Concomitant replacement of the aortic root and aortic arch with or without secondary thoracoabdominal aorta replacement

Objectives: Extensive aortic replacement, such as concomitant aortic root and arch replacement, thoracoabdominal aortic repair, and complete thoracic aorta replacement, remains controversial. We studied surgical morbidity and mortality in patients undergoing concomitant aortic root and arch replacement, and those undergoing secondary replacement of the thoracoabdominal aorta after this preceding procedure.Subjects and Methods: Between January, 1987 and March 1999, 21 patients (mean age: 52 years) underwent concomitant aortic root and arch replacement involving 3 surgical procedures—aortic root replacement with composite graft and arch (n=12), aortic root replacement with valve sparing and arch (n=4), or aortic root replacement with composite graft and arch and elephant trunk (n=5).Results: Overall hospital mortality was 4.8%. Six patients (mean age: 42 years) underwent secondary thoracoabdominal aorta replacement after the concomitant root and arch procedure. The mean time until secondary surgery was 9.5 months. There was 1 hospital death.Conclusion: Concomitant replacement of the aortic root and arch, or secondary replacement of the thoracoabdominal aorta after concomitant root and arch replacement can be conducted with low surgical morbidity and mortality.     

Extensive aortic reconstruction for aortic aneurysms in Marfan syndrome

Background. Marfan syndrome patients frequently develop aneurysms or dissections involving multiple segments of the aorta, and occasionally require staged replacement of the entire aorta. This study reviews the surgical outcome of patients with Marfan syndrome who underwent extensive aortic reconstruction. Extensive reconstruction is defined as reconstruction of more than two segments of the ascending, arch, descending thoracic, or abdominal aorta.

Methods. From March 1973 to December 1997, 101 patients with Marfan syndrome underwent aortic operation. Twenty-six patients (25.7%) had extensive aortic reconstruction. All 26 patients suffered from aortic dissection: 13 patients had Stanford type A and 13 had type B dissection. Twenty-three patients (88.4%) had annuloaortic ectasia and aortic regurgitation. Surgical procedures included composite valve graft replacement (n = 23, 88.4%), aortic arch reconstruction (n = 15, 57.7%), graft replacement of the descending thoracic aorta (n = 6, 23.1%), and graft replacement of the thoracoabdominal aorta (n = 16, 61.5%). Five patients (19.2%) had total thoracoabdominal aortic replacement, and three patients (11.5%) had replacement of the entire aorta. Twenty-one patients (80.8%) required multiple operations.

Results. Follow-up was complete in all patients. The 30-day survival rate was 88.5%. None of the survivors had paraplegia or paraparesis. The overall long-term survival rate was 88.5 ± 6% at 1 year, and 81.7 ± 9% at 9 years.

Conclusions. Aortic surgery prolongs survival in patients with Marfan syndrome, and currently there is a relatively low associated morbidity and mortality even for aggressive surgical treatment.     

Twenty-four year experience with reoperations after ascending aortic or aortic root replacement

Objective: A retrospective analysis of early and late outcome for late (>4 weeks) reoperations on the ascending aorta or aortic root. Materials and methods: During a 24-year interval, starting in 1974, 834 patients underwent replacement of the ascending aorta (39.2%) or aortic root (60.8%). During the same period, 56 patients with a mean age of 51.1±14.4 years underwent reoperation after ascending aortic or aortic root replacement. Predominant indications for reoperation were false aneurysm in 25 (44.6%) patients and true aneurysm in 18 (32.1%) patients. Most frequent surgical procedures were redo aortic root replacement in 30 (53.6%) patients and closure of a false aneurysm in 14 (25.0%) patients. Median interval between the operations was 51 months. Eighteen (32.2%) patients underwent concomitant partial or total aortic arch replacement. Results: Hospital mortality was 5.4% (n=3; 70% CL: 2.4–8.4%). Cause of death was low cardiac output in two patients and rupture of the aorta at the distal suture line in one patient. Univariate analysis identified two or more previous operations (P=0.038) and the interval between initial operation and reoperation for complication of less than 8 months (P=0.005) as risk factors for hospital death. Multivariate analysis indicated operation for active endocarditis or vascular graft infection as an independent risk factor for hospital death (P=0.038, odds 14.6). Follow-up was complete, median 3.1 years. Nine (16.9%; 70% CL: 11.7–22.1%) patients died during that period. Estimated survival at 1, 5 and 10 years was 91.2, 84.0 and 76.4%. One patient underwent another reoperation. Estimated event-free survival at 1, 5 and 10 year is 84.3, 72.2 and 65.6%. Conclusion: False aneurysm formation and progression of aneurysmatic disease are the predominant causes for late reoperations after aortic root or ascending aortic replacement. Reoperations can be performed with low hospital mortality and good late results.     

Long-term effectiveness of operations for ascending aortic dissections

OBJECTIVE: To evaluate long-term effectiveness of a strategy for managing the aortic root and distal aorta according to the pathology in ascending aortic dissection. METHODS: From 1978 to 1995, 208 patients underwent operations for acute (n = 135) and chronic (n = 73) ascending aortic dissection. Surgical strategies included valve resuspension with supracoronary aortic root repair and ascending aortic graft for normal sinuses and valve (n = 135), composite valve and ascending aortic graft for abnormal sinuses and valve (n = 47), and valve replacement and supracoronary ascending aortic graft for normal sinuses and abnormal valve (n = 26). Resection extended into the arch only if the intimal tear originated in or extended to the aortic arch (n = 31). RESULTS: Hospital mortality was 14%. Cardiogenic shock (P =.002) and concomitant coronary artery bypass grafting (P =.001) were associated with increased risk; use of circulatory arrest (P =.0003) decreased risk. Survival was 87%, 68%, and 52% at 30 days, 5 years, and 10 years, respectively. Advanced age, earlier date of operation, composite graft, and arch resection were associated with decreased survival; residual distal dissected aorta was not. Reoperation was required for 5 proximal and 8 distal problems. CONCLUSIONS: In both acute and chronic ascending aortic dissections, (1) circulatory arrest is associated with low early mortality; (2) with normal sinuses and valve, supracoronary repair of the dissected aortic root and valve resuspension is effective long term; and (3) residual distal dissected aorta does not decrease late survival and has a low risk of aneurysmal change and reoperation for at least 10 years.     

一期次全或全主动脉替换术的中期随访结果

目的 总结一期全主动脉替换术治疗全程主动脉瘤的中期随访结果.方法 2004年2月至2008年7月22例全程主动脉瘤的患者接受一期次全(7例)或全主动脉替换术(15例).男性17例,女性5例,年龄19～47岁.慢性A型夹层动脉瘤15例,主动脉根部瘤合并慢性B型夹层动脉瘤5例,主动脉根部瘤合并弓部和胸腹主动脉瘤1例,慢性B型合并急性A型夹层动脉瘤1例.手术均在全身麻醉深低温停循环顺行性脑灌注下进行.采用胸骨正中切口+左后外胸腹联合切口.采用分段阻断法用人工血管置换全部病变主动脉.结果 无手术死亡病例.术后早期死亡1例,死于多器官功能衰竭.术后发生脑梗死2例,二次开胸止血7例.存活21例,随访3～56个月,平均(35.0±16.9)个月,情况良好,无晚期死亡.1例David+全主动脉替换术患者术后1年因主动脉瓣反流行主动脉瓣置换术.此外无再手术病例.结论 一期次全或全主动脉替换术是治疗全程主动脉瘤的有效方法.手术结果满意,术后中期随访效果良好.     

Complete aortic root replacement in patients with small aortic annulus

BACKGROUND: We evaluated the effectiveness of our surgical method using a modified self-assembled valved composite graft in patients with a narrow aortic annulus. METHODS: Between August 2000 and May 2001, 10 consecutive patients with a narrow aortic annulus underwent replacement of the aortic valve and the ascending aorta using a valved composite graft with mechanical valve prosthesis. The indication for surgery was aneurysm of the ascending aorta (8 patients) and aortic dissection (2 patients). To avoid valve-patient mismatch, a modified self-assembled valved composite graft was used. RESULTS: There was no hospital mortality. Echocardiographic evaluation before discharge showed excellent hemodynamics with a mean transvalvular gradient of 10.7 mm Hg (standard deviation +/- 2.8 mm Hg). CONCLUSIONS: The described valved composite graft offers very good hemodynamic performance and is a simple and effective device to avoid valve-patient mismatch in patients with a small aortic annulus who need aortic root replacement.     

主动脉夹层的细化分型及其应用

目的探讨在Stanford分型的基础上根据主动脉夹层的部位和病变程度再进行细化分型,对指导临床选择手术时机、确定治疗方案和手术方式,以及判断预后的价值。方法1994年1月至2004年12月我院治疗主动脉夹层708例。其中Stanford A型夹层477例：（1）根据主动脉根部病变程度分为3型。A1型（主动脉窦部正常型）212例,行保留主动脉窦部的主动脉替换;A2型（主动脉窦部轻度受累型）72例,行主动脉窦部成形63例、David手术9例;A3型（主动脉窦部重度受累型）193例,行主动脉根部替换术（Bentall手术）。（2）根据主动脉弓部病变分为2型。C型（复杂型）78例,行主动脉弓部替换＋象鼻术;S型（单纯型）399例,行部分主动脉弓部替换。Stanford B型夹层231例,（1）根据主动脉扩张的范围分为3型：B1型：降主动脉无扩张或仅有近端扩张,147例,行腔内带膜支架主动脉腔内修复术103例（B1S型）、部分胸降主动脉替换术32例、部分胸降主动脉替换术＋远端支架象鼻术12例;B2型：全部胸降主动脉扩张,53例,行部分胸降主动脉替换术＋主动脉成形32例、全部胸降主动脉替换术21例;B3型：全部胸降主动脉及腹主动脉扩张,31例行胸腹主动脉替换术。（2）根据左锁骨下动脉和远端主动脉弓部是否受夹层累及分为2型：C型（复杂型）：夹层累及左锁骨下动脉或远端的主动脉弓部,44例,在深低温停循环下手术治疗;S型（单纯型）：远端主动脉弓部和左锁骨下动脉未受夹层累及,187例,介入治疗103例、手术治疗84例（常温阻断下手术60例,股动脉-股静脉转流下手术24例）。结果Stanford A型夹层住院病死率为4．6％（22／477）,并发症发生率为14．5％（69／477）。Stanford B型夹层：介入治疗组病死率1．9％（2／103）,并发症发生率为2．9％（3／103）,轻度内漏发生率为9．7％（10／103）;手术治疗组住院病死率为3．1％（4／128）,并发症发生率为18．8％（24／128）。结论细化主动脉夹层的分型对于术前判断手术时机、制定手术方案和初步判断预后,具有重要的指导作用。     

Improved outcome with composite graft versus homograft root replacement for children with aortic root aneurysms.

OBJECTIVE: Review of surgical repair of aortic root aneurysms using composite graft or homograft in children. METHODS: A consecutive series of 34 children (mean age 10.8+/-5.4 years) who underwent elective aortic root replacement using composite graft or homograft from 1987 to 2003 (mean follow-up 5.7+/-3.7 years). RESULTS: Preoperatively, the aortic annulus and aortic root average z-scores were 4.1+/-2.2 and 9.4+/-4.7, respectively. Composite graft root replacement was performed in 22 patients, and cryopreserved aortic homograft root replacement in 12 patients. There was one perioperative death in the homograft group due to sudden cardiovascular collapse. There was one late death in the composite graft group due to acute aortic dissection, and two late deaths in the homograft root replacement group, one at 7 months postoperatively due to coronary artery thrombosis and one due to severe chronic myocardial dysfunction 5 years postoperatively. One patient who initially had a homograft died due to mechanical valve thrombosis following reoperative composite graft replacement. Five patients had reoperations at a median of 7.1 years after initial surgery. One patient in the composite graft group underwent arch replacement. There were no graft related reoperations after composite graft root replacement, but 4 patients in the homograft group had reoperative composite graft replacement. Predictors of reoperation included age at surgery, lower weight, and longer ICU time (P<0.05). CONCLUSIONS: In children with aortic root aneurysms, reoperation is more common after homograft root replacement than composite graft replacement. Composite graft root replacement provides more stable repair of the aortic root.     

Aortic root replacement versus aortic valve replacement: a case-match study

BACKGROUND: There is increasing evidence that patients with aortic valve disease and dilatation of the ascending aorta are at risk for later dissection or rupture of the aortic wall when the dilated ascending aorta is not replaced or reinforced at the time of aortic valve replacement. In order to find out whether the more complex surgical procedure of aortic root replacement carries a higher early or late postoperative risk than isolated aortic valve replacement, we conducted a matched-pair study with patients of both groups. METHODS: Between June 1993 and August 1998, 100 consecutive patients with aortic valve disease and ectasia/aneurysm of the ascending aorta underwent replacement of the aortic valve and the ascending aorta with a CarboSeal composite graft (CarboSeal; Sulzer Carbo-Medics Inc, Austin, TX). Identical bileaflet valve prostheses (CarboMedics; Sulzer CarboMedics Inc, Austin, TX) were implanted during the same time period in 928 patients for aortic valve disease. On the basis of various preoperative clinical variables 100 patients with aortic valve replacement were matched to the 100 patients with replacement of the aortic root. The duration of follow-up for both groups was similar with 37 + 17 months (range, 9 to 70) for the CarboSeal group and 38 + 14 months (range, 13 to 65) for the CarboMedics group. Survival and morbidity were calculated by Kaplan-Meier analysis and risk-adjusted mortality was evaluated by multivariate analysis in a Cox regression model. RESULTS: The early postoperative mortality of 1% in the CarboSeal group and 4% in the CarboMedics group was insignificantly different. Although the overall survival rate at 5 years was lower (60.7% vs 86.3%; p = 0.13) in the CarboSeal group, the freedom from cardiac mortality and valve-related morbidity was similar in the two groups. CONCLUSIONS: Replacement of the ascending aorta and aortic valve can be performed with similar operative risk, valve-related morbidity, and late cardiac mortality as isolated aortic valve replacement.     

Five-year experience in aortic root replacement with the flanged composite graft

BACKGROUND: Replacement of the aortic root with a composite graft containing a prosthetic mechanic valve is the preferred surgical procedure for tailoring the aortic root. The aim of this study is to determine the 5-year experience with the composite root replacement using our new modification of the Bentall technique. METHODS: Between January 1996 and June 2001, 96 patients underwent aortic root replacement using a flanged composite graft. Eighty patients (83.3%) were male, and 16 patients (16.7%) were female with a mean age of 48.7 +/- 14.4 years. Indications for operation were a true or false aneurysm (65.6%), severe calcified aortic valve stenosis (4.2%) or severe aortic insufficiency (2.1%) with dilated ascending aorta, acute dissection (2.1%), or combination of indications (26%). Thirty-one patients (32.3%) received a concomitant cardiac procedure. Mean aortic cross-clamp time was 89.5 +/- 28.6 minutes, and mean cardiopulmonary bypass time was 146.2 +/- 45.6 minutes. Total follow-up was 253.9 patient-years. RESULTS: Operative mortality was 8.3% (8 patients). The causes of hospital mortality were severe bleeding (3 patients), low cardiac output syndrome (2), acute respiratory distress syndrome (2) and cerebrovascular event (1). No patient died of flange-related complications. Univariate predictors of early mortality were low cardiac output syndrome (p < 0.001), neurologic complication (p = 0.03), and renal complication (p = 0.03). Multivariate analysis demonstrated only low cardiac output syndrome to be significant (p = 0.001) predictor for early mortality. There were five (5.7%) late deaths. Actuarial survival was 82.65% +/- 4.8% at 5 years (1.95% patient-year). Cox proportional hazards regression analysis demonstrated only low cardiac output syndrome to be significant (p = 0.032) predictor for late mortality. Actuarial freedom from prosthetic- and technique-related mortality was 100% at 5 years. CONCLUSIONS: The flanged composite graft offers excellent long-term results, with very low prevalence of prosthetic-related complications. The new created sinuses and the flange are especially helpful to continue physiologic function of the aortic root.     

A 23-year experience with composite valve graft replacement of the aortic root.

BACKGROUND: This is a retrospective study of early and long-term results of composite valve graft replacement of the aortic root. METHODS AND RESULTS: Between July 1974 and July 1997, 244 patients underwent aortic root replacement with a composite valve graft. Mean age was 54+/-15 years. The inclusion technique was used in 178 patients (73.0%), the open technique in 65 (26.5%), and the Cabrol II technique in 1 patient (0.5%). Hospital mortality was 7.8% (70% confidence limit, 6.1% to 9.5%). Independent determinants of hospital mortality were preoperative creatinine level more than 150 micromol/L (p = 0.04), prolonged cardiopulmonary bypass time (p = 0.006), intraoperative technical problems (p = 0.048), and year of operation (p = 0.015). Follow-up was 99.6% complete, median 96 months (range, 2 to 256 months). Fifty-seven patients (25.3%; 70% confidence limit, 22.4% to 28.2%) died during follow-up. Cumulative survival at 5, 10, and 20 years was 76%, 62%, and 33%. Independent risk factors for late death were postoperative complications (p = 0.027), technique for coronary reattachment (p = 0.028), and concomitant aortic arch operation (p = 0.01). Twenty patients (8.8%; 70% confidence limit, 7.0% to 10.6%) underwent reoperation on the aortic root. Estimated freedom from reoperation for pseudoaneurysms at 3 years was 96% in the inclusion group and 94% in the open group (p = 0.236). CONCLUSIONS: Aortic root replacement with a composite valve graft can be performed with low hospital mortality and morbidity. Pseudoaneurysms did occur in the inclusion group, but also in the open group.     

Composite valve-graft replacement of aortic root using separate Dacron tube for coronary artery reattachment

Traditional techniques of aortic root replacement have consisted of separate valve and graft replacement or use of a composite valve graft. These methods have been associated with problems including hemostasis, suture line disruption, and pseudoaneurysm development. They have had limited application in patients without sinus segment enlargement and acute aortic dissection. Between May 21, 1986, and September 7, 1988, 90 patients (73 male and 17 female) underwent replacement of the aortic valve and ascending aorta using a composite valve graft with reattachment of the coronary ostia using a separate, smaller (10 mm) Dacron tube graft. Aortic root replacement was done alone in 41 patients (46%), in association with a concomitant cardiac procedure in 26 patients (29%), and in 23 patients (26%) undergoing cardiac reoperation with and without a concomitant procedure. Aortic arch replacement was required in 25 patients (28%). Profound hypothermia and circulatory arrest were employed in 29 patients (32%). Early survival was 91% (82/90), and there were 4 late deaths. The procedure was found to be hemostatic (only 4 patients [4%] required reexploration for hemorrhage) and durable (no reoperation for pseudoaneurysm formation was necessary).     

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.     

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.     

Concomitant graft replacement of the total aortic root and the transverse aortic arch for type A aortic dissection associated with annuloaortic ectasia]

Between April 1988 and February 1992, eight patients with type A aortic dissection associated with annuloaortic ectasia (AAE) underwent the concomitant graft replacement of the total aortic root and the transverse aortic arch at our institution. The acuity of the aortic dissection was acute stage in 3 patients and chronic stage in 5 including 3 cases of re-do operation. All operations were performed with an aid of extracorporeal circulation, blood cardioplegia, selective cerebral perfusion and open distal anastomosis. The operative techniques employed in this series consisted of total aortic root replacement using a composite graft (Bentall, Cabrol or Piehler's technique), and total arch replacement using en bloc arch reconstruction or three vessels graft replacement. One patients underwent re-do operation for coronary anastomotic false aneurysm following Bentall operation and aneurysmal dilatation of the false lumen at the aortic arch, and died of LOS because of the prolonged myocardial ischemia. Other seven patients survived the operation, and lead the normal life at the present time. The present data suggests that type A aortic dissection associated with AAE involving aortic arch could be treated by concomitant graft replacement of the total aortic root and the transverse aortic arch.     

Dealing with dilated ascending aorta during aortic valve replacement: advantages of conservative surgical approach

Five to fifteen percent of patients undergoing aortic valve replacement (AVR) will have an ascending aortic aneurysm requiring a concomitant surgical procedure. On the other hand, a dilated ascending aorta is known to be a potential source of complications after AVR. From 1972 to 1988, 2278 AVR, either isolated or combined with a second cardiac procedure, were performed in our institution. In the same time interval, a dilated ascending aorta was treated in additional 291 consecutive patients during AVR. Three different surgical options were employed: aortic remodelling and external wall support in 164 patients (56.4%), composite graft replacement in 81 patients (27.8%) and a supracoronary graft in 46 patients (15.8%). Early mortality was 4.8%. Aortic remodelling plus external wall support had the lowest early mortality (1.8%) and the best 8-year survival (89.6%). Supracoronary grafting had a higher early mortality (6.4%) and lower 8-year survival (73.2%). The results of the composite graft were least favourable: early mortality was 9.8% and 8-year survival 76.5%. The results point out the necessity for instituting the appropriate surgical procedure for a dilated ascending aorta during AVR. They show that conservative aortic surgery with preservation of endothelial lining gives excellent early and late results.     

Surgical results of hemiarch replacement for acute type A dissection

BACKGROUND: The appropriate surgical strategy for patients with an arch tear in acute type A dissection remains controversial. We retrospectively compared surgical results after hemiarch as compared with transverse aortic arch replacement in patients with an arch tear in acute type A dissection. METHODS: The records of 88 patients who consecutively underwent graft replacement for acute type A dissection between 1989 and 2001 were reviewed. The patients were divided into three groups: patients with ascending aortic replacement (group AS, n = 41), those with hemiarch replacement (group HA, n = 23), and those with transverse arch replacement (group AR, n = 24). Operative mortality and morbidity and late outcome were compared among the three groups. RESULTS: The overall early (30 day) mortality was 11.3% (10/88), and in-hospital mortality was 14.7% (13/88). In-hospital mortality in groups AS, HA, and AR were 7.3%, 8.6%, and 33.3%, respectively (p = 0.011). Cardiopulmonary bypass, circulatory arrest, and operation times were significantly shorter in group HA than in group AR (p < 0.001). A smaller amount of intraoperative transfusion of red blood cells (p = 0.0006) and fresh-frozen plasma (p = 0.0003) was needed in group HA than in group AR, and postoperative bleeding during the first 24 hours postoperatively was significantly less in group HA than in group AR (p = 0.0028). The incidence of postoperative coma did not differ among the three groups (p = 0.89), nor did the incidence of postoperative patent false channel in the descending thoracic aorta (p = 0.57). Actuarial survival rates after 5 years were significantly better in group HA (91.3% +/- 5.9%) than in group AR (44.4% +/- 14.3%, p = 0.018). Freedom from reoperation on the distal aorta within 5 years did not differ among the groups (p = 0.46). CONCLUSIONS: Hemiarch replacement for acute type A dissection demonstrated favorable early and late outcome. The extent of graft replacement influenced surgical mortality and morbidity. Whenever the intimal tear is located in the lesser curvature of the transverse arch, hemiarch replacement is recommended to improve overall operative mortality and morbidity.     

马方综合征主动脉根部手术后远端主动脉病变再次外科治疗

目的 总结马方综合征主动脉根部手术后远端主动脉病变的再次外科治疗结果,探讨相关治疗策略。方法 2000年1月至2010年1月,28例马方综合征主动脉根部手术后远端主动脉病变患者进行再次手术治疗。其中男20例,女8例;年龄23～52岁,平均(38.5±8.7)岁。首次手术包括Bentall手术24例,David手术4例。Stanford A型夹层8例,主动脉根部瘤20例。再次手术包括：胸腹主动脉置换术10例,全主动脉弓置换及支架象鼻术7例,胸降主动脉置换术6例,全主动脉置换术2例,全主动脉弓置换术2例,部分主动脉弓置换术1例。两次手术间隔1 ～12年,平均(6.43 ±3.07)年。结果 术后发生神经系统并发症4例(17％),包括脑卒中1例,截瘫1例,单侧下肢一过性运动障碍2例。二次开胸止血3例,急性肾功能衰竭接受血滤治疗1例。3例因术后呼吸机辅助时间延迟接受气管切开术。术后全部随访,随访时间10～ 118个月,平均(40.8±29.5)个月。住院死亡2例(7.1％),术后1年、5年实际生存率分别为(94.5±1.3)％、(90.6±1.4)％。结论 马方综合征行主动脉根部手术后因远端主动脉病变再次外科治疗临床结果满意。对于患主动脉A型夹层的马方综合征,首次手术即采用积极的主动脉全弓置换及象鼻手术更好。     

Aortic root replacement with composite valve graft

BACKGROUND: Composite valve graft replacement is currently the treatment of choice for a wide variety of lesions of the aortic root and the ascending aorta. In this study we report our experience with aortic root replacement using a composite graft. METHODS: Between October 1978 and May 2001, 274 patients (79.6% male and 20.4% female) with a mean age of 53.5 years underwent composite graft replacement of the aortic root. One hundred sixty-one patients (70.8%) had annuloaortic ectasia and 46 (16.8%) aortic dissection. The classic Bentall technique was used in 94 patients (34.3%), the "button technique" in 172 patients (62.8%), and the Cabrol technique in 8 patients (2.9%). RESULTS: The early mortality rate was 6.9% (19 of 274 patients). Cardiopulmonary bypass time longer than 180 minutes and associated coronary artery bypass grafting were found to be independent risk factors of early mortality. The actuarial survival rate was 77.7% at 5 years and 63% at 10 years. The independent risk factors for late mortality were coronary artery disease, chronic renal failure, and postoperative dialysis. The actuarial freedom from reoperation on the remaining aorta was higher among patients without Marfan syndrome (94.6% versus 79.6% at 10 years, p = 0.008). CONCLUSIONS: Composite valve graft replacement can be performed with low hospital mortality and morbidity. The button technique offers some advantages and should be used whenever possible. In case of acute aortic dissection root replacement is usually not necessary. Marfan patients should be treated with early root replacement before dissection occurs.     

Outcomes of total aortic arch replacement with coronary artery bypass grafting

There are few reports regarding outcomes of total aortic arch replacement (TAAR) with concomitant coronary artery bypass grafting (CABG). This study aimed to analyze outcomes after total arch replacement with CABG in our institute. Between July 2006 and December 2010, 126 patients underwent elective total arch replacement with or without CABG. Of these patients, 56 had concomitant CABG. The mean age was 73.9±5.6 years. Fifteen patients were female. Six patients had chronic aortic dissection, and two patients had previous aortic operations. Total arch replacement was performed with selective cerebral perfusion and the elephant trunk procedure. The mean number of coronary anastomoses was 1.9±1.0. An internal thoracic artery (ITA) and saphenous vein graft were used in 37 (66.1%) and 47 (83.9%) patients, respectively. Only the anastomosis between the in-situ ITA and the left anterior descending artery (LADA) was performed after declamping the aorta using the on-pump beating technique. Operative mortality was 3.6%. Stroke occurred in 7.1% of patients. Early graft patency of bypass grafts was 100%. Composite outcomes of mortality and the rate of major complications of patients with CABG was 19.6%. TAAR with CABG can be safely performed with favorable outcomes.