Femoral cannulation is safe for type A dissection repair

Background

Recently, surgeons have embraced axillary artery cannulation for type A aortic dissection repair out of concern for malperfusion phenomena with traditional femoral artery cannulation. My colleagues and I sought to determine whether these concerns are justified.

Methods

Records of 86 consecutive patients (51 men and 35 women; age, 30 to 86 years; mean, 62 years) undergoing surgical repair for acute type A dissection were reviewed. Cannulation site, specific operative repair, and complications related to cannulation were noted.

Results

Seventy-nine cannulations were performed in the femoral artery (47 left, 23 right, and 9 unspecified), 3 in the axillary artery (1 left and 2 right), and 4 in the ascending aorta or arch. Deep hypothermic arrest was used in 64 operations. Seven involved re-sternotomy. Seventy patients had supracoronary grafts (2 with valve replacement and 10 with valve resuspension), and 16 underwent aortic root replacement. Fourteen patients were in shock from cardiac tamponade. Eighty patients survived the operation, and 71 were hospital survivors. Malperfusion on initiation of cardiopulmonary bypass was noted in 3 patients. In 1, the original cannulation site was the ascending aorta, and the cannula was moved to the femoral artery for correction. In 2, the original cannulation site was the femoral artery, and the cannula was moved to the ascending aorta. Malperfusion on clamping of the aorta or on resumption of aortic flow was noted in no patient. Postoperative ischemia of any vascular bed was noted locally only in 3 (cannulated) lower extremities.

Conclusions

Straight femoral cannulation for all phases of type A dissection repair is appropriate and yields excellent clinical results. The anticipated malperfusion events are actually rare (2 of 79 with femoral artery cannulation, or 2.5%).     

Reduction aortoplasty and external wrapping for moderately sized tubular ascending aortic aneurysm with concomitant operations

Background

Replacement of the ascending aorta with a prosthetic graft is the preferred surgical procedure for an ascending aortic aneurysm. The choice of external wrapping of the aorta is a simple, fast, and effective method for moderately sized ascending aortic aneurysms with concomitant operations. In this study, we present the midterm results of 62 patients undergoing reduction aortoplasty with external wrapping and different cardiac procedures.

Methods

The study group consisted of 48 male and 14 female patients with a mean age of 59.3 ± 6.0 years. Measurement of the ascending aorta diameters was obtained at three points: before surgery, during the early postoperative period, and during the follow-up. The mean preoperative aortic diameter was 52.7 ± 0.5 mm. In all patients, the ascending aortic aneurysm was repaired by reduction aortoplasty with external wrapping.

Results

Mean follow-up time was 39.6 ± 18.0 months. There was only one mortality (1.6%) as a result of septic multiple-organ failure and no major surgical complications in the 30-day postoperative period. Reduction aortoplasty of the ascending aorta with external wrapping resulted in a significant reduction of the ascending aorta in all patients (p = 0.000). There was an increase in the mean aortic diameter during the follow-up period (p = 0.000). Although this increase was statistically significant, all measurements of the follow-up period were still within normal range.

Conclusions

External wrapping of the aorta offers excellent results with very low mortality and morbidity, and it can be regarded as a safe and effective method for the treatment of ascending aortic aneurysm in selected patients. However, the patients should be carefully monitored for redilatation after the procedure.     

Reoperations on the Aortic Valve Combined with Replacement of the Ascending Aorta

ABSTRACT Objective: To review the experience with reoperations on the aortic valve combined with replacement of the ascending aorta. Patients and Methods: From 1991 to 2000, 237 patients underwent reoperations on the aortic valve combined with replacement of the ascending aorta. The study consisted of 188 men and 49 women, with a mean age of 51 years. The operation was urgent or emergent in 44% of cases. Many patients (42%) were in New York Heart Association Class IV, and 24 had active infective endocarditis. The ascending aorta was replaced previously in 46 patients, while the remaining patients had aneurismal dilation. An aortic valve sparing operation was performed in 14 patients and aortic valve replacement in 223. The ascending aorta was replaced in all patients as follows: as a composite graft in 166 and supracoronary in 71. Mechanical valves were used in 145 (61%) patients. Results: The operative mortality was 9%. Postoperative complications were common and 30% of patients suffered an adverse event (death or complication). No independent predictor of operative mortality could be identified but urgent/emergent surgery, advanced functional class, infective endocarditis, coronary artery disease, and replacement of the transverse aortic arch were associated with higher operative mortality by chi-square analysis. The survival at 5 years was 74%± 4% for patients who had composite replacement of the aortic valve and ascending aorta. Conclusions: Reoperations on the aortic valve combined with replacement of the ascending aorta can be performed with acceptable operative risk and good mid-term survival.     

Impact of valve prosthesis-patient mismatch on left ventricular mass regression following aortic valve replacement

Background

Valve prosthesis-patient mismatch is a frequent problem in patients undergoing aortic valve replacement and its main hemodynamic consequence is to generate high transvalvular gradients through normally functioning prosthetic valves. The persistence of high gradients may hinder or delay the regression of left ventricular hypertrophy after aortic valve replacement.

Methods

The aim of the study was to determine the impact of prosthesis-patient mismatch on the postoperative regression of left ventricular mass.Left ventricular mass was measured by Doppler echocardiography in 109 patients undergoing aortic valve replacement with a single type of bioprosthesis (Carpentier-Edwards Perimount) for pure aortic stenosis. Prosthesis-patient mismatch was defined as a projected indexed effective orifice area less than 0.90 cm²/m². On this basis, 58/109 (53.2%) patients had prosthesis-patient mismatch.

Results

There was a good correlation (r = 0.61, p < 0.001) between the postoperative mean transprosthetic gradient and the projected indexed effective orifice area. The absolute and relative left ventricular mass regression was significantly (p = 0.002 and p = 0.01, respectively) lower in patients with prosthesis-patient mismatch (−48 ± 47 g, −17% ± 16%) compared to those with no prosthesis-patient mismatch (−77 ± 49 g, −24% ± 14%). In multivariate analysis, a larger projected indexed effective orifice area, female gender and a higher preoperative left ventricular mass are independent predictors of greater left ventricular mass regression.

Conclusions

This study shows that in patients with pure aortic stenosis prosthesis-patient mismatch is associated with lesser regression of left ventricular hypertrophy after aortic valve replacement. These findings may have important clinical implications given that prosthesis-patient mismatch is frequent in these patients.     

Outcome after aortic valve replacement in octogenarians

Background

The advancing age of the population in the western world and improvements in surgical techniques and postoperative care have resulted in an increasing number of very elderly patients undergoing cardiac operations. Therefore, the aim of this study is to evaluate the surgical outcome in 115 octogenarians after aortic valve replacement.

Methods

We retrospectively identified 115 patients (47 men, 68 women) aged 82.3 ± 2.1 years (mean, 80 to 92 years) who underwent aortic valve replacement alone (71 patients, 62.1%) or in combination with coronary artery bypass grafting (44 patients, 37.9%), between January 1992 and April 2003. These patients had significant severe aortic stenosis with a mean valve area of 0.62 ± 0.15 cm² and a mean gradient of 88.62 ± 24.06 mm Hg.

Results

The in-hospital mortality rate was 8.5%. The late follow-up was 100% complete. Actuarial survival at 1 and 5 years was 86.4% and 69.4%, respectively. Predictors of late mortality were ejection fraction (p < 0.01), preoperative heart failure (p < 0.03), and the type of prosthesis (p < 0.03).

Conclusions

The outcome after aortic valve replacement in octogenarians is excellent; the operative risk is acceptable and the late survival rate is good. Therefore, cardiac surgery should not be withheld on the basis of age alone.     

Replacement of the Ascending Aorta and Aortic Valve with a Composite Graft: Results in 86 Patients

We reviewed our entire experience with composite graft replacement of the ascending aorta and aortic valve during a 63 month interval ending in December, 1979. Anuloaortic ectasia was the most common indication for operation, followed by aortic dissection (acute and chronic). Hospital mortality was 5% and was related to the preoperative functional status and the duration of intraoperative myocardial ischemia. Reoperation on the ascending aorta for reasons other than postoperative hemorrhage was required in five of the 82 hospital survivors (6%). By actuarial analysis, 90% of hospital survivors were free of any reoperation on the ascending aorta or aortic valve three years postoperatively, and 93% were free of reoperation related specifically to the composite graft. Pseudoaneurysms at the coronary ostia or distal aortic anastomosis were observed in five of 16 patients having postoperative angiography. One of the five patients has required reoperation. Follow-up has averaged 23.5 months (range: 0.2-60 months). Three year actuarial survival for the 86 patients was 81%, for 44 patients with anuloaortic ectasia was 88%, and for 31 patients with aortic dissection was 83%. Composite graft replacement of the ascending aorta and aortic valve is a satisfactory alternative to supracoronary graft replacement and aortic valve replacement. It offers the advantage of excluding all aneurysmal tissue from the aortic anulus to the innominate artery, thereby eliminating the potential for later development of aneurysms of the sinuses of Valsalva, a known complication of the supracoronary technique. It is the method of choice for patients with anuloaortic ectasia and cephalad displacement of the coronary ostia. It is suitable for many patients with acute or chronic dissection and for patients with sinuses of Valsalva aneurysms following previous operations on the ascending aorta or aortic valve.     

Reoperations on the aortic valve combined with replacement of the ascending aorta

OBJECTIVE: To review the experience with reoperations on the aortic valve combined with replacement of the ascending aorta. PATIENTS AND METHODS: From 1991 to 2000, 237 patients underwent reoperations on the aortic valve combined with replacement of the ascending aorta. The study consisted of 188 men and 49 women, with a mean age of 51 years. The operation was urgent or emergent in 44% of cases. Many patients (42%) were in New York Heart Association Class IV, and 24 had active infective endocarditis. The ascending aorta was replaced previously in 46 patients, while the remaining patients had aneurismal dilation. An aortic valve sparing operation was performed in 14 patients and aortic valve replacement in 223. The ascending aorta was replaced in all patients as follows: as a composite graft in 166 and supracoronary in 71. Mechanical valves were used in 145 (61%) patients. RESULTS: The operative mortality was 9%. Postoperative complications were common and 30% of patients suffered an adverse event (death or complication). No independent predictor of operative mortality could be identified but urgent/emergent surgery, advanced functional class, infective endocarditis, coronary artery disease, and replacement of the transverse aortic arch were associated with higher operative mortality by chi-square analysis. The survival at 5 years was 74%+/-4% for patients who had composite replacement of the aortic valve and ascending aorta. CONCLUSIONS: Reoperations on the aortic valve combined with replacement of the ascending aorta can be performed with acceptable operative risk and good mid-term survival.     

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.     

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.     

Clinical outcomes with the Hancock II bioprosthetic valve

Background

The Hancock II bioprosthetic valve, which was first introduced to clinical use in 1978, differs from its predecessor in several ways. This study was designed to evaluate the durability and outcomes with this valve in patients who had isolated aortic or mitral valve replacements.

Methods

From 1991 to 1999, 459 patients underwent aortic valve replacement and 138 patients underwent mitral valve replacement with the Hancock II bioprosthesis (Medtronic Inc, Minneapolis, MN). The mean age was 73.2 ± 0.4 and 72.6 ± 0.8 years in the aortic and mitral groups, respectively. Most patients were in New York Heart Association Class III or IV (50% aortic group and 69% mitral group) and concomitant coronary artery bypass was performed in 49.4% and 52.8% of patients, respectively. Patients were assessed annually and follow-up was up to 129 months in the aortic group and 100 months in the mitral group.

Results

At 8 years, actuarial survival was 52% ± 5% in the aortic group and 57% ± 8% in the mitral group. Furthermore, the actuarial freedom from structural failure necessitating reoperation was 99% ± 0.5% in the aortic group and 98% ± 2% in the mitral group, and the actuarial freedom from repeat valve surgery due to all causes was 97% ± 2% and 96% ± 2%, respectively. Actuarial freedom from thromboembolic events was 89% ± 2% in the aortic group and 90% ± 5% in the mitral group.

Conclusions

The Hancock II valve has excellent midterm durability and clinical performance in older patients.     

Repair of aortic false aneurysm using deep hypothermia and circulatory arrest

Background

Aortic false aneurysms are a rare complication of surgery of the aorta that can occur several months to years after the initial operation. We reviewed our results with false aneurysm repair using deep hypothermia and circulatory arrest.

Methods

Eleven patients were reoperated on for false aneurysm of either the ascending or descending thoracic aorta. Femorofemoral cardiopulmonary bypass with full-dose aprotinin and a heparinized system was used in all patients. Hypothermic circulatory arrest at an average of 20°C was instituted in all patients for repair. Six patients had a patch repair with either polyethylene terephthalate fiber (Dacron) or bovine pericardium, 4 had tube replacement of the aorta, and 1 had primary repair of the defect.

Results

Three patients had false aneurysm formation at a site of coarctation repair in the descending aorta, and the 8 others had false aneurysms in the ascending aorta at the site of a previous aortotomy. Six patients had proven infection as the cause; the causative agent was Staphylococcus species in all cases. Mean cardiopulmonary bypass time was 178 ± 51 minutes, and circulatory arrest time averaged 39 ± 18 minutes. Operative mortality was 18% (2 of 11); the cause of death was cardiogenic shock in both patients. The mean time to extubation in survivors was 5 days, and the average time to discharge was 16 days.

Conclusions

Although mediastinal infection is a common cause, aortic false aneurysms can be safely approached using femorofemoral cardiopulmonary bypass, hypothermic circulatory arrest, and patch repair with acceptable operative mortality and long-term survival.     

Is routine computed tomography angiography justified in patients undergoing aortic valve replacement for bicuspid aortic valve disease?

Background

Role of Computed Tomography Angiography (CTA) in patients with Bicuspid Aortic Valve (BAV) undergoing Aortic Valve Replacement (AVR) needs assessment.

Patients and Methods

After echocardiography, 54 patients with BAV were referred for AVR. CTA was performed routinely. Pre-operative characteristics, echocardiographic and CTA findings, and details of surgery were obtained.

Results

The study population had 54 subjects (48 males). Median age was 35.5 years (range 7 to 78 years), and median weight was 57.5 Kg (range 14 to 83 kg). On echocardiography, aortic sinus diameter ranged from 13 to 38 mm (median 28 mm). In none of the patients, ascending aorta was reported to be dilated. On CT angiography, the sinus diameter ranged from 16 to 46 mm (median 35 mm). Sinus diameter was ≥40 mm in 13 patients. The sinus diameter on echocardiography was within the range of 0 to 2 mm of CT angiographic estimates in 31 patients, within 2.1 to 5 mm in 22 patients, and more than 5 mm in one patient. The ascending aortic diameter ranged from 19 to 70 mm (median 43 mm). In 26 patients, ascending aortic diameter was ≥45 mm. In 12 patients, the proximal arch diameter was ≥40 mm. In two patients, the distal ascending aorta and proximal arch were aneurysmally dilated (48 mm and 57 mm). In 12 patients, the ascending aorta was dilated (≥ 45 mm) without any sinus dilatation. In one patient, the distal ascending aorta and proximal arch were aneurysmally dilated (57 mm) without any proximal dilatation. Based on CT angiographic findings, 25 patients (46.3 %) underwent additional aortic replacement in the form of Bentall’s procedure (n?=?7), Bentall’s + Hemiarch replacement (n?=?6), aortoplasty (n?=?5), Wheat procedure (n?=?6) and Wheat procedure?+?Hemiarch replacement (n?=?1).

Conclusion

CT angiography is justified as a routine pre-operative evaluation tool in all patients with BAV who are undergoing open heart surgery for significant aortic valve dysfunction.     

Late incidence and determinants of stroke after aortic and mitral valve replacement

Background

Stroke is a devastating complication in patients with prosthetic valves, but characterization of its late occurrence from a large cohort is lacking.

Methods

Three thousand one hundred eighty-nine adult patients who underwent a total of 3,576 operations for left-heart valve replacement were managed with contemporary anticoagulation guidelines and prospectively followed in a dedicated clinic. Total follow-up was 20,096 patient years. Bootstrapped survival analysis was used to determine the impact of patient and valve related factors on the incidence of stroke.

Results

Most strokes were embolic. Linearized embolic stroke rates were 1.3% ± 0.2% per year for aortic bioprostheses, 1.4% ± 0.2% per year for aortic mechanical valves, 1.3% ± 0.3% per year for mitral bioprostheses, and 2.3% ± 0.4% per year for mitral mechanical valves (p = 0.002, vs other implant types). Age more than 75 years, female gender, and smoking were independent risk factors after aortic and mitral valve replacement. Atrial fibrillation, coronary disease, and tilting-disc mechanical prostheses were independent predictors of embolic stroke after aortic valve replacement. Preoperative left ventricular (LV) dysfunction was an independent risk factor in patients with mitral prostheses. Primary operative indication, diabetes, redo status, or the presence of two prosthetic valves were not associated with an increased hazard. The addition of acetyl salicylic or dipyridamole to warfarin anticoagulation did not significantly lower embolic stroke risk in patients with mechanical prostheses.

Conclusions

Approximately 20% of patients with valve prostheses have an embolic stroke by 15 years after valve replacement. Some risk factors such as the avoidance of smoking, mitral mechanical prostheses, aortic tilting-disc valves, and proceeding to mitral surgery before LV dysfunction occurs are potentially modifiable.     

Comparison of Three Different Surgical Methods in Aortic Root Aneurysms: Long-Term Results

Abstract Background: Degenerative ascending aortic aneurysms frequently present with aortic valve pathology. If only the noncoronary sinus of Valsalva is dilated, replacement of the noncoronary sinus by tailoring the supracoronary graft with or without aortic valve replacement (AVR) can be a simple operation strategy. We sought to describe our experiences in this kind of operation, and compare them with a relatively homogeneous group of patients who underwent the classical Bentall operation. Methods: Between January 1997 and June 2007, 99 patients who had dilated ascending aortas with root dilatation and aortic valve pathology underwent operation. Patients were divided into three groups according to the surgical procedure. Classical Bentall operation was applied in 54 patients with dilated sinuses (Group 1). The other patients with dilated noncoronary sinus underwent either ascending aortic replacement with noncoronary sinus replacement (NSR, n = 27) (Group 2), or separate AVR and ascending aortic replacement with NSR (AVR + NSR, n = 18) (Group 3). Results: There were significant reduction of aortic root in Group 2 (Z =?4.560, p < 0.001), and Group 3 (Z =?3.758, p < 0.001). Degree of aortic regurgitation was decreased from 1.56 ± 0.5 to 0.67 ± 0.5 postoperatively in Group 2 (Z =?3.874, p < 0.001). Hospital mortality was six (6.1%) (three in Group 1; three in Group 2). Late mortality rate was 6.1% (three in Group 1, three in Group 2). The type of operation was not found to be an independent predictor of overall mortality. No patients in the NSR and AVR‐NSR groups had aortic root aneurysm, and there were no reoperations or verified deaths caused by aortic root aneurysm in these patients. Conclusions: Noncoronary cusp replacement for aortic root remodeling in patients with ascending aortic aneurysm is a technically simple and durable operation. Short‐ and mid‐term results of this method were favorable compared to the Bentall procedure.     

Reoperative cryopreserved root and ascending aorta replacement for acute aortic prosthetic valve endocarditis

BACKGROUND: Prosthetic aortic valve endocarditis (PVE) is an important complication of aortic valve replacement (AVR) and is a particularly difficult situation after an operation combining AVR with ascending aortic replacement. METHODS: From 1988 through 2000, 27 patients with aortic valve PVE after previous ascending aortic replacement (aortic root replacement in 13, aortic valve replacement with a supracoronary graft in 14) underwent reoperation for aortic root replacement with a cryopreserved aortic allograft and prolonged intravenous antibiotic therapy. All patients were considered to have active PVE (25 with positive cultures); root abscess formation was present in 89% and aortoventricular discontinuity in 41%. RESULTS: One patient (3.7%) died in-hospital, and permanent pacemakers were required in 10 patients (37%). Mean postoperative follow-up interval was 3.9 +/- 3.0 years, and survival at 1, 2, 5, and 7.5 years was 92%, 88%, 70%, and 56%, respectively. One patient underwent reoperation for recurrent PVE 8 months after operation. CONCLUSIONS: Radical debridement of infected prosthetic material and tissue, and allograft aortic root and ascending aorta replacement, combined with intravenous antibiotic therapy, appears to achieve a low hospital mortality and a high degree of freedom from recurrent infection for patients with PVE after AVR and ascending aortic replacement.     

Surgical Treatment of Ascending Aortic Pathology

Among the first 10,200 valvular replacements performed in our unit, 288 complex repairs of the ascending aorta were done for various aortic pathology. Aneurysms of the ascending aorta were the most frequent; 53 supracoronary artery aneurysms with aortic valvular insufficiency were treated by the separate replacement of the aortic valve and the supracoronary ascending aorta; 206 annulo-aortic ectasia had total and combined replacement of the ascending aorta and the aortic valve with a personal modification of the Bentall's technique using an 8-mm diameter Dacron graft to perform the reimplantation of the coronary arteries on the composite aortic grafts. The operative mortality for the first 100 patients was 4% and for the entire 206 patients, 6%. Late mortality during a follow-up period ranging from 18 months to 8 years was 11%. The actuarial survival rate at 8 years is 75%; 25 patients restudied by angiography demonstrated satisfactory results with neither stenosis nor aneurysm on the coronary graft but a recurrent or persisting chronic distal aortic dissection in four patients. In 26 cases of aortic valvular endocarditis, large abscesses of the aortic annulus involved the aortic root. In 11, the aortic repair consisted of the insertion of a subcoronary valved conduit (two early deaths, two late deaths, one reoperation, seven good results--maximum follow-up of eight years). Twelve patients had a supracoronary valved conduit with four early deaths, one late death, and two reoperations; seven are alive and well, two to six years later. Three patients previously operated had a left ventricular abdominal aorta valved conduit; two of them are alive and well up to six years later. In three patients with iterative aortic paravalvular leak (recurring three or four times), ablation of the aortic insufficiency was obtained by interposition of a composite valved graft in the ascending aorta.     

Surgical treatment of the dilated ascending aorta: when and how?

Background. The aorta is considered pathologically dilated if the diameters of the ascending aorta and the aortic root exceed the norms for a given age and body size. A 50% increase over the normal diameter is considered aneurysmal dilatation. Such dilatation of the ascending aorta frequently leads to significant aortic valvular insufficiency, even in the presence of an otherwise normal valve. The dilated or aneurysmal ascending aorta is at risk for spontaneous rupture or dissection. The magnitude of this risk is closely related to the size of the aorta and the underlying pathology of the aortic wall. The occurrence of rupture or dissection adversely alters natural history and survival even after successful emergency surgical treatment.

Methods. In recommending elective surgery for the dilated ascending aorta, the patient’s age, the relative size of the aorta, the structure and function of the aortic valve, and the pathology of the aortic wall have to be considered. The indications for replacement of the ascending aorta in patients with Marfan’s syndrome, acute dissection, intramural hematoma, and endocarditis with annular destruction are supported by solid clinical information. Surgical guidelines for intervening in degenerative dilatation of the ascending aorta, however, especially when its discovery is incidental to other cardiac operations, remain mostly empiric because of lack of natural history studies. The association of a bicuspid aortic valve with ascending aortic dilatation requires special attention.

Results. There are a number of current techniques for surgical restoration of the functional and anatomical integrity of the aortic root. The choice of procedure is influenced by careful consideration of multiple factors, such as the patient’s age and anticipated survival time; underlying aortic pathology; anatomical considerations related to the aortic valve leaflets, annulus, sinuses, and the sino-tubular ridge; the condition of the distal aorta; the likelihood of future distal operation; the risk of anticoagulation; and, of course, the surgeon’s experience with the technique. Currently, elective root replacement with an appropriately chosen technique should not carry an operative risk much higher than that of routine aortic valve replacement. Composite replacement of the aortic valve and the ascending aorta, as originally described by Bentall, DeBono and Edwards (classic Bentall), or modified by Kouchoukos (button Bentall), remains the most versatile and widely applied method. Since 1989, the button modification of the Bentall procedure has been used in 250 patients at Mount Sinai Medical Center, with a hospital mortality of 4% and excellent long-term survival. In this group, age was the only predictor of operative risk (age > 60 years, mortality 7.3% [9/124] compared with age < 60, mortality 0.8% [1/126], p = 0.02).

Conclusions. This modification of the Bentall procedure has set a standard for evaluating the more recently introduced methods of aortic root repair.     

A型主动脉夹层动脉瘤的外科治疗

目的　总结 1996年 1月至 2 0 0 2年 8月收治的 34例 A型主动脉夹层动脉瘤的外科治疗经验。　方法　应用 Bentall手术 19例 ,升主动脉人工血管置换术 7例 ,升主动脉人工血管置换加主动脉瓣成形术 (Trusler's法 )5例 ,分别行升主动脉人工血管置换及主动脉瓣置换术 (Wheat术 ) 2例 ,升主动脉、主动脉弓人工血管置换术 1例。结果　手术死亡 6例 ,死亡率 17.6 %。其中慢性主动脉夹层动脉瘤死亡 3例 ,急性夹层动脉瘤死亡 3例。随访 2 0例 ,随访率 71.4 %。随访时间 2～ 4 6个月 ,平均 2 4 .7个月 ,1例术后 3个月猝死 (原因不明 ) ,1例术后 6个月死于心内膜炎。18例存活患者情况良好。　结论　应根据夹层动脉瘤的部位及范围采用不同的手术方式 ,保留主动脉瓣的升主动脉人工血管置换术治疗该病效果较好 ,准确可靠的吻合技术、保留瘤壁的完整性 ,将使手术更为安全。     

Surgical treatment of cardiovascular complications in Marfan syndrome: a 27-year experience.

Fifty-two patients with Marfan syndrome and ascending aortic pathology were treated surgically between 1964 and 1990. The indication for primary operation was true aneurysm of the ascending aorta with or without aortic insufficiency in 35 patients (67%) and dissection in 17 (33%). Composite grafts were used in 28 patients (54%; group I) and other procedures on the ascending aorta in 24 patients (46%; group II). The latter included supracoronary graft replacement with or without aortic valve replacement or reconstruction (n = 13), and reconstruction of the ascending aorta with or without aortic valve replacement (n = 11). Composite graft insertion was combined with mitral valve surgery at the same operation in 3 patients (6%). The early mortality after primary operations was 7.7% (4 deaths) and the late mortality was 27% (14 deaths). Eight late deaths were related to cardiovascular complications. The mean follow-up was 6.7 years (range 1-27 years). The actuarial 5-, 10-, and 15-year survival rates for all patients were 82%, 63%, and 44%, respectively; for group I (composite grafts) they were 87%, 76%, and 57%; and for group II (other types of operations) they were 73%, 53%, and 37%. The incidence of late complications was much higher in group II than in group I (50% vs. 16%). At 5 and 10 years, the actuarial rates of freedom from late complications related to the primary operation were 88% and 80%, respectively, in group I and 65% and 18% in group II. Composite graft insertion is the operation of choice when approaching the ascending aorta and/or aortic valve in Marfan syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)