experience with the Bentall procedure in patients with aortic valve, aortic root, and ascending aortic disease.

MATERIALS AND METHODS

Between March 1982 and December 2010, a total of 218 patients underwent the Bentall procedure using a composite valved conduit. The "inclusion technique" was used in 30 patients (13.8%), the "open-button technique" in 181 patients (83.0%), and the Cabrol technique in 7 patients (3.2%).

RESULTS

The early mortality rate was 5.5% (12/218). The mean follow-up duration was 108.0±81.0 months (range: 1-329 months). Seven patients required re-operation, and 1 patient required stent graft insertion at the descending thoracic aorta for progression of aortic arch or descending thoracic aortic dissection or aneurysm after the first operation, and 5 of them had Marfan syndrome. Kaplan-Meier estimated survival rates at 1, 5, 10, 20, and 25 years were 90.4%, 82.7%, 77.6%, 65.3%, and 60.3%, respectively. Freedom from reoperation rates at 1, 5, 10, 20, and 25 years were 99.0%, 98.3%, 95.5%, 90.8%, and 90.8%, respectively.

CONCLUSION

In our experience, the Bentall procedure provided optimal survival with improved functional status. The disease of the aorta may progress, especially in patients with Marfan syndrome. Therefore, careful follow-up with regular computed tomography angiograms should be performed in these patients.

Aneurysms of the ascending aorta and arch: the role of imaging in diagnosis and surgical management

Thoracic aortic aneurysms tend to be asymptomatic and were previously often diagnosed only after a complication such as dissection or rupture occurred. Better imaging techniques and an increase in the use of cross-sectional imaging has led to an increase in the diagnosis of aortic aneurysms, which has allowed for elective treatment prior to the development of a complication. The location, size and etiology of an aneurysm all impact the clinical outcomes and these factors are used to determine the appropriate timing of surgical replacement. Surgeons often rely on the information obtained from preoperative imaging to determine when to intervene and what type of procedure will be necessary, making it important for the radiologist to understand these issues in order to provide the necessary information. Postoperative imaging after surgical replacement of the aorta is also important, as there are some common findings that occur in this patient population that can impact how they are treated. The purpose of this article is to review the etiology and associated findings of aneurysms of the ascending aorta and arch, with a focus on how computed tomography angiography and magnetic resonance angiography findings are used to determine the appropriate timing for elective replacement and the type of surgical procedure, as well as the role of follow-up imaging. This will include a review of the most commonly performed types of surgical procedures, to provide an understanding of how the findings of preoperative imaging studies impact what the surgeon does in the operating room, as well as the expected findings of postoperative imaging studies.

Reoperations for aortic false aneurysms after cardiac surgery

BACKGROUND

Aortic false aneurysm is a rare complication after cardiac surgery. Aortic dissection, infection, arterial wall degeneration, and poor surgical technique are recognized as risk factors for the occurrence of postsurgical false aneurysm. Despite some recent reports about percutaneous false aneurysm exclusion, a complex surgical reoperation is needed in most of the cases.

METHODS

We retrospectively reviewed our experience in 43 patients who received a reoperation for postsurgical aortic false aneurysm in the last 14 years. Thirty-three patients were male. The mean age was 60 ± 12 years. Most of the patients received prior aortic surgery on the aortic root, the ascending aorta, the aortic arch, and the descending thoracic aorta (38 patients). False aneurysm was diagnosed during follow-up evaluation in the absence of any symptoms in 23 cases. Univariate and multivariate analyses on 18 perioperative variables were performed.

RESULTS

In-hospital mortality was 6.9% (3 patients). The postoperative course was complicated in 17 cases (39%). At multivariate analysis, a preoperative history of coronary artery disease and postoperative sepsis were independent risk factors for hospital mortality. Survival rates at 1, 5, and 10 years were 94%, 79%, and 68%, respectively. Freedom from reoperation was 86% at 1 year and 72% at 5 and 10 years.

CONCLUSIONS

Despite a high postoperative complication rate, a reoperation for postsurgical aortic false aneurysm can be performed with acceptable mortality and good mid-term and long-term outcomes.

Follow-up paradigms for stable aortic dissection

While limited data exist on which follow-up paradigms for chronic aortic dissections can be based, what information is present suggests that long-term follow-up is mandatory. In spite of the treatment modality, deaths from aortic disease continue to accrue and repeat interventions are often required over long-term follow-up. The only prospective trial data available indicate a roughly equal incidence of secondary interventions during the first and second year. Recent studies with longer follow-up suggest that the likelihood of a need for intervention ultimately diminishes. With increasing time after presentation, it may be possible to decrease the frequency of follow-up interrogations. Definitive recommendations in this regard, however, must await the availability of longer-term data.

Presentation and outcome of Marfan's syndrome patients with dissection and thoraco-abdominal aortic aneurysm

BACKGROUND

In Marfan's syndrome, there is a paucity of data regarding intervention criteria for surgery of the dissected thoraco-abdominal aorta.

METHODS

A retrospective analysis of 22 Marfan's patients with distal aortic dissection managed between September 1999 and April 2006 was performed. Serial diameters and linear expansion rates were calculated from imaging studies and the outcome of intervention was analysed.

RESULTS

There were 14/22 male patients (median age 38 years), and 18 had prior aortic surgery. Surgery was recommended in 20 patients and undertaken in 19 (1 died prior to operation). Of the operated patients, 2 presented with rupture, 2 with airway obstruction, 1 with intermittent paraplegia and 14 underwent planned surgery for increased expansion rate or pain. All patients had residual type A or chronic type B dissection. The median aortic dimension at surgery was 6.7 cm (interquartile range (IQR) 5.5-8.2). The preoperative mean expansion rate increased from 0.5 cm/year to 1.7 cm/year (p<0.001), prior to operation. Fifteen patients underwent Crawford Extent II, two underwent Extent I and two underwent Extent III repair. Profound hypothermia and CSF drainage was used in 16 and 18 patients, respectively. There was no early mortality, paraplegia or renal failure. At a median postoperative follow-up of 56 months (range 6-86), the survival of the operated cohort was 90%.

CONCLUSIONS

Thoraco-abdominal aortic aneurysm repair in Marfan's syndrome can be performed with good outcomes. Intervention should be based on size or accelerated expansion. Any role of endovascular management needs careful consideration.

Reoperation for Giant False Aneurysm of the Thoracic Aorta: How to Reenter the Chest?

BACKGROUND

Giant false or pseudoaneurysm of the aorta is a rare but dreadful complication occurring several months or years after cardiac or aortic surgery. We describe a surgical approach that allowed safe reentry in the chest in five patients, with a mean follow-up of almost seven years.

METHODS

From December 1991 to October 1999, five patients aged 34 to 74 years (mean age, 55 +/- 11.6 years), who had previously undergone a total of nine operations in other institutions, required reoperation for giant false aneurysm of the ascending aorta in a mean delay of 22.6 +/- 20.3 months (3 months to 6 years) after the last surgical procedure. In order to avoid major mediastinal wound and patient's exsanguination during resternotomy, the following technique has been used: femoral artery cannulation; right atrial cannulation through the femoral vein; femoro-femoral full-flow cardiopulmonary bypass; rectal temperature lowered to 25 degrees C; direct cannulation and cross-clamping of both carotid arteries through a direct cervical approach, and selective cerebral perfusion with cold blood (10 degrees C to 12 degrees C); circulatory arrest of the main circuit; chest opening; and mediastinal division.

RESULTS

Despite the fact that the false aneurysm was entered in all patients, reopening of the chest has been safe in all cases. In four cases, the aortic repair consisted of complete graft replacement (Dacron) of the compromised aortic segment (ascending aorta in two; both ascending aorta and aortic arch in two). In one case, reimplantation of the left coronary ostium and closure of a fistula with the left ventricle was carried out. One patient with ongoing mediastinitis died from intractable septicemia and multiorgan failure. Presently, two patients are in excellent condition; one suffers from light neurologic sequelae (oculomotor nerves palsy) and one patient had a nonrelated stroke one year postoperatively.

CONCLUSIONS

The technique of separate carotid cannulation and selective antegrade brain perfusion with cold blood during circulatory arrest at moderate core hypothermia has, in our opinion, many advantages. In addition to allowing harmless opening of the chest in the presence of most dangerous mediastinal false aneurysms, it implies no general deep hypothermia, reduced duration of cardiopulmonary bypass, and circulatory arrest of the lower part of the body, and safe and permanent brain protection throughout chest opening and mediastinal division. It has allowed us to safely reoperate on patients who are generally considered as a major surgical risk.

Prosthetic replacement of the ascending aorta increases wall tension in the residual aorta

BACKGROUND

Prosthetic replacement of the ascending aorta with nonelastic vascular grafts impairs the local Windkessel function. Whether this increases wall tension in the remaining aorta is still a not completely investigated hypothesis but is of clinical relevance with respect to postprocedural development of aneurysms and dissections, especially in the proximal descending aorta.

METHODS

Fresh porcine thoracic aortas, including the root, were set up in a mock circulation before and after prosthetic replacement of the ascending aorta. Cyclic changes in aortic dimensions were measured by ultrasonic micrometers at defined positions at the proximal part of the descending aorta. At the same positions, aortic pressures were recorded simultaneously using Millar tip manometers. Wall thickness was measured after pulsatile testing, and the resulting wall tension was calculated from the Laplace law.

RESULTS

After prosthetic replacement of the ascending aorta, peak systolic pressure in the proximal descending aorta increased from 117.6 +/- 6.1 mm Hg to 129.2 +/- 6.3 mm Hg, resulting in a rise of wall tension by 12.4% +/- 4.2% (p = 0.001). The maximum rate of pressure rise (dp/dt(max)) increased by 42.6% +/- 16.4% (p < 0.001).

CONCLUSIONS

Replacement of the ascending aorta with noncompliant prosthetic material significantly increases wall tension and rate of pressure rise in the residual aorta. This may have clinical impact with respect to a sudden and sustained rise of mechanical load, especially at the vulnerable proximal descending aorta.

Spectrum of Aortic Operations in 300 Patients With Confirmed or Suspected Marfan Syndrome

BACKGROUND

Cardiovascular disease is the main cause of morbidity and mortality in patients with Marfan syndrome. Many patients with presumed Marfan syndrome do not meet current diagnostic criteria. This study reviews the surgical aspects of aortic disease in 300 patients referred with the diagnosis of Marfan syndrome.

METHODS

During a 16-year period, 300 patients with presumed Marfan syndrome underwent 398 operations on the aorta and branch arteries, including 125 aortic root operations, 59 aortic arch repairs, 31 descending thoracic aortic repairs, and 178 thoracoabdominal aortic repairs. Based on medical record review, patients were classified as confirmed Marfan syndrome if documented features satisfied current diagnostic criteria; patients not meeting these criteria were classified as suspected Marfan syndrome.

RESULTS

There were 17 operative deaths (4.3%) after the 398 operations. Survival after the initial referral operation was 96.2% +/- 1.5% at 1 year, 82.7% +/- 2.4% at 5 years, and 74.6% +/- 3.1% at 10 years. Presentations, operative details, and outcomes were remarkably similar in the 137 patients (45.7%) with confirmed Marfan syndrome and the 163 patients (54.3%) with suspected Marfan syndrome. Freedom from repair failure, however, was significantly better in patients with confirmed Marfan syndrome (90.3% +/- 2.3% at 10 years) than in those with suspected Marfan syndrome (82.0% +/- 3.1% at 10 years; p = 0.001).

CONCLUSIONS

Operative treatment of the full spectrum of aortic disease in Marfan patients enables excellent long-term survival. Similarities in surgical aspects of aortic disease suggest that patients with features of Marfan syndrome who do not meet diagnostic criteria should be managed in the same manner as patients with confirmed Marfan syndrome.

Aortic valve-sparing operation and a total arch replacement by an elephant trunk method for Marfan's syndrome with aortic regurgitation and a DeBakey type IIIb dissection

A 35 year-old male with Marfan's syndrome was referred with a fortuitous echographic finding of an abdominal aorta flap. Transthoracic echocardiography showed moderate aortic regurgitation and an aneurysm in the sinus of Valsalva. Computed tomography demonstrated an aneurysm in the sinus of Valsalva 60 mm in size and a DeBakey type IIIb dissection extending from the left subclavian artery to the right common iliac artery. An aortic valve-sparing operation (reimplantation), total aortic arch replacement and the elephant trunk method were used in this patient. An aortic valve-sparing operation is preferable because the patient is young, and has no need for anticoagulant therapy after surgery. The extent of the aortic reconstruction, including the intact aortic arch, was appropriate to prohibit future dilatation of the aortic arch and retrograde dissection from a DeBakey type IIIb dissection.