Drawback of aortoplasty for aneurysm of the ascending aorta associated with aortic valve disease

Suture reduction of the borderline ascending aortic dilatation during aortic valve replacement

BACKGROUND

This study was conducted to evaluate the efficacy of simple suture reduction of the ascending aorta(SRA) performed with aortic valve replacement(AVR) in patients with borderline ascending aortic dilatation(45-50mm).

METHODS

98 patients (ascending aortic diameter=47.7±3.4mm) who underwent concomitant SRA with AVR were enrolled. Median follow-up duration was 83 (interquartile=27,173) months. Computed tomographic angiography(CTA) follow-up was performed at 71(47,149) months after surgery(n=69). At least two CTA scans were performed in 34 patients (interval=63[46,156] months). Early and long-term outcomes were evaluated, and dilatation rate (mm/year) of the repaired aorta was analyzed. Major adverse aortic events(MAEs) were defined as death related to aortic events, including sudden death, aortic rupture or dissection, aortic reoperation and recurrent aortic aneurysm(>45mm).

RESULTS

Early mortality rate was 2.0%. No patients had postoperative complications associated with SRA. A recurrent aortic aneurysm(>45mm) was found in 9 patients, but none of the patients had an ascending aorta diameter>50mm. A multivariable analysis demonstrated that neither preoperative diameter of the ascending aorta nor bicuspid valve was associated with dilatation of the repaired aorta. Co-existing coronary artery disease was associated with both recurrent aneurysm and increased dilatation rate after SRA. There were 2 cases of sudden death and no one suffered from aortic dissection, rupture or aortic reoperation. Ten- and 20-year freedom rates from MAE were 90.3% and 79.3%, respectively.

CONCLUSIONS

Concomitant SRA might be a safe and effective surgical alternative to ascending aorta replacement in AVR patients with borderline ascending aortic dilatation regardless of aortic valve pathology.

Midterm follow up in patients with reduction ascending aortoplasty

BACKGROUND

The reduction ascending aortoplasty in patients with an aortic ectasia/dilatation is a common procedure during concomitant cardiac operations. Aim of the follow up study was the evaluation of possible re-dilatation and complications.

METHODS

From 1998 to 2010 124 patients (69% male; mean age 66.6 ± 12 ys) with ectasia of the ascending aortic who had no further indication for an aortic replacement, were included. The mean preoperative diameter of the ascending aorta was 4.2 ± 0.6 cm. The patients risk profile was moderate (mean EF 51% ± 11%, Euroscore 4.2 ± 2.1). To treat the dilatation of the ascending aorta, a longitudinal incision was performed and a strip of the aortic wall was resected. A reduction aortoplasty was carried out with a double-layered suture line using a 4/0 Prolene mattress suture with an additional 4/0 Prolene running suture. A follow up (rate 95%) was performed by echocardiography- and clinical examination.

RESULTS

All patients underwent reduction aortoplasty associated with a primary cardiac surgical procedure (AVR 63%, CABG 13%, other or combination 24%). The intrahospital mortality rate was 4%. Four aortic bleeding complications occurred. After a mean postoperative period of 57 ± 39 months, the ascending aortic diameter (3.6 ± 0.6 cm) was still significantly (P < 0.01) reduced. No postoperative aortic-related complications including aortic rupture, dissection and reoperation were observed. In 4 patients, the ascending aorta had re-dilated to the preoperative diameter.

CONCLUSION

Reduction ascending aortoplasty without external wrapping is a safe procedure with acceptable midterm results in patients with asymptomatic dilatations and concomitant cardiac surgical procedures.

Toward individualized management of the ascending aorta in bicuspid aortic valve surgery: the role of valve phenotype in 1362 patients

OBJECTIVE

Decision making regarding the management of the ascending aorta (AA) in patients with a bicuspid aortic valve (BAV) undergoing valve surgery has hardly been individualized and remains controversial. We analyzed our individualized, multifactorial approach, focusing on the BAV phenotype.

METHODS

In 1362 patients (1044 men) undergoing aortic valve surgery, the BAV phenotypes were intraoperatively classified and retrospectively analyzed. The mean follow-up was 5.4±3.6 years (range, 0-14; 7334 patient-years), and the data were 96.5% complete. The individualized AA management decision process mainly included the AA diameter, age, body surface area, macroscopic AA configuration, and the perceived tissue strength of the aortic wall resulting in 3 AA treatment groups: no intervention, aortoplasty (AoP), and AA replacement (AAR).

RESULTS

In 906 patients (66.5%), no intervention was performed and 172 (12.6%) and 284 (20.9%) underwent AoP and AAR, respectively. The hospital mortality was 1.1% for no intervention, 0.6% for AoP, and 0.4% for AAR (P=.4). The 10-year survival was similar for all 3 groups and comparable to that of the general population. Five reoperations on the AA occurred, 4 in the no intervention and 1 in the AoP group. BAV type 2/unicuspid patients were younger and more had undergone AAR in absolute numbers and after allowing for the AA diameter. Also, in patients with BAV type 1 LR and regurgitation, AAR was performed more often.

CONCLUSIONS

The individualized, multifactorial management of AA in patients with BAV during aortic valve surgery leads to excellent results. The threshold AA diameter for intervention (AoP or AAR) varied from 34 to 51 mm (mean, 43.9). BAV type 2/unicuspid and BAV type 1 LR with regurgitation emerged as determinants for more liberal AAR in our practice. Longer term follow-up is necessary to confirm our conclusions.

Bicuspid aortic valve disease: recent insights in pathophysiology and treatment

Bicuspid aortic valve is a common congenital cardiac malformation with a broad spectrum of clinical outcomes. Bicuspid aortic valve may go undetected throughout an individual's lifetime or, alternatively, they may have devastating clinical consequences, resulting in death. Both clinicians and medical scientists have taken a renewed interest in the development, pathophysiology and treatment options for this subtle but often substantial clinical entity. Evidence is mounting to suggest that an underlying disease of the aorta is inherited with bicuspid aortic valve, although considerable controversy surrounds this theory. Novel molecular mechanisms underlying the valve and vascular pathologies, as well as new surgical therapies for these patients have been proposed in the past 10 years.

Risk of proximal aortic dissection in patients with bicuspid aortic valve: how to address this controversy?

The risk of acute aortic events in patients with bicuspid aortic valve (BAV) disease is a controversial issue. The real risk of aortic dissection in patients with BAV disease is unknown. An indirect assessment of this risk, however, could be gained with a more detailed understanding of the pathogenesis of BAV aortopathy. There are two major issues that should be clarified before one addresses the question of aortic dissection risk in BAV patients. The first issue, when analysing the data from previous BAV cohorts, is to determine what stage of BAV disease was present in the described patient population. In particular, was the risk of aortic dissection in BAV patients determined before or after aortic valve replacement (AVR) surgery? The second issue to consider is the functional state of the pathological valve within the observed population. In particular, did patients predominantly suffer from BAV stenosis or BAV insufficiency? Unfortunately, the vast majority of published reports do not separate between the different BAV phenotypes, thereby complicating interpretation of the results. Considering these two important clinical variables (i.e. the stage of BAV disease and the functional phenotype), we herein aim to explain the inconsistency of the published data with regard to the risk of aortic dissection in patients with BAV disease.

Comparison of aortic media changes in patients with bicuspid aortic valve stenosis versus bicuspid valve insufficiency and proximal aortic aneurysm

OBJECTIVES

The aim of this study was to evaluate aortic media changes in bicuspid aortic valve (BAV) patients who underwent aortic valve replacement (AVR) and simultaneous replacement of the proximal aorta for BAV stenosis vs BAV insufficiency.

METHODS

Review of our institutional BAV database identified a subgroup of 79 consecutive BAV patients (mean age 52.3 ± 13 years, 81% men) with BAV stenosis or insufficiency and concomitant proximal aortic dilatation of ≥50 mm who underwent AVR and simultaneous replacement of proximal aorta from 1995 through 2005. All cases of BAV disease and concomitant ascending aortic dilatation of 40-50 mm underwent isolated AVR and therefore were excluded from this analysis. Proximal aortic media elastic fibre loss (EFL) was assessed (graded 0 to 3+) and compared between patients with BAV stenosis (Group I, n = 44) vs BAV insufficiency (Group II, n = 35). Follow-up (690 patient-years) was 100% complete and 9.1 ± 4.6 years long.

RESULTS

Mean aortic media EFL was 1.3 ± 0.7 in Group I vs 2.5 ± 0.8 in Group II (P = 0.03). Moderate/severe EFL (i.e. defined as grade 2+/3+) was found in 13 patients (29%) in Group I vs 28 patients (80%) in Group II (P < 0.001). Logistic regression identified BAV insufficiency as the strongest predictor of moderate/severe EFL (OR 9.3; 95% CI 3.2-29.8, P < 0.001). Valve-related event-free survival was 64 ± 8% in Group I vs 93% ± 5% in Group II at 10 years postoperatively (P = 0.05). A total of 4 patients (5%, 3 from Group I and 1 from Group II) underwent redo aortic root surgery for prosthetic valve endocarditis during follow-up.

CONCLUSIONS

Patients with BAV insufficiency and a proximal aorta of ≥50 mm have a significantly higher rate of moderate/severe EFL as compared to their counterparts with BAV stenosis.

Isolated aortic root dilatation following sinotubular junction reduction using prosthetic rings

'Comprehensive Aortic Root and Valve Reconstruction' technique, which was first introduced in 2005 involves aortic root reduction using prosthetic rings in order to preserve the native aortic sinuses in patients having aortic regurgitation associated with aortic root dilatation. We report a case of isolated aortic sinus aneurysm in a Marfan syndrome patient following the aortic root preserving surgery in the presence of ascending aorta aneurysm and annuloaortic ectasia. Re-operation consisted of aortic sinus resection and replacement with an artificial graft, and coronary reimplantation using a button technique. Close follow-up is essential for patients who underwent aortic root preserving surgery to appropriately manage this kind of complication.

Bicuspid aortic valve and aortic root disease

Bicuspid aortic valve (BAV) is the most common form of congenital heart disease, with frequent and premature occurrence of cardiac events, dominated by significant valvular dysfunction. BAV has a high prevalence of aortic wall abnormalities such as ascending aortic dilatation. Because more rapid aortic dilatation can occur, once the ascending aorta reaches 40 mm, annual imaging with echocardiography or other imaging techniques is indicated. The most feared complication is aortic dissection. However, the actual incidence of this complication is low (4%). Although limited data exist regarding prophylactic intervention, it is suggested that elective surgical repair of BAV-associated aortic dilatation should be more aggressively recommended. In patients with BAV, the decision to indicate surgical treatment in aortic diameters between 50 and 55 mm should be based on patient age, body size, comorbidities, type of surgery, and the presence of additional risk factors.

Reduction aortoplasty for the ascending aortic aneurysm with aortic valve disease. Does bicuspid valve matter?

BACKGROUND

The outcomes of reduction ascending aortoplasty (RAA) performed with aortic valve surgery were evaluated and the results of RAA in patients with bicuspid aortic valve (BAV) were compared with those in patients with tricuspid valve.

METHODS AND RESULTS

From October 1994 to April 2009, 88 patients underwent RAA. Aortic valve was bicuspid in 45 patients (BAV group) and tricuspid in 43 patients (TAV group). Total circulatory arrest was required in 45 patients. Preoperative ascending aortic diameter was 45.5±4.7mm. Early mortality rate was 1.1%. Ten-year survival rate and freedom from cardiac death were 91.1% and 96.2%, respectively. No differences in clinical outcomes were found between the 2 groups. No aorta-related complications including aortic rupture, dissection and reoperation were observed. Aortic diameter at the last follow-up (61±43 months) was 37.8±4.3mm. The interval between surgery and follow-up CTA was associated with aneurysmal recurrence (P=0.022). Average rate of dilatation was 0.42±0.49mm/year (n=37). A need for total circulatory arrest was associated with an increase of the aortic diameter (P=0.009). BAV was associated with neither aneurysmal recurrence nor increase of aortic diameter.

CONCLUSIONS

RAA in patients with an ascending aortic aneurysm combined with aortic valve disease could be performed with acceptable early and long-term outcomes, even in patients with BAV. Long-term follow-up evaluation might be necessary due to the risk of redilatation especially in patients with an extended aneurysm, which required total circulatory arrest for RAA.

Surgery Insight: the dilated ascending aorta—indications for surgical intervention

Awareness of the clinical significance of thoracic aortic aneurismal disease has increased in recent years. As diagnostic tools have improved our ability to identify aortic pathology, surgical outcomes have also improved, making intervention a life-saving option in the majority of cases. Here, we aim to examine the indications for surgical intervention on the dilated aorta, particularly the ascending segment. Studies of the natural history of ascending aortic aneurysms indicate that aneurysms exceeding 6 cm in maximum diameter are associated with a particularly high risk of complications. In the interest of providing some margin of safety, most surgeons would agree that intervention is indicated with an aortic diameter of 5.5 cm. Many would intervene even earlier (at 5.0 cm) for patients at low surgical risk, or for those with known connective tissue disorders such as Marfan's syndrome. In some cases, only the ascending aortic segment needs to be treated, while in others full root replacement is required. Reduction aortoplasty has been superseded largely by interposition graft replacement. The standard procedure involves replacement of the valve and root with a composite mechanical conduit or tissue root prosthesis, and results are excellent. Recently developed valve-sparing root reconstructive options, however, are promising and have encouraged an even more aggressive surgical stance.

Unsupported Reduction Ascending Aortoplasty: Fate of Diameter and of Windkessel Function

BACKGROUND

Moderate aneurysms of the ascending aorta that are associated with other cardiac diseases are frequently encountered by cardiac surgeons. Reduction ascending aortoplasty (RAA) provides an elegant technique to handle these aneurysms; however, its applicability is still under debate. Many surgeons reject RAA because of an assumed redilatation. We investigated the postoperative stability of RAA without external support and whether the elastic property of the aorta (Windkessel function) remains preserved.

METHODS

From 1996 to 2003, 97 patients (mean age, 67 years) underwent RAA without external stabilization in our institution as a concomitant procedure during cardiac surgery. The diameter of the ascending aorta was measured before and directly after surgery, as well as postoperatively from 10 to 96 months (median, 32 months).

RESULTS

The mean preoperative diameter was 4.55 +/- 0.43 cm, while the early postoperative diameter measured 3.53 +/- 0.44 cm. Fifty-four of the 97 patients were available for follow-up. The mean diameter measured at follow-up was 3.68 +/- 0.41 cm. The mean increase was 0.17 +/- 0.27 cm. There was no relevant difference in redilatation between patients with follow-up of more than 60 months or less. Furthermore, the aortic wall demonstrated a near normal diastolic-systolic augmentation assessed by echocardiography.

CONCLUSIONS

Reduction ascending aortoplasty without external stabilization is a reliable treatment for patients suffering from a moderately enlarged ascending aorta who require cardiac surgery for other indications. In these cases, with the technique described, a redilatation can be prevented and the Windkessel function of the ascending aorta remains preserved.

Safe wrapping of the borderline dilated ascending aorta during aortic valve replacement

Background

Techniques of reduction aortoplasty are widely published in the literature with conflicting results. External support seems to be an important factor in preventing recurrence but, in some cases, this technique caused erosion of the aorta because of the wrinkles the prosthesis creates in the rear side of the aorta.

Case presentation

A 73 year old patient with aortic valve stenosis and borderline dilated ascending aorta had aortic valve replacement and simple wrapping without aortoplasty. To avoid the formation of wrinkles, the dacron external support was tailored appropriately to obtain a curved, custom-made prosthesis. This custom-made prosthesis had the same diameter as the dilated aorta and, after valve replacement, fitted it properly. After 18 months neither computerized axial tomography nor ecocardiography detected wrinkles or dilatation recurrence.

Conclusion

A safe, simple and probably new way to prepare an external wrapping is presented, which in this patient respected the shape of the aorta and prevented the formation of wrinkles in the prosthesis and possible complications such as wall erosion.

Reduction Ascending Aortoplasty: Midterm Follow-Up and Predictors of Redilatation

BACKGROUND

Reduction ascending aortoplasty is an alternative procedure to the replacement of the ascending aorta in case of ascending aorta aneurysm without aortic root involvement. This study was designed to evaluate the midterm follow-up of aortoplasty and to determine predictors of redilatation.

METHODS

From January 1, 1998, to April 30, 2005, 68 patients with dilatation of the ascending aorta underwent unsupported reduction aortoplasty in combination with other cardiac procedures. All patients underwent associated surgical procedures. Sixty patients (88.2%) underwent associated aortic valve replacement. Cumulative follow-up time was 191.4 patient-years and was 100% complete. Median follow-up time was 2.5 years, and mean follow-up time was 2.9 +/- 1.7 years (range, 0.4 to 6.3 years).

RESULTS

The overall perioperative mortality rate was 1.5%. Overall survival estimates at 3 and 6 years were 93.3% +/- 4.5% and 89.3% +/- 5.9%, respectively. The actuarial freedom from cardiac-related death at 3 and 6 years was 100% and 95.7% +/- 4.3%, respectively. Ascending aorta redilatation occurred in 5 patients (7.5%). The actuarial freedom from redilatation at 3 and 6 years was 97.7% +/- 2.3% and 79.8% +/- 8.4%, respectively. The actuarial freedom from reoperation at 3 and 6 years was 100% and 86.3% +/- 7.5%, respectively. Only preoperative diameter was a significant predictor of redilatation using multivariate stepwise logistic regression analysis.

CONCLUSIONS

Unsupported reduction aortoplasty is a safe and effective technique with low mortality, low morbidity, and rare late complications for selected chronic aneurysm of the ascending aorta with diameter less than 55 mm.

Ascending aorta dilatation in aortic valve disease: morphological analysis of medial changes

We investigated whether and how the severity of medial degeneration lesions varies along the circumference of the dilated intrapericardial aorta. Two groups of aortic wall specimens, respectively harvested in the convexity and concavity of ascending aorta in 72 patients undergoing surgery for dilatation of the intrapericardial aorta associated with aortic valve disease, were separately sent for pathology, morphometry, and ultrastructural examination. Cystic medial necrosis, fibrosis, and elastic fiber fragmentation were classified into three degrees of severity; their mean degree and morphometric findings in the convexity and in the concavity specimens were compared by paired t-test. Correlation between echocardiographic degree of aortic dilatation and severity of medial degeneration was assessed separately for each of the two groups of specimens. Morphologically, medial degeneration was found in all cases; a higher mean degree was found in the convexity group (2.39 +/- 0.58 vs 1.44 +/- 0.65 in the concavity group; P < 0.001). At morphometry normal smooth muscle cells in the convexity specimens were significantly reduced (P = 0.007); the length (P = 0.012) and number (P = 0.009) of elastic fibers reduced and increased, respectively. Moreover, in the convexity specimens a significantly smaller amount of smooth muscle cells and an increase of immunohistochemical labeling of apoptosis-associated proteins in the subintimal layer of the media was noticed. Correlation between aortic ratio and medial degeneration degree was significant in the convexity group (P < 0.001), but not in the concavity group (P = 0.249). Scanning electron microscopy analysis confirmed morphological results and allowed us to better distinguish the early pathological cavities from the microvessels, which were in the outer media in normal aorta and ubiquitous in aortitis or atherosclerosis. Electron transmission microscopy analysis showed changes in the extracellular matrix and smooth muscle cells, and these changes increased from the intima to the adventitial layer of the media. In dilated intrapericardial aorta, medial degeneration changes and expression of apoptosis-associated proteins are more marked in the ascending aorta convexity, likely due to hemodynamic stress asymmetry. Ultrastructural findings allow us to distinguish the early medial changes not yet evident on light microscopy.

Aortic dilatation in patients with bicuspid aortic valve

The association of a bicuspid aortic valve (BAV) with abnormalities of the proximal thoracic aorta, including dilatation, aneurysm and dissection, has been previously described, leading to the hypothesis of a common underlying developmental defect involving the aortic valve and the aortic wall. Consequently, any patient with BAV should receive a careful assessment not only of the valve function, but also of the aortic root and the ascending aorta. Dilatation of the proximal thoracic aorta is a common finding in patients with BAV and is believed to be related to aortic rupture and dissection. Because progressive dilatation can occur, careful long-term surveillance of the aortic dimensions is required. Prophylactic surgical repair of the dilated aorta should be recommended more aggressively for patients with BAV than for those with a tricuspid aortic valve. However, the optimal timing of aortic surgery in BAV patients remains uncertain because of the limited data available on the natural history of asymptomatic aortic dilatation.

Should the ascending aorta be replaced more frequently in patients with bicuspid aortic valve disease?

OBJECTIVE

The optimal diameter at which replacement of the ascending aorta should be performed in patients with bicuspid aortic valve disease is not known.

METHODS

We reviewed all patients with bicuspid aortic valves undergoing aortic valve replacement at our institution from 1979 through 1993 (n = 201). Patients undergoing concomitant replacement of the ascending aorta were excluded.

RESULTS

Follow-up was obtained on 98% of patients and was 10.3 +/- 3.8 (mean +/- SD) years. The average patient age was 56 +/- 15 years, and 76% were male. The ascending aorta was normal (<4.0 cm) in 115 (57%) patients, mildly dilated (4.0-4.4 cm) in 64 (32%) patients, and moderately dilated (4.5-4.9 cm) in 22 (11%) patients. All patients with bicuspid aortic valves with marked dilation (>5.0 cm) underwent replacement of the ascending aorta and were therefore excluded. Fifteen-year survival was 67%. During follow-up, 44 patients required reoperation, predominantly for aortic valve prosthesis failure. Twenty-two patients had long-term complications related to the ascending aorta: 18 required an operative procedure to replace the ascending aorta (for aortic aneurysm), 1 had aortic dissection, and 3 experienced sudden cardiac death. Fifteen-year freedom from ascending aorta-related complications was 86%, 81%, and 43% in patients with an aortic diameter of less than 4.0 cm, 4.0 to 4.4 cm, and 4.5 to 4.9 cm, respectively ( P < .001).

CONCLUSIONS

Patients undergoing operations for bicuspid aortic valve disease should be considered for concomitant replacement of the ascending aorta if the diameter is 4.5 cm or greater.

Reduction aortoplasty and external wrapping for moderately sized tubular ascending aortic aneurysm with concomitant operations

BACKGROUND

Replacement of the ascending aorta with a prosthetic graft is the preferred surgical procedure for an ascending aortic aneurysm. The choice of external wrapping of the aorta is a simple, fast, and effective method for moderately sized ascending aortic aneurysms with concomitant operations. In this study, we present the midterm results of 62 patients undergoing reduction aortoplasty with external wrapping and different cardiac procedures.

METHODS

The study group consisted of 48 male and 14 female patients with a mean age of 59.3 +/- 6.0 years. Measurement of the ascending aorta diameters was obtained at three points: before surgery, during the early postoperative period, and during the follow-up. The mean preoperative aortic diameter was 52.7 +/- 0.5 mm. In all patients, the ascending aortic aneurysm was repaired by reduction aortoplasty with external wrapping.

RESULTS

Mean follow-up time was 39.6 +/- 18.0 months. There was only one mortality (1.6%) as a result of septic multiple-organ failure and no major surgical complications in the 30-day postoperative period. Reduction aortoplasty of the ascending aorta with external wrapping resulted in a significant reduction of the ascending aorta in all patients (p = 0.000). There was an increase in the mean aortic diameter during the follow-up period (p = 0.000). Although this increase was statistically significant, all measurements of the follow-up period were still within normal range.

CONCLUSIONS

External wrapping of the aorta offers excellent results with very low mortality and morbidity, and it can be regarded as a safe and effective method for the treatment of ascending aortic aneurysm in selected patients. However, the patients should be carefully monitored for redilatation after the procedure.

Calculated Reduction Aortoplasty for Dilatation of the Ascending Aorta Associated with Aortic Valve Replacement

BACKGROUND

Previous studies have advocated reduction aortoplasty to normalize the diameter of a moderately dilated ascending aorta associated with aortic valve disease. One of the reported techniques is the shawl lapel aortoplasty, which we have adopted and modified by setting a simple set of calculations. We present our midterm results.

METHODS

Between February 1996 and February 2004, 25 patients underwent reduction aortoplasty during replacement of their aortic valves. Concomitant cardiac procedures were performed in 11 patients. Eighteen patients had predominantly severe aortic valve stenosis and 7 patients moderate to severe aortic valve insufficiency. Ascending aortic aneurysm size ranged from 43 to 50 mm, measured echocardiographically. In one small sized patient the aorta was 38 mm. Following their discharge patients were instructed to have control echocardiograms every 6 months for the first postoperative year and then annually. They were interviewed by telephone annually to date.

RESULTS

There were no hospital deaths. Twenty-four patients were alive at follow-up, at 2 to 96 months (average 2.9 years). There was one late death, 2 years postoperatively. The first follow-up transthoracic echocardiogram performed at a mean of 6.2 months postoperatively (range, 1-11 months), as well as the subsequent annual echocardiograms in all patients, showed no evidence of further enlargement of the ascending aorta, compared to the reduced diameter obtained during the initial operation. The first 3 patients of this study remained essentially unchanged postoperatively, with only a minor reduction of their aortic diameter.

CONCLUSIONS

The shawl lapel technique based on simple calculations, used as a diameter-reduction strategy for ascending aortic dilatation encountered during aortic valve replacement, is an efficacious method with excellent medium-term results.

Long-term durability of resection and end-to-end anastomosis for ascending aortic aneurysms

BACKGROUND

Ascending aortic aneurysms with normal sized sinotubular junction are generally treated by resection of the dilated aorta and replacement with tubular graft. Aortic resection and direct end-to-end anastomosis has been applied to repair aortic coarctation, interrupted aortic arch, and traumatic aortic rupture. No data exist regarding the long-term durability of this approach in ascending aortic aneurysms. The aim of this case-control study was to illustrate the durability of this operation by presenting our entire experience and the long-term follow up of a cohort of 34 patients who underwent ascending aortic aneurysm resection and primary end-to-end anastomosis between January 1990 and March 2003 in Caen University Hospital (Caen, France).

METHODS

The mean age of patients was 61.5 +/- 12.5 years, and there were 18 male and 16 female patients. The operative technique included extensive mobilization of the arch, supra-aortic trunks, and inferior vena cava to enable approximation of the aortic ends, thus avoiding tension on the suture lines. Associated aortic valve replacement was performed in 27 patients; mechanical valves were used in 19. A bicuspid aortic valve was present in 9 patients; in 3 cases the valve was regurgitant. Aortic valve regurgitation was present in a total of 7 patients. Patients were followed up at regular intervals; total follow-up was 2187 patient-months, with a median follow-up time of 72 months per patient (25th-75th percentile 10.5-102.7 months).

RESULTS

One patient died 10 days after the operation of aortic rupture related to suture infection caused by mediastinitis. Late deaths occurred in 3 patients, who died 12, 62, and 71 months after the operation, but none of these deaths were attributable to late aortic repair failure. No patient in this series required reoperation, including patients with aortic regurgitation or bicuspid aortic valve. Follow-up was 91.1% complete at the closing date of April 1, 2003. The Kaplan-Meier estimate of survival for all patients was 120.4 months (95% confidence interval 105.1-135.7 months). The median of preoperative maximal aortic diameter was 55.1 mm (range 50.3 to 67.5 mm, 25th-75th percentile 50.5-56.8 mm). The median immediate postoperative diameter was 40.3 mm (range 33.4-46.4 mm, 25th-75th percentile 37.2-42.0 mm, P <.0001 relative to preoperative diameter), and the median length of the resected aortic segment was 52 mm (range 48-76 mm, 25th-75th percentile 50.1-66.4 mm). The median decrease of aortic diameter was 24.9 mm (range 8.9-32.6 mm, 25th-75th percentile 18.2-26.6 mm). The median aortic diameter at the end of the follow-up was 41.0 mm (range 34.6-46.1 mm, 25th-75th percentile 37.0-43.2 mm, P =.6 relative to immediate postoperative diameter).

CONCLUSIONS

Ascending aorta aneurysm resection and primary end-to-end anastomosis provides effective long-term outcome and in selected cases represents a good alternative to aortic interposition grafting. Aortic regurgitation and bicuspid aortic valve do not represent a contraindication for this treatment.

Ascending aortic aneurysms treated by cuneiform resection and end-to-end anastomosis through a ministernotomy

BACKGROUND

Ascending aortic aneurysms without dilatation of the sinuses of Valsalva are generally handled by resection and replacement with a tubular graft or by tailoring aortoplasty. We propose an alternative treatment with a direct anastomosis of the two stumps of the aorta after complete aneurysm resection through an upper J ministernotomy.

PATIENTS AND METHODS

We have applied this procedure to 45 patients. Mean age was 60.2 +/- 12.1 years. Mean aneurysm diameter was 51.0 +/- 8.0 mm. The skin incision averaged 6.5 cm. Two circumferential aortotomies were made: one at the level of the sinotubular junction, the other one just below the innominate artery. The two ends of the aorta were then sutured with a 3-0 Prolene running suture. In 31 cases (61%) aorta-associated valve replacement was carried out.

RESULTS

Hospital mortality was 4.4%. Mean CPB and cross-clamp times were 104 +/- 71 and 68 +/- 25 minutes respectively. Mean blood loss was 380 +/- 300 mL. Median ventilation requirement and intensive care unit stay were 17 and 21 hours. Median hospital stay was 7 days. During the follow-up period (23.7 +/- 12.3 months), 1 patient required reoperation and 2 patients died. Event-free survival is 88.4 +/- 5.7 at 44 months. The surviving patients are routinely checked with ultrasonography and angio computed tomography scan. There was a very low redilatation rate (1 patient, 2.3%) and no incidence of pseudoaneurysm.

CONCLUSIONS

Complete resection of ascending aortic aneurysms with end-to-end anastomosis through an upper ministernotomy represents a feasible, safe, physiologic and cost-effective minimally invasive surgical option in cases of aneurysms with normal or nearly normal sinotubular junctions.

Malformations in adult cases in Egypt

The pathologic patterns as an indication for cardiac surgery in adults with congenital heart diseases and subsequently the surgical techniques have changed greatly in the last decade. The presence of fully equipped pediatric cardiac units helped in early surgical repair in many lesions. However, this service is not always readily available in many parts of the world with the effect of seeing patients with congenital heart diseases latter on during their life needing intervention. Also, older surgical concepts (like considering a trileaflet mitral valve as normal) resulted in the presentation of a subgroup of patients who needed re-intervention latter during adulthood. Surgeons are also faced with the residual effects of putting in different kinds of prosthetic valves or homografts that degenerates or the child overgrows and need to be dealt with latter during the child life. Although the interventional transcatheter techniques helped in the closure of small atrial septal defects, patent ducti, pulmonary arteriovenous fistulas, and dilatation of coarctations, it helped in the emergence of a new pathologic entities like failed or complicated transcatheter closure or dilatations. As a result of competition with the cardiologists, minimal access cardiac surgery emerged. Upper and lower partial ministernotomies and right thoracotomy and fast-track congenital heart operation in some lesions had effectively decreased pain and discomfort, shortened the recovery period, and improved the cosmetic result.

Medial degeneration does not involve uniformly the whole ascending aorta: morphological, biochemical and clinical correlations

OBJECTIVE

To investigate whether and how the severity of medial degeneration (MD) lesions varies along the circumference of the dilated intrapericardial aorta.

METHODS

Two groups of aortic wall specimens, respectively harvested 1cm distal to the non-coronary (NC) sinus (right postero-lateral wall) and to the right coronary sinus (anterior wall) in 22 patients undergoing surgery for dilatation of the intrapericardial aorta associated with aortic valve disease, were separately sent for pathology, morphometry and ultrastructural examination. MD lesions found at histology were classified into three degrees of severity. MD mean degree and morphometric findings in postero-lateral ('NC') and anterior ('coronary') specimens were compared by paired t-test. Correlation between degree of aortic dilatation at echocardiography and severity of MD was assessed separately for each of the two groups of specimens. After the preliminary results of the morphological study, we decided to send the specimens for biochemical investigation of protein electrophoretic patterns. This was performed in the last seven patients of this series.

RESULTS

At histology, MD was found in all cases. A higher mean MD degree was found in the NC group (2.59+/-0.50 versus 1.59+/-0.67 in the coronary group; P<0.001). At morphometry, normal smooth muscle cells in the NC specimens were significantly reduced (P=0.012) and the length (P=0.011) and number (P=0.015) of elastic fibres reduced and increased, respectively. Correlation between aortic ratio and MD degree was significant in the NC specimens (P<0.001), not in the coronary ones (P=0.227). Quantitative differences between coronary and NC proteins from the same patient and between coronary proteins from different patients were found at electrophoresis. However, at this stage of the study, the sample was too small to allow for the identification of proteins involved in those differences.

CONCLUSIONS

MD lesions in dilated intrapericardial aorta are more severe in the right postero-lateral wall area, likely due to haemodynamic stress asymmetry.

Reduction aortoplasty for dilatation of the ascending aorta in patients with bicuspid aortic valve

BACKGROUND

Individuals with bicuspid aortic valve tend to develop a dilatation of the ascending aorta. It is controversial whether the dilated ascending aorta should be replaced with a tube graft or whether the diameter of the aorta should be reduced by reduction aortoplasty. Furthermore, it is unclear whether an external prosthetic support of the reduction aortoplasty is necessary. The aim of this study is to analyze the results of reduction aortoplasty with and without external prosthetic support.

METHODS

Between 1985 and 1999, a total of 115 patients with bicuspid aortic valve and dilatation of the ascending aorta underwent reduction aortoplasty in combination with other types of open-heart procedure at our institution. The diameter of the ascending aorta was measured before and early after surgery and then later between 12 and 144 months (mean 40 months) postoperatively using echocardiography and computed tomography.

RESULTS

The reduction aortoplasty decreased the internal diameter of the aorta from 48.7+/-5.1 mm preoperatively to 36.9+/-3.6 mm early after surgery (p = 0.0001). During follow-up, there was no increase of the aortic diameter either in patients with external prosthetic support or in 97 of 106 patients without external prosthetic support. The diameter increased only in 9 (8.5%) of 106 patients without external aortic support by 4 to 8 mm. In patients with postoperative diameter increase, the aortic diameter after operation had been higher than in patients without a postoperative increase of the aortic diameter (41.4+/-3.1 mm vs 36.6+/-3.4 mm; p < 0.0001).

CONCLUSIONS

Reduction aortoplasty showed good long-term results in patients with bicuspid aortic valve and dilatation of the ascending aorta. Redilation of the aorta occurred only in patients with a suboptimal diameter reduction.

Asymmetric medial degeneration of the intrapericardial aorta in aortic valve disease

BACKGROUND

A geometrical and functional asymmetry in the normal aortic root has been recently demonstrated. Whether the distribution of medial degeneration (MD) within the wall of the dilated ascending aorta in adult patients reflects such asymmetry, still has to be assessed.

METHODS

Nineteen patients with fibrocalcific aortic valve disease and dilatation of the intrapericardial aorta, without clinical signs and familiar history of primary elastic connective tissue disorders, underwent surgery. Biopsies (57 specimens) were taken in each patient from three areas of the ascending aortic wall distal to the three sinuses of Valsalva. MD lesions found at histology in each specimen were classified in three degrees. Comparisons were made between the three sites as to distribution of the three degrees and between one site and the other two as to incidence of the highest degree.

RESULTS

A mild degree of MD was found in 26 specimens (45.6%), moderate in 14 (24.6%), severe in 17 (29.8%). The distribution of the three degrees of MD changes was significantly different between one of the three studied wall areas and the other two (P<0.001): a significantly greater incidence of the highest degree of involvement in the aortic wall distal to the non-coronary sinus than in the wall areas corresponding to the coronary sinuses was found (P<0.001).

CONCLUSIONS

MD lesions in dilated intrapericardial aorta are more severe in the wall area distal to the non-coronary sinus, likely due to haemodynamic stress asymmetry.

Implantation of the Toronto SPV stentless porcine bioprosthesis in dilated ascending aorta

In the presence of severe dilatation of the ascending aorta the implantation of a Toronto SPV stentless bioprosthesis is compromised by the risk of postoperative central regurgitation. A modification of the implantation technique is described that restores the normal shape of the ascending aorta and thereby avoids the risk of dysfunction of the prosthesis.