Ross procedure for ascending aortic replacement

Background. Patients with aortic valve disease and aneurysm or dilatation of the ascending aorta require both aortic valve replacement and treatment of their ascending aortic disease. In children and young adults, the Ross operation is preferred when the aortic valve requires replacement, but the efficacy of extending this operation to include replacement of the ascending aorta or reduction of the dilated aorta has not been tested.

Methods. We reviewed the medical records of 18 (5.9%) patients with aortic valve disease and an ascending aortic aneurysm and 26 (8.5%) patients with dilation of the ascending aorta, subgroups of 307 patients who had a Ross operation between August 1986 and February 1998. We examined operative and midterm results, including recent echocardiographic assessment of autograft valve function and ability of the autograft root and ascending aortic repair or replacement to maintain normal structural integrity.

Results. There was one operative death (2%) related to a perioperative stroke. Forty-two of 43 survivors have normal autograft valve function, with trace to mild autograft valve insufficiency, and one patient has moderate insufficiency at the most recent echocardiographic evaluation. None of the patients has dilatation of the autograft root or of the replaced or reduced ascending aorta.

Conclusions. Early results with extension of the Ross operation to include replacement of an ascending aortic aneurysm or vertical aortoplasty for reduction of a dilated ascending aorta are excellent, with autograft valve function equal to that seen in similar patients without ascending aortic disease.     

The Ascending Aortic Aneurysm: Replacement or Repair?

Between 1971 and 1980, 100 patients underwent operation for ascending aortic aneurysm. Acute dissection was present in 29, chronic dissection in 11; 56 had dilatation only, and 4 had inflammatory disease of the ascending aorta. Four different operative procedures were applied independent of the type of disease: repair and reduction aortoplasty (21), reduction aortoplasty reinforced by nylon net (17), supracoronary graft replacement (42), and composite graft replacement with reimplantation of both coronary ostia (20). Early mortality was 10%, and late mortality was 12% after a mean follow-up of 45 months.Retrospective comparative analysis of the four operative methods led to the following conclusion: reduction aortoplasty supported by a tightly wrapped synthetic net is a suitable method in patients with a normal sinus of Valsalva and without dissection or inflammatory disease. Particular attention needs to be drawn to the proximal anchor stitches to avoid late net displacement. Compared with supracoronary or composite graft replacement, this method carried a lower complication rate, particularly in regard to cerebrovascular accidents and myocardial infarction. For patients with acute and chronic dissection with intact aortic root, supracoronary graft replacement is preferred, whereas in those with annuloaortic ectasia with dilated sinus of Valsalva and in all patients with Marfan's syndrome, composite graft replacement has become the procedure of choice.     

One advice to the decision of graft size for ascending and total arch graft replacement (in a case of differential diameters in ascending aorta and descending aorta)

We carried out the surgery of thoracic aortic aneurysm in fifty-eight patients from June 1994 to February 1999 (including aortic dissection in twenty-six patients). The mean size of grafts were 28.1 mm in ascending graft replacement, 25.8 mm in both ascending and arch graft replacement and 23.8 mm in descending graft replacement. The grafts for ascending aortic aneurysm were significantly larger than those for descending aortic aneurysm. In two of twenty-six patients undergoing both ascending and arch graft replacement, different size of grafts were used for ascending replacement and for arch replacement with satisfactory results in terms of bleeding from the anastomotic sites. Case 1; A 45-year-female with aortitis syndrome and aortic regurgitation due to annuloaorticectasia and thoracic aortic aneurysm underwent simultaneous aortic root replacement with composite graft (25 mm St. Jude Medical valve and 28 mm Hemashield graft) and total arch replacement (30 mm Hemashield graft with two side branches). Case 2; A 64-year-female was diagnosed as chronic type II dissecting aneurysm combined with acute type I aortic dissection. Ascending aorta was replaced with a 26 mm Hemashield graft, and the aortic arch was replaced with a 24 mm Hemashield graft with three side branches.     

Operative management of atherosclerotic aortic aneurysm in a patient with bicuspid aortic valve disease

An adult patient with a congenital bicuspid aortic valve, an aneurysm, and a calcific atherosclerotic plaque of the ascending aorta, underwent an aortic valve replacement, a vertical reduction aortoplasty, an endarterectomy, and a distal external synthetic wrapping.     

Surgical approach to ascending aorta in bicuspid aortic valve

OBJECTIVE: Former studies have pointed out that hemodynamic stress imposed by associated valvular disease is the primary factor in the development of ascending aorta dilatation. At present, intrinsic wall pathology is blamed for dilatation and aneurysm formation in bicuspid aortic valve (BAV). MATERIALS AND METHODS: Aortic valve replacement (AVR) was performed on 78 adult patients with BAV. Patients were divided into two groups. Group I (n = 27) underwent only AVR. Group II (n = 51) underwent AVR and additional ascending aorta procedures such as Shawl-Lapel aortoplasty (n = 12) and tailoring aortoplasty (n = 9). Dacron wrapping was performed after both techniques were done. Ascending aorta replacement was done on 11 patients by using composite graft. Supracoronary graft replacement was performed in 3 patients after AVR. RESULTS: Ascending aorta diameter increment was 1.25 mm/year in normotensive and 2.80 mm/ year in hypertensive patients. Ascending aorta aneurysm (diameter > 55 mm) developed in eight patients in the postoperative period in group I. Ascending aorta dilatation did not develop in group II patients. Mean survival time +/- standard error (SE) was 128 +/- 11 and 99 +/- 4 months and survival possibility was 77.78% and 92.16%. Freedom from reoperation was 65.4% and 95.9% in 8 years in group I and group II, respectively. CONCLUSION: Aortic wrapping with or without aortoplasty has a beneficial effect not only in dilated ascending aorta but also in all nondilated BAV patients with normal-sized aortic diameter. Ascending aorta wrapping in BAV patients preserves the endothelial lining and prevents further dilatation, aneurysm formation, and dissection.     

Combined aortic valve replacement and coronary artery bypass grafting for a calcified ascending aorta

Although a severely calcified ascending aorta is encountered infrequently, it presents formidable problems during cardiac surgery. We describe a case of severe aortic valve stenosis and coronary artery disease combined with a severely calcified ascending aorta. The patient was an 80-year-old man with a calcified ascending aorta. He successfully underwent an aortic valve replacement and a single coronary artery bypass graft (CABG) using a saphenous vein graft with the proximal end connected on a Dacron patch, which was used for aortoplasty of the calcified plate along the aortotomy. These procedures were performed under moderate hypothermia with aortic clamping. This patch aortoplasty can be a useful alternative in cases that require aortotomy and proximal anastomoses of a CABG on a calcified ascending aorta.     

Reoperations on the ascending aorta and aortic root. Early and late results?

AIM: We have retrospectively evaluated our results after aortic root and ascending aorta reoperations to determine risk factors of early death and late mortality. METHODS: From January 1986 to April 2002, 73 patients underwent 'reoperative' procedures on the aortic root and the ascending aorta. The mean age was 56.1+/-13.4 years and males numbered 62 (84.9%). The most frequent indication for reoperation was degenerative aortic aneurysm (49.3%) followed by post-dissection aneurysm (11%). Aortic root replacement with composite valve graft was performed in 47 patients (64.4%) and with aortic homograft in 2 (2.7%). Nineteen patients (26%) underwent ascending aorta replacement with tubular graft, and 4 (5.5%) underwent tailoring aortoplasty of the ascending aorta. RESULTS: The 30-day mortality rate was 16.4% (12 patients). Mortality following elective operations was 8%, and that following urgent or emergency operations was 34.8% (p=0.002). Late survival of hospital survivors at 1, 5 and 10 years was 93.8%, 77.7% and 37%, respectively. In the multivariate Cox regression analysis chronic renal failure (p=0.003) and urgent or emergency operation (p=0.018) were found to be independent predictors of late mortality. CONCLUSIONS: Reoperations on the ascending aorta can be accomplished with acceptable early mortality and satisfactory long-term RESULTS: More radical treatment of the aortic pathology at the initial operation may reduce the need for further reoperations. A careful follow-up is extremely important for detecting complications of the first operation or progression of the aortic pathology before an emergency operation, predictive of poorer early and late outcome, is needed.     

Valve-sparing root reduction plasty in aortic aneurysm: the "Jena" technique

Reconstruction of the aortic valve and replacement of the ascending aorta instead of use of a composite graft is the preferred method in patients, who demonstrate an ascending aneurysm accompanied by aortic root enlargement and aortic valve insufficiency with morphologically intact cusps. Two techniques inaugurated by David and Yacoub have gained widespread acceptance. However, both approaches are technically demanding. We present a simplified alternative technique for aortic valve reconstruction by means of a reduction plasty of the aortic root without the necessity of transection maneuvers.     

Is size-reducing ascending aortoplasty with external reinforcement an option in modern aortic surgery?

OBJECTIVE: Enlargement of the ascending aorta is often combined with valvular, coronary, or other cardiac diseases. Reduction aortoplasty can be an optional therapy; however, indications regarding the diameter of aorta, the history of dilatation (poststenosis, bicuspid aortic valve), or the intraoperative management (wall excision, reduction suture, external reinforcement) are not established. METHODS: In a retrospective study between 1997 and 2005, we investigated 531 patients operated for aneurysm or ectasia of the ascending aorta (diameter: 45-76mm). Of these, in 50 patients, size-reducing ascending aortoplasty was performed. External reinforcement with a non-coated dacron prosthesis was added in order to stabilize the aortic wall. RESULTS: Aortoplasty was associated with aortic valve replacement in 47 cases (35 mechanical vs 12 biological), subvalvular myectomy in 29 cases, and CABG in 13 cases. The procedure was performed with low hospital mortality (2%) and a low postoperative morbidity. Computertomographic and echocardiographic diameters were significantly smaller after reduction (55.8+/-9mm down to 40.51+/-6.2mm (CT), p<0.002; 54.1+/-6.7mm preoperatively down to 38.7+/-7.1mm (echocardiography), p<0.002), with stable performance in long-term follow-up (mean follow-up time: 70 months). CONCLUSIONS: As demonstrated in this study, size reduction of the ascending aorta using aortoplasty with external reinforcement is a safe procedure with excellent long-term results. It is a therapeutic option in modern aortic surgery in patients with poststenotic dilatation of the aorta without impairment of the sinotubular junction of the aortic valve and root.     

Repair of a penetrating ascending aortic ulcer with localized resection and extracellular matrix patch aortoplasty

Penetrating ascending aortic ulcers are rarely encountered, yet they present significant risk of hemorrhage and aortic dissection. Expedient recognition and repair is of vital importance. The current management of penetrating ulcer of the ascending aorta includes replacement of the ascending aorta with a prosthetic graft. We describe our technique of repairing a penetrating ulcer of the ascending aorta with localized ulcer resection and extracellular matrix patch aortoplasty.     

Extended repair of thoracic aorta through left thoracotomy after aortic root replacement

A patent distal false lumen after repair of type A aortic dissection often poses serious late complications. We present a successful repair of dissecting aortic aneurysm through left thoracotomy, extending from the ascending to descending thoracic aorta after composite graft replacement of the aortic root. Although staged operations, including the elephant trunk procedure, are usually chosen for remaining extensive aortic disease after replacement of the aortic root or the ascending aorta, a single-stage repair from the ascending to the descending thoracic aortas through left thoracotomy can be a favorable option to treat a patient with this type of aortic disease.     

Remodeling of aortic root by annular reconstruction and plication of sinuses of Valsalva

We describe a successful new surgical technique for aortic root aneurysm, combined aortic valve repair by annular stabilization and externally reinforced reduction aortoplasty. The aortic valve annulus is defined in size at the level of the basal ring using a prosthetic ring made of the collar of a Gelweave Valsalva vascular graft. Dilated sinuses of Valsalva are plicated from outside the aorta. The aortic root is wrapped with the Valsalva vascular graft, the distal aortic root is sutured to the vascular graft, and the aortic annulus is thus stabilized at the sinotubular junction.     

Aortic insufficiency secondary to aortic root aneurysm or dissection.

Twenty-four patients with aortic regurgitation secondary to aortic root aneurysm (13 patients) or dissection (11 patients) were operated on, utilizing a variety of surgical procedures to cope with the varied pathological findings. These ranged from primary repair of the ascending aorta without any prostheses in patients with acute aortic dissection to replacement of the valve and the entire ascending aorta for aortic root aneurysm. In four patients with Marfan syndrome the right coronary artery was transplanted to the ascending aortic graft, allowing an extension of the graft to the valve anulus and excision of the entire aneurysmal aorta. The immediate and late results have been most encouraging.     

Aortic root aneurysm after off-pump reduction aortoplasty

We present a patient with aortic root aneurysm and severe aortic regurgitation who had a previous off-pump reduction ascending aortoplasty and external wrapping with concomitant coronary bypass grafting. Preliminary aortic dissection and erosion of the aortic intima were detected during the operation. This complication warrants the re-evaluation of the indications for reduction ascending aortoplasty and emphasizes the necessity for close follow-up.     

Aortic root replacement after operation for the ascending aorta and/or aortic valve

We reviewed ten cases who underwent aortic root replacement after operation for the ascending aorta and/or aortic valve. As initial operation, aortic valve replacement (AVR) was performed in five patients, replacement of the ascending aorta in two, original Bentall operation in two, and entry closure and suspension of the aortic valve in one. At reoperation, three patients were diagnosed as aneurysm of the ascending aorta, two were annulo-aortic ectasia, and one was acute aortic dissection, chronic dissecting aneusym, pseudoaneurysm of the ascending aorta, prosthetic valve endocarditis, and massive aortic regurgitation. Aortic root replacement was performed using mechanical valved composite graft in all cases. One patient who underwent repeat aortic root replacement for prosthetic valve endocarditis was died of septemia and ventricular fibrillation. Five patients had nine complications (two low output syndrome, respiratory failure and cerebral infarction, one gastrointestinal bleeding, septemia and ventricular fibrillation). In conclusion, aortic root replacement after operation for the ascending aorta and/or aortic valve was performed with acceptable morbidity and mortality.     

Modified reduction aortoplasty with external reinforcement of the ascending aortic aneurysm caused by giant cell arteritis treated as polymyalgia rheumatica

A 74-year-old Japanese woman was referred to our hospital for surgical repair of an ascending aortic aneurysm and severe aortic valve regurgitation. She had received low dose steroid treatment for 6 years due to a diagnosis of the polymyalgia rheumatica (PMR), and no signs of inflammation were detected serologically. Modified reduction aortoplasty with external prosthetic support of the ascending aorta was performed following uneventful aortic valve replacement under cardiopulmonary bypass. The macroscopic view of the ascending aortic wall showed the diffuse spotty medial defects. The pathological interpretation of the aneurysmal wall was giant cell arteritis (GCA). Because PMR is intimately associated with GCA, physicians should be aware of the development of thoracic aortic aneurysm even in the course of PMR. Reduction aortoplasty is simple and may not be precluded from the treatment option for the aortic dilatation associated with giant cell arteritis.     

Emergent David-V operation for a ruptured aortic root aneurysm in a 9-year-old child.

Ruptured aortic root aneurysm is very rare in children less than 10 years of age. Isolated dilatation of the ascending aorta and/or aortic root in a child is mostly associated with Marfan's syndrome, and the standard surgical treatment is aortic root replacement with a composite valve graft or homograft. We report here a successful emergent T. David-V operation using two grafts of different sizes for a ruptured aortic root aneurysm in a 9-year-old child with Marfan's syndrome.     

Ascending aortic aneurysms with associated aortic regurgitation

A safe method for replacement of the entire aortic valve, root, and ascending aorta for aortic insufficiency associated with an ascending aortic aneurysm is supported. This method utilizes a composite synthetic graft and valve with direct annular suture and implantation of the coronary arteries in the graft. The advantages of the technique include a shortened operation and freedom from postoperative hemorrhage, paraprosthetic leakage, and recurrent aneurysm formation.     

Repair of tetralogy of Fallot with ascending and proximal aortic arch aneurysm: case report

Abnormalities in the aorta of patients with tetralogy of Fallot (TOF) can lead to aortic dilatation and aortic regurgitation. We report a six-year-old male with TOF with dysplastic aortic valve, severe aortic regurgitation, and aortic aneurysm involving the aortic root, ascending aorta, and the proximal aortic arch, who underwent TOF repair with aortic replacement up to the proximal aortic arch with a composite graft without circulatory arrest.     

Total aortic arch graft replacement for recurrent aortic aneurysm

We successfully performed a total aortic arch replacement for a recurrent aortic aneurysm following repair of an aortic dissection. A 59-year-old man underwent a patch aortoplasty through median sternotomy for Stanford type B aortic dissection in other hospital. Three years and 6 months later an aneurysm developed. Computed tomography and magnetic resonance imaging angiography demonstrated an enlargement of the aneurysm, resulting in a diagnosis of recurrent distal aortic arch aneurysm. A graft replacement of the total aortic arch with the aid of selective cerebral perfusion was performed through a median resternotomy and left lateral thoracotomy. Additional left lateral thoracotomy offered a sufficiently optimal operating field for distal anastomosis. However, care must be taken not to overlook the bleeding from intercostal arteries. Since aortoplasty may lead to subsequent dilation and aneurysmal formation, initial replacement of the segment of the aorta is recommended, and careful long-term follow-up of the patient is important.