Redo aortic valve replacement

Thirty two patients had a second operation after previous aortic valve replacement during a six-year period. The indications for reoperations were infection, thrombo embolism, paraprosthetic leak and actual or anticipated valve failure. Three patients died at operation and there were four late deaths. Two patients developed heart block at operation. Mortality was highest in patients undergoing emergency and urgent surgery.     

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.     

Marfan's syndrome: combined composite valve graft replacement of the aortic root and transaortic mitral valve replacement

Echocardiographic studies in patients with Marfan's syndrome indicate that 95% eventually have aortic root dilatation, mitral valve prolapse, or a combination of these. Both lesions can progress and require operation for aortic root aneurysm, aortic valve insufficiency, and mitral valve insufficiency. This report reviews the simplified treatment of 6 patients by combined composite valve graft replacement of the aortic root and transaortic mitral valve replacement at one operation. All patients survived and are well for periods extending from 1 month to 12 months.     

Our experience with aortic root replacement using hand-sewn composite valve graft

Background The purpose of this study is to examine our experience with aortic root replacement using composite valve grafts in patients with proximal aortic disease. Methods and Results Since 1986, 16 patients underwent aortic root replacement using composite valve grafts for various indications which were Marfan's syndrome with annuloaortic ectasia (n=2), aortic regurgitation with ascending aortic aneurysm (n=3), aortic stenosis with regurgitation with poststenotic dilatation (n=9) and progressive aortic dilatation following AVR (n=2). There were 12 males and 4 females. The age range varied between 19 years and 52 years. The choice of conduit was a custom made valved graft using a monoleaflet tilting disc valve (Medtronic Hall valve=11, St Vincent's valve=3, TTK Chitra=1 and Bjork Shiley Valve=1) placed in a Dacron graft (Hemashield=13, Verisoft Cooley=3) prepared using a 4-0 polypropylene suture. The average time taken to construct a valved graft was 20 min±8 min. The coronary implantation was by isolated button technique. There was no size mismatch encountered in any patients. Postoperative bleeding necessitated a delayed sternal closure in 3 patients and re-exploration in another 2. The immediate operative mortality was 2, the cause being ventricular arrhythmia in one and cerebrovascular accident in other. Follow-up period ranged from 2 months to 16 years with a median follow-up of 12 months. One patient had an asymptomatic perigraft collection and no intervention was needed. There was no valve related complications in any of these patients. There was one late death of unknown cause. Conclusions Aortic root replacement using a custom made composite graft offers excellent long-term results, with negligible mortality rate and prosthesis related complications. Custom made grafts make this conduit easily affordable in our country and their performance is comparable to other available composite grafts.     

A case report of combined composite valve graft replacement of the aortic root and graft replacement of the abdominal aorta

A 55-year-old man who had both aortic root aneurysm with severe aortic regurgitation and enlarging abdominal aortic aneurysm was admitted to our hospital. We employed the combined composite valve graft replacement of the aortic root and Y-graft replacement of the infrarenal abdominal aorta at one stage operation. At the operation, median sternotomy was made and the composite graft replacement of the aortic root was performed under cardiopulmonary bypass prior to the abdominal procedure. After cardiopulmonary bypass was removed, abdominal incision was made. Although ventricular arrhythmias and mild hypotension transiently occurred when the abdominal aorta was clamped, the Y-graft replacement was also completed uneventfully, and no complication occurred postoperatively. We conclude that the combined operation of the aortic root and the abdominal aorta is clinically feasible in certain situation.     

Eleven-year experience with composite graft replacement of the ascending aorta and aortic valve

Between September, 1974, and December, 1985, 127 patients had replacement of the ascending aorta and aortic valve with a composite graft. Annuloaortic ectasia was the most common indication for operation (69 patients), followed by aortic dissection (51 patients). Twenty-four patients (19%) had the Marfan syndrome. Hospital mortality was 4.7%. Emergent operation for acute dissection was the only independent predictor of hospital death (p = 0.03). Reoperation for postoperative hemorrhage was required in 15 patients (11.8%) and for prosthesis-related complications (pseudoaneurysm, prosthetic endocarditis, technical problems, and valve thrombosis) in 16 patients (12.6%). Since we adopted a technique of preclotting the prosthesis with whole blood or albumin plus autoclaving and abandoned the inclusion technique, the reoperation rate has declined substantially. At 5 years, the actuarial freedom from reoperation for any reason on the ascending aorta or aortic valve for the 24 patients in whom this modification was used was 90% and for the remaining 103 patients, 73% (p = 0.17). No reoperations for pseudoaneurysms or technical problems were required in these 24 patients, whereas 10 reoperations for these complications were necessary in the other patients. The mean duration of follow-up was 54 months. The actuarial survival rate at 7 years for the entire group was 65%; for the patients with annuloaortic ectasia, 70%; for those with aortic dissection, 61%; for the patients with the Marfan syndrome, 57%. Actuarial freedom from operation on the remainder of the aorta at 7 years was 89%, but it was 78% for the subgroup with the Marfan syndrome. The satisfactory results with extended follow-up support the continued use of the composite graft technique as the preferred method of treatment for patients with annuloaortic ectasia or recurrent aneurysms of the sinuses of Valsalva and for patients with aortic dissection who require aortic valve replacement.     

Mitral valve replacement and subsequent composite graft replacement of the aortic root for infantile Marfan syndrome.

The cardiovascular lesions commonly seen in Marfan syndrome can frequently be the primary cause of premature death. Cardiac lesions involving both the mitral valve and the aortic root are commonly observed among patients diagnosed during early infancy, as so-called infantile Marfan syndrome. Since the lesions tend to progress rapidly with the end results of high morbidity and mortality, the majority of patients require surgical intervention at a young age. However, patients who undergo surgical intervention for both lesions during the first decade of life have been rarely reported in literature. In this report, we present a case of a 9-year-old boy who underwent aortic root replacement with a composite graft at 3.5 years after a prior prosthetic valve replacement of the mitral valve. Although the immediate result was satisfactory, the long-term result remains to be seen.     

Redo total aortic arch replacement using an extended homograft for graft infection

A 65-year-old man developed graft infection 3 years after total aortic arch replacement for a chronic dissecting aneurysm. Redo total aortic arch replacement was performed using an extended homograft following 2 days of open drainage of the mediastinum. The patient has been free from a recurrent mediastinitis over the last 3 years.     

Aortic root replacement with the Carboseal composite valve graft: analysis of risk factors

This retrospective analysis of a selected series of Bentall-De Bono procedures was carried out in order to evaluate the performance of the Carboseal composite valve graft (Sulzer Carbomedics Inc, Austin, TX, USA). Between October 1997 and April 2004, 120 patients underwent aortic root replacement with the Carboseal Composite Valve Graft. The mean age of patients was 59.7+/-13.4 years (range, 21-83 years); 96 patients (80%) were male. Eighty-nine patients (74.2%) had annulaortic ectasia, 10 patients (8.3%) post-stenotic dilatation, 3 (2.5%) post dissection aneurysm, 2 (1.7%) acute type A dissection and 1 (0.8%) endocarditis. The average follow-up duration was 29.2 months (range 2-82 months). Hospital mortality was 1.7% (2 of 120 patients). The actuarial survival rate (including hospital mortality) was 97.2+/-1.5% at 1 year, 91.6+/-3.5% at 3 years and 84.0+/-8.0% at 5 years. Chronic renal failure was an independent risk factor for late mortality (P=0.02). The actuarial freedom from pseudoaneurysms at 3 years was higher among patients without Marfan syndrome (94.7+/-3.2% vs. 75.0+/-21.6% at 3 years, P<0.003). In our recent series, the Bentall-De Bono operation provided good results with low incidence of prosthetic related complications. Pseudoaneurysms requiring re-operation have a higher incidence among patients with Marfan syndrome.     

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.     

Redo aortic valve replacement due to early structural valve deterioration in a trifecta valve: A case report

Introduction and importanceWhile the number of SAVR cases has been increasing for patients below their sixties due to the improvement of bioprosthetic valves, some early structural valve deterioration (SVD) in Trifecta valves has been reported.Case presentationWe present a case of a female who presented with sudden shortness of breath. Ultrasonography diagnosed SVD. We performed redo aortic valve replacement due to SVD in Trifecta valve. With our surgical technique we could remove the bioprosthetic valve easily.Clinical discussionWe could easily remove the mounted prosthetic valve along with the titanium band. These cases may emerge with acute heart failure due to sudden massive aortic regurgitation, not like the gradual progression of stenosis due to calcification.ConclusionThe postoperative course in Trifecta recipients must be followed carefully.     

New vascular graft for assembling the stentless valve composite graft

The use of a new vascular tube with an uncrimped section for assembling the stentless valve composite graft is described. The graft simplifies the fixation of the valve within the tube because no stretching of the crimping is necessary to achieve optimal commissural height of the valve during sewing. Furthermore, this allows the composite construction outside the chest and reduces the cross-clamp time.     

Coronary ostial aneurysms after composite graft replacement

Coronary ostial aneurysms after composite graft replacement of the ascending aorta and aortic valve is a rare complication. We report two patients with Marfan syndrome who developed coronary ostial aneurysms at the sites of the coronary anastomosis, presumably because of oversized windows made in the graft. They were successfully treated by redo composite graft replacement. To prevent this complication, it is important to consider that the hole made in the tube graft should not be larger than the diameter of the respective coronary ostium to avoid exposure of the diseased aortic wall to the circulating blood as much as possible, and that the suture used to anastomose the coronary buttons should pass through the rim of the ostium rather than through the aortic wall surrounding it.