Aortic valve sparing operations: basic concepts

Aortic valve sparing surgery offers a unique opportunity to save the normal aortic valve in patients who require surgery for aortic root disease such as aneurysms, annuloaortic ectasia or aortic dissection. The surgical anatomy of the aortic root and the basic concepts of aortic valve sparing surgery are reviewed to provide surgeons and cardiologists a better understanding of when such operations might be suitable.     

Ascending aortic aneurysms: composite conduit replacement

From July 1980 to February 1984, 26 patients underwent composite replacement of ascending aortic aneurysm and aortic valve with coronary reimplantation. This group included 14 patients with dissecting aneurysm (ten and four respectively, belonging to Types I and II), and 12 patients with chronic aneurysm (six atherosclerotic aneurysms, two Marfan's syndrome and four annuloaortic ectasia cases). Hospital mortality was 35.7% (5/14) in the dissection subgroups and 16.6% (2/12) in the chronic aneurysm subgroup (difference NS). No operative risk factor was recognized. The 19 survivors have been followed up for a total of 393 patient-months (range 5 to 49 months). Controls included echocardiography and computed tomography scanning. Two patients died because of rupture of a persistently dissected aorta; another patient died of an unknown cause. Total actuarial survival rate at 4 years was 58.3 +/- 10.4% (83.3 +/- 10.7% for chronic aneurysms and 42.3 +/- 13.4% for dissecting aneurysms). Among late survivors, there were no paravalvular leaks, new dissections, or thromboembolisms, although two perigraft hematomas and a persistent dissection were later disclosed. When appropriate, composite conduit replacement of the ascending aorta can increase the survival rate, and can also be useful in high-risk patients.     

Actual management of patients with familial ascending aortic aneurysms and type-A aortic dissections

BACKGROUND: There are few families with the diagnosis of ascending aortic aneurysm and acute type-A aortic dissection inherited as an autosomal-dominant disorder in the absence of a known genetic syndrome. METHODS: We investigated a family with 26 members in whom ascending aortic aneurysms and acute type-A aortic dissections occurred over three generations. Examinations were performed to identify family members at specific risk. RESULTS: Six members presented with acute type-A aortic dissections and three relatives had ascending aortic aneurysms. Clinical examinations showed no characteristics of a known genetic syndrome. Molecular genetic analysis revealed no mutations known to cause a form of autosomal-dominant inherited aortic disease. CONCLUSION: Adequate diagnostic measures are mandatory in families with ascending aortic aneurysms or type-A aortic dissections to identify or exclude family members at risk for aortic diseases. Even in the absence of identifiable mutations causing isolated aortic aneurysms or aortic dissections, we recommend standardised examinations of all first-degree relatives of affected families. An indication for prophylactic aortic root replacement should be considered for patients at risk.     

The surgical experience with annuloaortic ectasia at the Medical University of South Carolina

Hemodynamically significant aortic insufficiency can result from dilatation of the aortic valve annulus in association with an ascending aortic aneurysm (annuloaortic ectasia). Controversy has centered around the optimal surgical management. This study evaluates the results of total replacement of the aortic valve and ascending thoracic aorta with a valved aortic prosthesis and reimplantation of the coronary arteries in a small series. In 7 patients with a mean preoperative New York Heart Association Classification (NYHAC) of III, there have been no operative or long-term mortalities, and the average upgrade in NYHAC is 1.6. There have been no major complications or technical difficulties. The composite approach to the repair of patients with annuloaortic ectasia is described and advocated.     

The complementary role of magnetic resonance imaging, Doppler echocardiography, and computed tomography in the diagnosis of dissecting thoracic aneurysms

Non-ECG gated MRI was compared with 2DE and/or CT scans in 10 patients with dissecting aneurysms proven by angiography and/or surgery. Patient ages ranged from 48 to 85 years (mean 69.6). Six had DeBakey type I dissections and four had DeBakey type III dissections. MRI was diagnostic for aortic dissection in nine cases and suggestive in the tenth. 2DE was diagnostic in six out of nine patients, suggestive in two patients, and nondiagnostic in one patient. CT was diagnostic in the three cases in which it was employed. MRI demonstrated a dilated ascending aorta with thickened walls in all type I dissections as well as an intimal flap and slow flow in the false channel in four patients. In the other two patients with type I dissection, MRI detected the intimal flap in the descending aorta but not in the ascending aorta, whereas 2DE revealed the ascending aortic intimal flap in both of these patients and CT showed it in one of them. In the type III dissections, MRI demonstrated a thickened wall and thrombus in the lumen in all four cases, and the intimal flap in three out of the four. 2DE excluded ascending aortic involvement in all three type III dissections. Six other patients with fusiform dilated ascending aortas had no evidence of dissection by MRI, 2DE, and aortography. Thus, non-ECG gated MRI alone or in combination with 2DE and/or CT is useful in the diagnosis of dissecting thoracic aneurysm and in assessing the extent of the dissection. In addition, the differentiation of dissecting aneurysms of the aorta from fusiform dilatation of the aorta is made possible by these noninvasive techniques.     

Risk factors for aortic dissection: a necropsy study of 161 cases

Among 161 necropsy cases of aortic dissection, 87 (54%) were type I, 34 (21%) type II, and 40 (25%) type III, and an intimal tear was identified in each. Systemic hypertension had been present in 63 of 121 cases (52%) with type I or II dissection and in 30 of 40 (75%) with type III dissection. Aortic dissection involved 7 of 16 cases (44%) with the Marfan syndrome. In the 154 cases without the Marfan syndrome, grade 3 or 4 medial degeneration (cystic medial necrosis) was observed in the ascending aorta in only 27 (18%). The risk of aortic dissection in persons with congenitally bicuspid and unicommissural aortic valves, respectively, was 9 and 18 times that in subjects with tricuspid aortic valves. The mean age of those with aortic dissection and tricuspid, bicuspid and unicommissural aortic valves was 63, 55 and 40 years, respectively, and aortic dissection was more common in men than in women. Grade 3 or 4 atherosclerosis involved the intimal tear in only 11 of 121 type I or II dissections (9%) but 32 of 40 type III dissections (80%). Accordingly, the major risk factors for aortic dissection were systemic hypertension, the Marfan syndrome, and, for type I and II dissections, congenitally bicuspid or unicommissural aortic valves. Aortic medial degeneration was a less important risk factor. Rupture of ulcerocalcific aortic atheromas may have initiated the intimal tear in some type III dissections.     

Twenty-seven-year experience with composite valve graft replacement of the aortic root

BACKGROUND AND AIM OF THE STUDY: The study aim was to assess early and late outcome in patients undergoing composite valve graft replacement (CVGR) of the aortic root by means of the Bentall procedure, and to identify predictors of early and late death associated with this surgical approach. METHODS: Between August 1975 and July 2002, 162 consecutive patients underwent a Bentall procedure for CVGR. Demographic, treatment and clinical outcome data from these patients were gathered, reviewed, and analyzed. Potential predictors of early and late mortality were analyzed. RESULTS: The study population was predominantly male (n = 132; 81.5%) and middle-aged (mean age 51.3 +/- 15.8 years; range: 10-79 years). The main indications for surgery were annuloaortic ectasia (n = 75; 46.3%), aortic dissection (n = 44; 27.2%) and Marfan syndrome (n = 34; 21%). Reoperation was required in 37 cases (22.8%). The mean follow up was 74 months. Early (in-hospital) mortality was 1.9% (n = 3). The only independent determinant of early mortality was cardiopulmonary bypass time (p = 0.025). Late mortality was 27.7% (n = 44). On multivariate analysis, the only independent risk factors for late mortality were age >60 years (p = 0.044) and left ventricular ejection fraction <50% (p = 0.037). Actuarial survival rates were 92.9%, 77%, 56.2%, and 47.1% at one, five, 10, and 15 years, respectively. Rates of freedom from reoperation on the aortic root and ascending aorta were 90.6% and 72.5% at five and 15 years, respectively. No false aneurysms were observed at any coronary reimplantation sites. CONCLUSION: In this series, the Bentall procedure was associated with low operative mortality and good early and late results. This suggests that the procedure may be considered as a reference to other operations on the aortic root, at least in adult patients.     

Composite graft replacement of the aortic root: long-term results, incidence of reoperations

BACKGROUND: Long-term results after composite graft replacement of the aortic root may depend on the insertion technique. METHODS: 181 consecutive patients (mean age 53 years; 153 men) operated on between 1983 and 1993 were studied. Indications for surgery were annuloaortic ectasia (n=98), acute aortic dissection (n = 46), other indications (n = 12), and various indications after previous aortic valve replacement (n = 25). Mean follow-up was 28 months. The open-button technique was performed in 74 patients (41 %) and the Bentall inclusion technique in 107 patients (59%), with a Cabrol shunt to the right atrium in 16 patients. RESULTS: Overall survival was 75% after 7 years, significantly decreased in acute aortic dissection (p = 0.0019) and without difference between the two surgical techniques (p = 0.3166). Reoperation-free survival was 69% at 7 years and significantly decreased after acute dissection (p = 0.0421 ). Pseudoaneurysm formation only occurred in 3 patients operated with the Bentall technique not including a Cabrol shunt. CONCLUSIONS: Long-term results are satisfactory. In acute aortic dissection survival is decreased and late reoperations more frequent. The open technique is safe in non-dissection and in acute dissection and avoids pseudoaneurysm formation. The Bentall technique combined with Cabrol shunt is indicated if there is a high risk of hemorrhage. Long-term monitoring of the aorta is mandatory in patients with acute dissection and/or Marfan disease.     

Aortitis

Inflammatory or noninfectious aortitis may be idiopathic or it may be part of a systemic autoimmune disease, such as Takayasu's arteritis, Beh?et's disease, or giant cell arteritis. At the acute stage, there is thickening of the aortic wall with dilatation of the aorta, more commonly in the thoracic aorta. If it involves the aortic root, there may be annuloaortic ectasia or aortic regurgitation. At a later stage, there may be aneurysmal dilatation of the aorta and rarely dissection or rupture of the aorta. In Takayasu's arteritis, stenosing lesions can occur as well as aneurysmal dilatation of the aorta or arteries. Stenosing lesions may be treated with angioplasty with or without stenting, whereas aneurysmal dilatation of the aorta is treated by aneurys-mectomy with arterial reconstruction or conduit. Severe aortic regurgitation may require aortic valve surgery with or without replacement of the ascending aorta. Irrespective of the interventional procedure undertaken as appropriate for the lesion, control of inflammation with steroid therapy with or without other immunosuppressive agents is of paramount importance. Otherwise, prosthetic valve or graft dehiscence may occur after aortic surgery, and restenosis rate is also higher after percutaneous transluminal angioplasty or stenting.     

Surgical consideration of replacement of the ascending aorta and aortic valve with a composite valve graft--operative and long-term results of Bentall and DeBono procedure

Our experience with the Bentall and DeBono procedure is reviewed. Between April, 1977 and April, 1985, seventeen patients underwent repair of annulo-aortic ectasia (9 cases), and dissecting aneurysm with aortic regurgitation (8 cases). Three patients had cardiac tamponade due to rupture of dissecting aneurysm. In regard to this procedure, we recently performed the continuous suture method on the prosthetic valve ring, coronary ostia, and distal anastomosis sites. In this study, there was one early death due to a sudden rupture of the dissecting aneurysm of the left thoracic cavity on the 10th postoperative day. In addition, there were two late deaths due to sepsis and suspected arrhythmia. The late follow-up period ranged from 6 months to 8 years (mean 35 months), and all patients were in NYHA Class I or II. We conclude that the composite valve graft method is an excellent technique for annuloaortic ectasia and ascending aortic dissections with aortic regurgitation because of its low operative mortality and fair survival rate.     

Are there surgical implications to aortic root motion?

BACKGROUND AND AIM OF THE STUDY: By increasing the longitudinal stress in the ascending aorta, downward movement of the aortic root might promote the proximal transverse tears seen in aortic dissections. The study aim was to evaluate the influence of five common cardiac conditions on the magnitude of aortic root displacement in cardiac patients. METHODS: Aortic root contrast injections were analyzed in 90 patients (mean age 68 years) to measure downward motion of the root perpendicular to the plane of the sinotubular junction (STJ). RESULTS: Displacement of the aortic root ranged from 0 to 14 mm (mean 4.8 mm). Patients with aortic insufficiency (AI) showed increased aortic root movement (7.3 versus 4.3 mm, p = 0.003), whereas those with left ventricular hypokinesis (3.7 versus 5.5 mm, p = 0.014) or with myocardial hypertrophy (3.8 versus 5.1 mm, p = 0.073) exhibited reduced downward movement. These variables were independent, and correlated with the magnitude of aortic root motion. A stress analysis of the aortic root, arch and branches of the arch determined that the longitudinal stress approximately 2 cm above the STJ, in the outer curve of the aorta, was increased by 32% in patients with AI compared to patients without AI. CONCLUSION: Patients with cardiac conditions associated with increased aortic root motion such as AI may be at greater risk of aortic dissection because of increased longitudinal stress in the ascending aorta. Therefore, AI should be used as an indicator and aortic root displacement monitored to prevent the risk of aortic dissection.     

Surgical treatment of aneurysms of the ascending aorta. Twelve years' experience in 66 patients

This study presents the results in 66 patients undergoing surgery for concomitant supracoronary vascular interposition and valve replacement carried out at the Department of Cardiac Surgery of the University of Munich, West-Germany, over a period of 12 years (from July 1, 1973 to June 30, 1985) using a technique similar to that described by Wheat. Forty-seven percent of the cases were true aneurysms and 20% chronic dissections. Thirty-three percent of patients had acute dissections. Early mortality was 16% in the total patient population, 9% in the group having true aneurysm and 32% in the group having acute dissection. No early death was observed in association with chronic dissections. The actuarial one-year survival rate in patients with true aneurysm or chronic dissection was 83.6%, and 54.1% in patients with acute dissection. The corresponding 4-year survival rates were 76.4% and 54.1%, respectively. The average improvement according to the New York Heart Association classification was 1.5 grades. These results confirm that the operative approach to ascending aortic aneurysms is superior to medical treatment, with the operative method involving vascular graft without concomitant aortic valve replacement as well as the method described by Wheat having both proved successful.     

Single-stage aortic valve-sparing root replacement and extra-anatomic bypass for aortic arch interruption in an adult

We describe the treatment of an extremely rare case of interrupted aortic arch, annuloaortic ectasia, and aortic regurgitation in a 34-year-old man who presented with dyspnea and palpitation. We performed a single-stage operation involving aortic root reconstruction and valve repair with concomitant extra-anatomic bypass from the ascending to the descending aorta with a Dacron tube graft. The patient made a full recovery. To the best of our knowledge, this is the first such report in the English medical literature.     

Replacement of the ascending aorta and aortic valve with a composite graft. Results and follow-up in 71 patients

Composite graft replacement of the ascending aorta and aortic valve was performed in 71 patients over an 8-year period. Degenerative lesions of the aortic root in Marfan's syndrome (annuloaortic ectasia) was the indication for operation in 51 cases. Other causes of aortic root dilatation and aortic valve disease were present in the remaining 20 patients. Overall hospital mortality was 8%. Reoperation was required in 6 of the 65 hospital survivors. Follow-up has ranged from 1 to 9 years (average 41/2 years). Four year actuarial survival was 77%. Composite graft replacement eliminates paraprosthetic leakage and the risk of aneurysm formation of the sinuses of Valsalva; postoperative hemorrhage is also reduced. It appears to be the method of choice for the aortic root complications of the Marfan's syndrome.     

Surgical Treatment of Ascending Aorta and Aortic Root Aneurysms

Aneurysms of the aortic root and ascending aorta are often due to degenerative disease of media. Aneurysm of the aortic root often affects patients in their second to fourth decades of life, whereas aneurysm of the ascending aorta occurs mostly in the fifth to seventh decades of life. These aneurysms can cause aortic insufficiency, dissection, and/or rupture. Current guidelines recommend surgical treatment when the diameter of the aneurysm exceeds 50 mm. In patients with family history of aortic dissection or with Loyes-Dietz syndrome (a more severe form of Marfan syndrome), surgery should be considered when they are even smaller. Composite replacement of the aortic valve and ascending aorta used to be the standard treatment for patients with aortic root aneurysms. During the past 2 decades, a conservative procedure whereby the aneurysm is replaced with Dacron graft and the aortic valve is preserved has gained widespread use, and the results have been excellent in experienced hands.     

Right axillary artery cannulation for surgical management of the hostile ascending aorta

Extensive aortic disease, such as atherosclerosis with aneurysms or dissections that involve the ascending aorta, can complicate the choice of a cannulation site for cardiopulmonary bypass. To date, the standard peripheral arterial cannulation site has been the common femoral artery; however, this approach carries the risk of atheroembolism due to retrograde aortic perfusion, or it is undesirable because of severe iliofemoral disease. Arterial perfusion through the axillary artery provides sufficient antegrade aortic flow, is more likely to perfuse the true lumen in the event of dissection, and is associated with fewer atheroembolic complications. From September 2000 through March 2004, 27 patients underwent right axillary artery cannulation for acute ascending aortic dissection (n = 16), ascending aortic aneurysm (n = 9), or coronary artery bypass grafting (n = 2). Direct artery cannulation was performed in the first 4 patients, and the last 23 patients were cannulated through a longitudinal arteriotomy via an 8-mm woven Dacron graft. Seventeen patients underwent hypothermic circulatory arrest and antegrade cerebral perfusion. Two patients died intraoperatively: one due to low cardiac output and one due to diffuse bleeding. One patient suffered mild right-arm paresthesia postoperatively, but recovered completely. Axillary artery cannulation was successful in all patients; it provided sufficient arterial flow, and there were no intraoperative problems with perfusion. In the presence of extensive aortic or iliofemoral disease, arterial perfusion through the axillary artery is a safe and effective means of providing sufficient arterial inflow during cardiopulmonary bypass. In this regard, it is an excellent alternative to standard femoral artery cannulation.     

Self-Expanding Endovascular Stent-Graft Implant for Treatment of Descending Aortic Diseases

Abstract Background: Aneurysms and dissections involving the descending thoracic aorta and the distal portion of the aortic arch are difficult to resolve surgically. The introduction of endovascular self-expanding stent-grafts has simplified the operation. Given the complications associated with their peripheral placement, we explored the feasibility of surgical insertion. Methods: Thirteen patients underwent surgical insertion of a stent-graft into the aortic arch via longitudinal aortotomy. Six patients had aneurysms (ruptured in two, and seven dissections (acute in two, ruptured in one). Five patients also underwent associated procedures including aortic valve replacement (one), ascending aorta replacement (two), arch replacement (one), and coronary artery bypass (one). Results: There was one intraoperative death due to ascending aortic dissection, and two hospital deaths due to multiple complications. Of ten patients discharged, one died 3 months postoperatively. The remaining survivors are well, and imaging studies confirmed adequate correction of the aortic disease. Conclusions: The use of this technique simplifies the operation and treatment of particular cases of aortic disease. The observed morbidity and mortality are due to factors independent of the technique.     

Dissected aortic sinuses repaired with gelatin-resorcin-formaldehyde (GRF) glue are not stable on follow up

BACKGROUND AND AIM OF THE STUDY: The chemical glue, gelatin, resorcin and formaldehyde (GRF) is widely used to obliterate the false lumen of acute dissected aortic wall tissue. METHODS: A retrospective review of 41 consecutive patients operated upon for ascending aortic dissection between 1993 and 2000 was conducted. This study focused on 19 patients with acute aortic dissection in whom the aortic valve was resuspended and GRF glue used in the proximal aortic sinuses. These patients were compared with ascending aortic dissection patients in whom the aortic valve was not resuspended. In total, nine acute and 13 chronic dissections were performed in which aortic valve replacement, valve-sparing root reconstruction (without GRF glue), or no aortic valve surgery was carried out. RESULTS: The operative mortality for ascending aortic dissections was 24.4%; identified risk factors included the specific surgeon involved. Third-degree heart block occurred only in patients in whom GRF glue was used in the proximal aortic sinus (15% incidence). Operative survivors in whom the aortic valve was resuspended and GRF glue used in the proximal aortic sinus, had a 64% incidence of late recurrent aortic regurgitation requiring reoperation due to recurrent aortic sinus aneurysm formation with or without recurrent proximal aortic dissection. No recurrence of aortic regurgitation or proximal disease occurred in the other two groups (p <0.01). Actuarial survival of patients in whom the aortic valve was resuspended with GRF glue was 52.1+/-11.6% at five years and 27.8+/-14.3% at eight years, compared with 55.6+/-16.6% at five years if the aortic valve was not resuspended using GRF glue. CONCLUSION: The use of GRF glue to repair acute dissected aortic sinuses combined with the resuspension of the aortic valve is associated with an unacceptable incidence of failure of aortic valve repair and recurrence of aortic regurgitation. It may be more appropriate to resect all acute dissected aortic sinus tissue.     

Aortic valve-sparing surgery for aortic root aneurysm.

BACKGROUND: Replacement of the aortic valve and ascending aorta with a composite graft is the most common surgical treatment for aortic root aneurysms with or without aortic regurgitation (AR). In the early 90's reconstructive procedures of the aortic root have been described with encouraging results. This paper presents our experience with this technique. METHODS: Between January 2001 and May 2003, 28 patients (25 males, 3 females, mean age 60 years) with aortic root aneurysm were treated with reimplantation of the aortic valve. Twenty-two patients had AR > 2+, 5 had Marfan syndrome, 5 had an aortic arch aneurysm, 4 had type A aortic dissection, 2 patients had associated coronary artery disease, and one had mitral valve insufficiency. The only contraindication was primitive disease of the aortic leaflets. RESULTS: There was one perioperative death (type A aortic dissection) and 1 patient was discharged with mild to moderate AR requiring aortic valve replacement. The cardiopulmonary bypass and aortic cross-clamping times were 230 and 184 min respectively. No neurological events were recorded. During follow-up (mean 16.7 months, range 3-32 months) 1 patient died and one had mild AR. Freedom from reoperation and from AR at 24 months was 94 and 89% respectively. At multivariate analyses we did not find any correlation between Marfan syndrome, type A aortic dissection, grade of preoperative AR, and recurrence of AR. CONCLUSIONS: In our experience, valve-sparing surgery was feasible with a low mortality and morbidity and with good early results. It should be applied to all patients requiring aortic root surgery for aortic root aneurysm, a diseased aortic valve being the only contraindication.     

Annuloaortic ectasia and adult polycystic kidney. A frequent association

The association of annuloaortic ectasia and polycystic kidney in 18 consecutive patients who had intravenous pyelograms was 22 percent (4/18). Due to this high association rate, some type of work-up to study the kidney anatomy should be performed in every case of annuloaortic ectasia. For the same reasons, patients with adult polycystic kidney should have a careful cardiovascular evaluation.