Redo composite valve graft replacement

How to replace a bioprosthetic aortic valve within the Bentall graft

The Bentall procedure using a bioprosthesis-containing conduit carries the risk of structural valve deterioration within the patients' lifetime. Failed aortic bioprosthesis replacement requires a redo aortic root replacement that is associated with significant morbidity and mortality. We describe an original "neo-annulus" technique of aortic valve replacement (AVR) within the Bentall graft. This technique involves an incision of the Bentall valve-containing aortic root conduit, cutting the stainless wireform stent and the inner plastic stent of the bioprosthetic valve at the tips of commissure posts with a wire cutter, removal of semilunar fragments of the remaining stainless wire, division of the fabric of the valve between the valve sewing cuff and the Elgiloy alloy base ring leaving the sewing cuff of the excised aortic valve bioprosthesis attached to the Bentall conduit as a "neo-annulus". Subsequently, this neo-annulus is stitched with interrupted 2/0 Ticrone sutures and another prosthetic aortic valve implanted inside of the old Bentall conduit. The graft incision is closed with a continuous 4/0 polypropylene suture.

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The "Button Inside" Technique for the Aortic Root Replacement: A Modified Button Technique

Modified button technique for reattachment of coronary arteries in the aortic root replacement is reported. Anastomosis of the coronary buttons is performed from the inside of the composite valve graft previously including the coronary buttons in the composite valve graft. Reduced tension is present between coronary arteries and the composite valve graft once the heart is beating and the systemic pressure is increasing. In this way coronary buttons are reinforced directly by the composite aortic wall graft prosthesis. The coronary ostia are perfused with lower tension at the site of the coronary anastomoses. No bleeding from the suture line of the coronary buttons occurs using this new surgical approach.

Aortic root replacement after previous surgical intervention on the aortic valve, aortic root, or ascending aorta

BACKGROUND

Aortic root replacement after a previous operation on the aortic valve, aortic root, or ascending aorta remains a major challenge.

METHODS

Records of 56 consecutive patients (44 men; mean age, 56.4 +/- 13.6 years) undergoing reoperative aortic root replacement between June 1994 and June 2005 were reviewed retrospectively.

RESULTS

Reoperation was performed 9.4 +/- 6.7 years after the last cardiac operation. Indications for reoperation were true aneurysm (n = 14 [25%]), false aneurysm (n = 10 [18%]), dissection or redissection (n = 9 [16%]), structural or nonstructural valve dysfunction (n = 10 [18%]), prosthetic valve-graft infection (n = 12 [21%]), and miscellaneous (n = 1 [2%]). Procedures performed were aortic root replacement (n = 47 [84%]), aortic root replacement plus mitral valve procedure (n = 5 [9%]), and aortic root replacement plus arch replacement (n = 4 [7%]). In 14 (25%) patients coronary artery bypass grafting had to be performed unexpectedly during the same procedure or immediately after the procedure to re-establish coronary perfusion. Hospital mortality reached 17.9% (n = 10). Multivariate logistic regression analysis revealed the need for unplanned perioperative coronary artery bypass grafting as the sole independent risk factor for hospital death (P = .005). Actuarial survival was 83.8% +/- 4.9% at 1 month, 73.0% +/- 6.3% at 1 year, and 65.7% +/- 9.0% at 5 years after the operation. One patient had recurrence of endocarditis 6.7 months after the operation and required repeated homograft aortic root replacement.

CONCLUSION

Reoperative aortic root replacement remains associated with a high postoperative mortality. The need to perform unplanned coronary artery bypass grafting during reoperative aortic root replacement is a major risk factor for hospital death. The optimal technique for coronary reconstruction in this setting remains to be debated.

Reoperation for ascending aortic aneurysm, coronary ostial aneurysm and patent Cabrol trick after bentall operation for aortitis syndrome

A 38-year-old woman who had undergone an original Bentall operation in December 1995 for annuloaortic ectasia associated with ulcerative colitis required reoperation for ascending aortic aneurysm, coronary ostial aneurysm, and patent Cabrol trick. The initial Bentall operation included aortic root replacement using a valved conduit and reconstruction of the coronary arteries. Both coronary ostia were directly anastomosed to the composite valved graft, which was wrapped with the dilated aortic wall, and a Cabrol trick was added at the same time. She underwent reoperation for a 60 mm ascending aortic aneurysm which had been used for wrapping at the initial operation. The findings at reoperation were a patent Cabrol trick, leakage from the distal anastomosis, aneurysm of both coronary ostia, and paravalvular leakage. The repairs included graft replacement, leaving the valvular prosthesis, reconstruction of both coronary arteries by the Piehler method and Carrel patch technique, repair of the paravalvular leakage, and closure of the Cabrol trick. Her postoperative course was uneventful, and the serum concentration of C-reactive protein remained within normal limits. Strict follow-up care is required to avoid further anastomotic dehiscence.