Replacement of the ascending aorta and aortic valve with a valved stentless composite graft

Surgical Options for Aortic Root Replacement in Destructive Endocarditis

Objective

To analyze patients’ preoperative characteristics, surgical data, postoperative courses, and short- and long-term outcomes after implantation of different full-root prostheses for destructive aortic valve endocarditis.

Methods

Between 1999 and 2018, 80 patients underwent aortic root replacement due to infective endocarditis in our institution. We analyzed the abovementioned data with standard statistical methods.

Results

The Freestyle stentless porcine prostheses were implanted in 53 (66.25%) patients, biological valve conduits in 13 (16.25%), aortic root homografts in nine (11.25%), and mechanical valve conduits in five (6.25%). There were no significant preoperative differences between the groups. The incidence of postoperative complications and intensive care unit length of stay did not differ significantly between the groups. The 30-day mortality rate was low among Freestyle patients (n=8, 15.1%) and high in the mechanical conduit cohort (n=3, 60%), though with borderline statistical significance (P=0.055). The best mean survival rates were observed after homograft (13.7 years) and stentless prosthesis (8.1 years) implantation, followed by biological (2.8 years) and mechanical (1.4 years) conduits (P=0.014). The incidence of reoperations was low in the mechanical conduit group (0) and stentless bioroot group (n=1, 1.9%), but two (15.4%) patients with biological conduits and three (33.3%) patients with homografts required reoperations in the investigated follow-up period (P=0.005).

Conclusion

In patients with the destructive form of aortic valve endocarditis, homografts and stentless porcine xenografts offer better survival rates than stented valve conduits; however, the reoperation rate among patients who received homograft valves is high.

Preassembled stentless valved-conduit for the replacement of the ascending aorta and aortic root

Here we report the early clinical results of a new preassembled stentless valved-conduit incorporating artificial sinuses of Valsalva (BioValsalva). This new composite conduit incorporates a stentless porcine aortic valve (Elan, Vascutek Terumo, UK) suspended within a triple-layered vascular conduit (Triplex, Vascutek Terumo, UK) constructed with sinuses of Valsalva. Between December 2006 and January 2008, 17 patients with the mean age of 65 years underwent aortic valve, root and ascending aorta replacement with the BioValsalva valved-conduit. There was no perioperative mortality. There were no myocardial infarctions, cardiac failure or cerebrovascular events. Mean cardiopulmonary bypass time was 156+/-56 min and ischemic time was 112+/-33 min. Eight patients required deep hypothermic circulatory arrest for additional distal ascending aorta replacement. Mean mediastinal drainage was 499+/-262 ml. Postoperative transthoracic echocardiography and CT-scans of the aorta in all patients before discharge demonstrated well-functioning prosthetic aortic valves with small residual mean gradients, no regurgitation, and the presence of sinuses of Valsalva. In conclusion, the novel prefabricated, composite stentless valved-conduit BioValsalva possesses excellent hemodynamic performance and can be implanted with low morbidity. In addition, the conduit material has good hemostatic properties which reduced bleeding, and is easy to implant with a variety of surgical techniques.

Modified ross procedure for dysplasic ascending aorta

We present a modification of the Ross procedure, to help reduce the risk of late pulmonary artery wall dilatation. The strength of this modified technique is its composite graft construction, consisting of a pulmonary valve autograft inserted in a Dacron tube. This composite graft can be used either as a free graft or a mini-root implant.

Composite stentless valve with graft extension for combined replacement of the aortic valve, root and ascending aorta

OBJECTIVE

The composite mechanical valve conduit has been most commonly used for patients who require combined aortic valve, root, and ascending aorta replacement, but is limited, especially in the elderly, because of the need for long-term anticoagulation. We report the first consecutive series of patients in whom a composite stentless valve with graft extension, which does not require long-term anticoagulation, was performed.

METHODS

Between April 1998 and July 2000, eight patients with severe aortic root and ascending aortic pathology underwent a combined aortic valve, root, and ascending aorta replacement with a Freestyle stentless porcine valve with a Hemashield graft extension. Mean age was 74 (range 56--82), three were males. Concomitant procedures included coronary artery bypass graft (CABG) alone (n=2), mitral valve replacement with atrial septal defect repair (n=1) and CABG with septal myomectomy (n=1).

RESULTS

Operative mortality was zero. Median aortic cross-clamp and cardiopulmonary bypass times were 150 and 203 min, respectively. Two patients returned to the operating room for bleeding. Median blood transfusions and hospital length of stay were 4 units and 11 days, respectively.

CONCLUSIONS

The composite stentless valve with graft extension is a reasonable alternative to a mechanical valve conduit for patients who require a combined aortic valve, root, and ascending aorta replacement, in whom anticoagulation is not desirable or contraindicated.

Acute Type A Aortic Dissection. Influence of Early Management on Results

One hundred and six patients were operated upon for acute type A aortic dissection in 7 years between February 1992 and May 1999. There were 102 males and 4 females, aged 18 to 83 years with a mean of 59 ± 14 years. All patients underwent surgery within 14 hours of diagnosis. The ascending aorta was replaced with a Dacron graft in 103 patients; in the other 3 cases, the repair extended to the aortic arch. The aortic valve was preserved by resuspension in all except 4 patients, 3 of whom had Marfan's syndrome. There were 9 (8.5%) deaths, all due to respiratory and multiorgan failure. Nine patients (8.5%) needed hemodialysis; only one of these required permanent dialysis. Ten patients (9.4%) had transient neurological disorders, 2 others (1.9%) suffered permanent hemiplegia. Three patients (2.8%) underwent reoperation for bleeding. Tracheostomy for prolonged respiratory assistance was required in 6 patients (5.7%), of whom 1 died from respiratory failure. Early surgical intervention could be performed with low morbidity and mortality.

Bentall procedure with a stentless valve and a new aortic root prosthesis

We describe a technique to replace the aortic root by means of a stentless valve and a new aortic root Dacron graft (Gelweave Valsalva, Sulzer Vascutek, Renfrewshire, Scotland) that allows an anatomical reconstruction of the sinuses of Valsalva.

Replacement of the aortic valve and ascending aorta with a valved stentless composite graft: technical considerations and early clinical results

BACKGROUND

Replacement of the aortic valve and the ascending aorta with a conduit consisting of a mechanical valve and a Dacron tube has become a fairly common procedure. Commercially available conduits employing xenografts are rarely used for the same purpose, because if a reoperation becomes necessary due to degeneration of the valve prosthesis, usually the entire conduit must be replaced. A composite graft with a stentless valve, such as we describe in this article, avoids this problem, because in case of reoperation only the valve cusps need to be resected and the tube graft may be left in place.

METHODS

Surgical technique of replacement of the aortic valve and the ascending aorta with a stentless composite graft and early results of the procedure are presented.

RESULTS

Hemodynamics of the graft soon after surgery were excellent, with an average systolic gradient of 8 mm Hg and no regurgitation across the valve. There were two reoperations for bleeding in the early postoperative period.

CONCLUSIONS

The stentless composite graft we describe provides excellent hemodynamics, has no need for anticoagulation, and is expected to offer a benefit in case of reoperation.