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.     

Prognosis of spontaneous echocardiographic contrast in the thoracic aorta

The aim of this study was to assess the predictive value of spontaneous echocardiographic contrast (SEC) detected in the thoracic aorta by transesophageal echocardiography (TEE) on intermediate-term cardiovascular morbidity and mortality. We studied 299 consecutive patients (aged 61 +/- 13 years) without aortic aneurysm or dissection, who underwent TEE in 1995 to 1996. Cardiovascular deaths and nonfatal events were recorded over a period of < or = 60 months. Left ventricular function was classified as preserved versus depressed according to ejection fraction values (>40% vs < or = 40%) on 2-dimensional echocardiography. SEC was identified in 35 patients (11.7%). During follow-up, 66 patients died (36 deaths were due to cardiovascular causes; 10 and 26 cardiovascular deaths occurred in patients with and without SEC, respectively [p <0.001]). Survival time was significantly reduced in patients with versus without SEC (28 +/- 18 vs 39 +/- 19 months, p = 0.0012). Multivariate analysis revealed that the presence of SEC doubled the odds for cardiovascular death and for the combined end point of cardiovascular death and events. There was a significant difference in survival distributions between patients with and without SEC between both genders (p <0.001). In patients with normal or mildly reduced left ventricular function, SEC was predictive of an adverse outcome, whereas this was not the case in patients with more severely depressed cardiac function. It is concluded that the presence of SEC in the thoracic aorta is associated with a high risk of cardiovascular events and/or death over intermediate-term follow-up.     

Evolution of aortic dissection after surgical repair

Patients after aortic dissection repair still have long-term unfavorable prognosis and need careful monitoring. The purpose of this study was to analyze the evolution of aortic dissection after surgical repair in correlation to anatomic changes emerging from systematic magnetic resonance imaging (MRI) follow-up. Between January 1992 and June 1998, 70 patients underwent surgery for type A aortic dissection. Fifty-eight patients were discharged from the hospital (17% operative mortality) and were followed by serial MRI for 12 to 90 months after surgery. In all, 436 postoperative MRI examinations were analyzed. In 13 patients (22.5%) no residual intimal flap was identified, whereas 45 patients (77.5%) presented with distal dissection, with a partial thrombosis of the false lumen in 24. The yearly aortic growth rate was maximum in the descending aortic segment (0.37 +/- 0.43 cm) and was significantly higher in the absence of thrombus in the false lumen (0.56 +/- 0.57 cm) (p <0.05). There were 4 sudden deaths, with documented aortic rupture in 2. Sixteen patients underwent reoperation for expanding aortic diameter. In all but 1 patient, a residual dissection was present (in 13 without any thrombosis of the false lumen). Close MRI follow-up in patients after dissection surgical repair can identify the progression of aortic pathology, providing effective prevention of aortic rupture and timely reoperation. Thrombosis of the false lumen appears to be a protective factor against aortic dilation.     

Mid-term results of aortic valve preservation: remodelling vs. reimplantation

OBJECTIVE: Valve-preserving root replacement has become an accepted alternative to composite replacement both in dissection and in aneurysmal disease. We retrospectively analysed 5-year results comparing root remodelling and reimplantation procedures. METHODS: From October 1995 to January 2001, 119 patients underwent either root remodelling (group A; n = 98; age: 61 +/- 14 years) or valve reimplantation within a vascular graft (group B; n = 21; age: 47 +/- 17 years). In group A, 26 patients were operated for aortic dissection type A and 72 for aortic valve regurgitation and aneurysmal disease. In group B, 8 patients were operated for aortic dissection type A, 13 for aortic valve regurgitation and aneurysm. Concomitant arch surgery was performed in 65 patients (group A: 57; group B: 8). RESULTS: Time on cardiopulmonary bypass was 121 +/- 30 min in group A, 143 +/- 24 min in group B, and aortic cross-clamp time was 87 +/- 19 min in group A and 113 +/- 24 min in group B. Average duration was therefore longer in group B (p = n.s.) Hospital mortality was 3.1 % in group A and 0 % in group B. Following elective procedures, hospital mortality was 1.1 % in group A. Freedom from aortic regurgitation over grade 2 at 4 years was 86 % in group A and 94.7 % in group B. At 4 years, freedom from proximal reoperation was 97.8 % in group A and 100 % in group B. There was no deterioration of valve function or need for reoperation observed after 1 year in either group. CONCLUSION: Five-year results are comparable and encouraging for remodelling and reimplantation procedures. If the initial valve function and geometry is adequate, the chance of secondary failure beyond the first year is minimal.     

Long-term results of surgery for type A acute aortic dissection

The cases of 160 patients (126 men, mean age 57.5 +/- 13.3 years) operated consecutively as an emergency for a Stanford type A dissection of the aorta between 1980 and 2000 were reviewed. The cumulative follow-up was 716.7 patient-years with an average follow-up of 4.51 +/- 5.6 patient-years. The risk factors for early postoperative mortality (up to 3 months), late mortality (> 3 months) and reoperation (cardiac and/or vascular) were determined by multivariate analysis. The hospital mortality was 27.5%. Older ages, obesity, previous cardiac surgery, preoperative shock, medullary, renal or mesenteric ischaemia were significant risk factors for early mortality. The probability of actuarial survival was 66.1 +/- 3.8%, 57.7 +/- 4.2%, 52.2 +/- 4.6% and 45.3 +/- 5.5% respectively at 1, 5, 10 and 15 years. Chronic obstructive airways disease and a more recent operation date were significant risk factors for late mortality. Thirty patients underwent 37 reoperations after an average of 5.7 +/- 4.5 years. The actuarial probability for no reoperation was 96.9 +/- 1.8%, 74.7 +/- 5.3%, 60.8 +/- 6.8% and 39.3 +/- 9.1% at 1, 5, 10 and 15 years respectively. The presence of severe preoperative aortic regurgitation was the only significant risk factor for reoperation. Type A acute dissection of the aorta continues to have a high early mortality and a significant incidence of late complications. Patients with severe aortic regurgitation before surgery are at high risk for reoperation and should probably have more radical aortic repair at the initial operation.     

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.     

Long-term results of Bentall composite aortic root replacement for ascending aortic aneurysms and dissections

STUDY OBJECTIVES: The aim of this study was to evaluate the early and long-term outcomes in patients undergoing aortic root replacement (ARR) with the Bentall procedure. DESIGN: Retrospective study. SETTING: Cardiothoracic surgery unit. PATIENTS AND METHODS: Between January 1986 and January 2002, 72 patients (mean age 58.3 +/- 12.4 years, 81.9% males) underwent ARR by means of a Bentall operation. Annuloaortic ectasia was the most frequent cause of aortic disease in this series of patients (31 patients; 43.1%), followed by type A dissection (19 patients; 26.3%), atherosclerotic aneurysm (18 patients; 25.1%), and poststenotic dilatation (4 patients; 5.5%). Nine patients (12.5%) had Marfan syndrome, and 10 patients (13.8%) underwent a concomitant replacement of the aortic arch. Follow-up ranged from 2 to 192 months (mean [+/- SD], 86.6 +/- 23.8 months). RESULTS: The mean 30-day mortality rate was 5.5 +/- 2%. The mean early mortality rate was 21 +/- 4% and 0% (p < 0.001), respectively, in patients with and without dissecting aortic aneurysms. There were two late deaths that were due to a pulmonary neoplasm and a cerebrovascular accident. The mean 16-year survival rate was 91.7 +/- 3.2%. The mean hazard of freedom from death was constant beyond 3 years (8.5 +/- 3.5%). No patient required reoperation. Furthermore, the long-term clinical follow-up was marked by a complete absence of endocarditis, anticoagulant-related hemorrhage, valve thrombosis, and prosthesis failure. Finally, patients showed a significant improvement in mean New York Heart Association functional status (1.3 +/- 0.1; p < 0.001 [postoperatively vs preoperatively]). CONCLUSIONS: In our experience, the late results of the Bentall operation were satisfactory. Our findings confirm that this technique still represents the procedure of choice for ARR with coronary reimplantation.     

Aortic valve preservation in acute type A dissection: mid-term results.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the long-term effectiveness of a strategy for managing the aortic valve, aortic root and ascending aorta according to the pathology in acute aortic type A dissection. Results after surgery for acute type A dissection with preservation of the aortic valve were reviewed. METHODS: The patient group included 57 hospital survivors operated on according to a surgical strategy of aortic valve resuspension and supracoronary ascending aortic graft implantation. Reinforcement of the aortic stumps with gelatin-resorcinol-formaldehyde glue was performed in all patients. Aortic valve function in all survivors was investigated by echocardiographic follow up at 30 days, 6 and 12 months after surgery, and yearly thereafter. RESULTS: During the follow up period, nine patients (16%) died without reoperation. Actuarial probability of freedom from reoperation for aortic valve failure in the complete series was estimated as 100% after both 30 days and 12 months. Postoperatively, one patient underwent reoperation 14 months for aortic regurgitation, and three patients for aortic regurgitation with sinus of Valsalva dilatation between 48 and 88 months. The hospital mortality rate at reoperation was 50% (n = 2). CONCLUSION: Valve-sparing surgery is possible and can be recommended for the majority of patients with acute type A aortic dissection.     

Value of echocardiography in patient follow-up after surgically corrected type A aortic dissection.

BACKGROUND: To identify patients (pts) at risk of late complications, follow-up after surgery for type A aortic dissection is essential. We assessed the value of echocardiography to monitor patients after surgery for type A aortic dissection. METHODS: 80 out of 108 pts operated between 1989 and 1999 for type A aortic dissection survived surgery. 62 pts with at least one TEE, CT or MRI examinations during follow-up were included in this study. All pts had transthoracic echocardiography (TTE), 53 transesophageal echocardiography (TEE), 51 had CT, and 39 had MRI. RESULTS: At the first follow-up, 12 of 48 pts with aortic valve sparing surgery presented with aortic insufficiency >I degrees detected using echocardiography. 16 pts evolved a distal aortic aneurysm of over 5 cm, all seen in TEE, CT and MRI. A distal intimal flap was present in 39 pts and could be seen in TEE, CT and MRI in all patients. A new proximal aortic root dissection took place in 5 pts. Progressive aortic pathology led to reoperation in 9 pts. TEE was especially useful in 2 pts to confirm redissection, in 1 pt to rule out redissection assumed by CT, and in 1 with paraprosthetic blood flow after ascending aortic replacement. MRI led to additional information in 1 patient with false aneurysm of the distal anastomosis and 1 with redissection not seen in TEE 6 month before. CT and MRI were superior to TEE in demonstrating aortic arch pathology, whereas TEE was more effective in showing the flow pattern and residual entry sites. CONCLUSIONS: Echocardiography is an effective and cost-saving diagnostic tool to monitor pts after surgery for type A aortic dissection, and should be the method of choice to ascertain aortic pathology initially after surgery. Follow-up intervals and need for additional CT or MRI should be determined afterwards according to specific pathologies.     

Reoperations for aortic aneurysm after the Ross procedure

BACKGROUND AND AIM OF THE STUDY: Among late complications after the Ross operation, autograft dilatation is likely the most common. In order to define prevalence, consequences and management of autograft dilatation, a 10-year clinical experience was reviewed. METHODS: A total of 112 patients (mean age 29 +/- 10 years) underwent cross-sectional echocardiographic follow up. End-points of the study were freedom from autograft dilatation (diameter >4 cm, indexed as 0.21 cm/m2) and from reoperation for dilatation. Risk factors for autograft dilatation were also identified. RESULTS: There were 110 late survivors; average follow up was 5.1 +/- 1.9 years (range: 0.3 to 10.6 years). At 10 years, autograft dilatation was identified in 32 patients (29%), compatible with aortic aneurysm (>5.0 cm) in seven patients (6%). Seven of 32 patients (22%) presented moderate or greater autograft insufficiency. Ten-year freedom from dilatation was 43 +/- 8%, and from regurgitation was 75 +/- 8%. At multivariate analysis, preoperative aneurysm (p = 0.02), root replacement technique (p = 0.03) and absence of root buttressing (p = 0.04) were predictive of dilatation. Reoperation for autograft aneurysm was performed in five patients at a mean of 7.3 +/- 0.8 years after the Ross procedure, while two patients await reintervention. Two patients had root replacement and three remodeling with valve preservation (two root replacements, one sinotubular junction replacement): all survived reoperation. Ten-year freedom from root reoperation was 81 +/- 6%, and from full root replacement was 94 +/- 2%. CONCLUSION: With increasing follow up after the Ross operation, the incidences of root dilatation and reoperation are likely to rise. Graft replacement of coexisting aneurysm, avoidance of root replacement technique and the use of root-stabilization measures may reduce the prevalence of late root pathology. Early replacement of dilated autograft roots may allow preservation of the autologous pulmonary valve.     

Ascending aortic aneurysm resection: 15 years' experience

Between September 1989 and June 2004, 148 consecutive patients underwent ascending aortic replacement for aneurysm or dissection. There were 130 males (88%) and 18 females (12%). Their mean age was 46.20 +/- 13.36 years. Fifty-seven patients (39%) were treated for type 1 and type 2 aortic dissection, and 91 (61%) for ascending aortic aneurysm. The Bentall procedure was performed in 81 patients (55%), the Cabrol procedure in 7 (5%), separate ascending aortic replacement and aortic valve replacement or repair was carried out in 24 (16%), and ascending aortic replacement only in 36 (24%). Hospital mortality was 4.05% (6 deaths). On univariate analysis, left ventricular ejection fraction < or = 30%, emergency surgery, contained rupture, concomitant coronary artery bypass grafting, and age > or = 65 years were risk factors for early mortality. However, on multivariate analysis, ejection fraction < or = 30% and contained rupture were the only factors significantly associated with early mortality. The long-term survival rates were 87.2% +/- 3.7% at 5 years, 78.0% +/- 5.6% at 10 years, and 60.9% +/- 9.9% at 15 years. Ascending aortic resection for aneurysm or dissection can be performed with low mortality and morbidity.     

Analysis of perioperative risk factors in mortality and morbidity after modified Bentall operation

The objective of the present study was to determine the risk factors for operative and short-term mortality, and morbidity after a Bentall operation. Between July 1994 and February 2001, 86 consecutive patients (70 males) underwent a modified Bentall operation at our hospital. The aortic pathology was acute aortic dissection in 12 (14%), chronic dissection in 9 (10.5%) and degenerative aneurysm in 65 (75.6%). Mean age was 48 +/- 15 years. Eleven preoperative, 8 intraoperative and 6 postoperative variables of these patients were retrospectively analyzed using univariate and multivariate logistic regression analysis. Six patients died in the hospital (6.9%) and 2 died within four months after being discharged from the hospital. Mean follow-up time was 33 +/- 23 months (2 months to 8 years). The survival rate among hospital survivors was 88% at 3 years and 77% at 6 years. Univariate predictors of in-hospital and short-term mortality were the presence of aortic valve calcification, stenotic aortic valves, renal failure, and cardiac failure after the operation. Multivariate analysis revealed no independent risk factors. Risk factors for morbidity were etiology of acute dissection, use of circulatory arrest, transfusion of blood and fresh frozen plasma more than 2 units each, cross clamp and cardiopulmonary bypass times (exceeding 90 and 140 minutes, respectively), and performing concomitant procedures. Modified Bentall procedures are safe in general. Meticulous dissection, careful handling and positioning of the coronary buttons are of paramount importance in patients with stiff aortic root since technical errors are more likely to occur.     

Resuspension of the aortic valve in acute type A dissection: long-term results

BACKGROUND AND AIM OF THE STUDY: Preservation of the aortic valve during the repair of acute type A aortic dissection (AADA) is a viable option to prevent lifelong oral anticoagulation. The study aim was to assess aortic valve function following resuspension and supracoronary ascending aortic grafting. METHODS: Among a collective of 210 consecutive patients undergoing surgery for AADA, 140 (66.7%) with resuspension of the aortic valve and supracoronary ascending graft were analyzed. Of these patients, 83 (59.3%) had a complete follow up (mean 61.2 +/- 40.8 months), with 65 of the subgroup (78.3%) being followed by computed tomography scanning and echocardiography. RESULTS: Reoperation due to severe aortic valve regurgitation was required in seven patients (10.8%). The perioperative characteristics were similar in these patients; notably, no significant difference was evident with regards to the aortic annulus diameter and the severity of regurgitation at the time of surgery. The left ventricular mass index was significantly higher in patients requiring reoperation due to aortic valve regurgitation (219.3 +/- 146.6 versus 123.9 +/- 146.6 g/m2; p <0.05). None of the patients died as a result of reoperation. CONCLUSION: The long-term functional results following resuspension of the aortic valve in AADA were very good. A close echocardiographic follow up was necessary, as reoperation of the aortic valve was required in more than 10% of the collective, with an average follow up of five years. Reoperation was mainly related to secondary dilatation of the aortic root.     

Aortic root remodeling: functional MRI as an accurate tool for complete follow-up

BACKGROUND: After aortic valve-sparing procedures patients should be evaluated regularly because of the risk for further disease progression in the remaining aorta as well as recurrent aortic insufficiency. The purpose of this study was to evaluate the potential of functional MRI as a single examination for complete follow-up of these patients. METHODS: Twenty-two patients with a mean age of 54 years (range 30 - 66) were prospectively examined at 1, 12, 24, 36, and 74 months postoperatively, following a Yacoub aortic root remodeling operation, using a 1.5 T MRI. The original disease was chronic aneurysm of the ascending aorta or root in 17, chronic dissection in 3, and acute dissection in 2 patients. Transverse graft diameters, regurgitant fraction, LVEDV, and cardiac index were measured using cine MRI. Results were compared to spiral computed tomography and transthoracic color Doppler echocardiography. Mean time of follow-up was 24.9 months and ranged from 1 to 74 months. RESULTS: There were 2 re-operations, 2 years after primary surgery, due to high aortic insufficiency. CT and MRI measurements of graft diameters correlated well (p = 0.4544). Mean graft diameter (mean +/- SD) was 30 +/- 3.7, 33 +/- 3.4, 36.5 +/- 1.5, 37 +/- 2.8, and 38.3 +/- 2.8 mm at 1, 12, 24, 36, and 74 months, respectively, indicating a significant increase of graft diameter (p < 0.0001). Mean regurgitant fraction as determined by MRI was 14 +/- 7, 12 +/- 9, 13 +/- 9, 15 +/- 7, and 14 +/- 9 % at 1, 12, 24, 36, and 74 months, respectively. Flow based grading of aortic insufficiency by MR imaging correlated well with color Doppler echocardiography (p < 0.0001). CONCLUSIONS: MRI provides an excellent, noninvasive, comprehensive tool for follow-up after valve-sparing aortic root reconstruction. The determination of regurgitant fraction, ventricular dimensions and functions, and graft diameters allows standardized imaging protocols with a high reproducibility, which may lead to this technique being favored for the follow-up of patients after aortic root remodeling.     

Extensive aortic surgery in Marfan syndrome: 16-year experience

The aim of this study was to evaluate the clinical outcome of surgical treatment in patients with Marfan syndrome. Between 1985 and November 2001, 33 patients with Marfan syndrome were operated for chronic aneurysm of the aortic root with involvement of the ascending aorta in 20 patients and type A dissection in 13 patients. The patients comprised 24 males and 9 females with a mean age of 31.9 +/- 9.7 years (range, 18 to 54 years). The mean diameter of the ascending aorta was 6.6 +/- 1.6 cm and that of the aortic root was 5.4 +/- 1.2 cm. Hemodynamic instability was observed in 11 patients. The aortic arch was replaced in 7 patients. There was no hospital mortality. Late mortality was 6%, involving 2 patients who had aortic valve replacement. Actuarial freedom from death was 92.3% +/- 7.4% at 12 years and from late aortic complications was 86.4% +/- 9.4% at 13 years. Aortic aneurysm was a significant univariate adverse factor for late aortic complications. Aortic surgery can be performed in Marfan patients with low morbidity and mortality. Aggressive surgical intervention does not impair surgical outcome while it decreases reoperation risk.     

Prognosis of postoperative aortic dissection. Assessment with magnetic resonance]

OBJECTIVE: To evaluate operated type A aortic dissection by Magnetic Resonance Imaging (MRI), in order to detect long-term complications and identify prognostic indexes of evolution. DESIGN: Prospective study with a three-year period of follow-up. Prognosis evaluation. SETTINGS: Outpatient Clinic at Hospital de Santa Maria and Magnetic Resonance Imaging Center at Hospital da Cruz Vermelha. PATIENTS: A sample of 37 patients submitted to type A aortic dissection surgery, included sequentially, after exclusion of those with contraindication to MRI. METHODS: Initial evaluation (clinical and MRI study) at 3 to 4 months and at 1, 2 and 3 years after surgery. The mean follow-up time was 39.3 +/- 2.9 months. We evaluated the following complications over the aorta (aortic graft and five segments of residual aorta) and the aortic valve: aneurysm, pseudoaneurysm, rupture, re-dissection, progressive aortic valve regurgitation, reoperation and death. The prognostic indexes analysed were: presence of residual flap; false lumen patency; presence of re-entry points; false lumen to aorta dimension ratio; initial aortic dimension; increase of aortic dimension. RESULTS: All patients, with the exception of three that died, remained asymptomatic. COMPLICATIONS: Aneurysm was detected in 45.9% of patients, located in one or more segments; rupture occurred in three patients, preceded by aneurysm and pseudoaneurysm development; moderate or severe aortic regurgitation was detected in 47.8% of patients. Prognostic indexes: 1. Aneurysm development in each segment yeilded a significant association with: presence of residual flap in the same and other segments; higher initial dimension of the same and other segments, with the exception of the abdominal segment; higher increase in dimension of the same and other segments, with the exception of the abdominal segment; 2. Moderate or severe aortic regurgitation development showed a tendency to association with higher increase in dimension of proximal ascending aorta. 3. No association was found between aneurysm and aortic regurgitation development. CONCLUSIONS: Patients operated for type A aortic dissection had a high incidence of late complications which lead to reoperation and in some cases death. The presence of a residual flap, increased aortic dimensions and higher increase rate of aortic dimensions were associated with a complicated evolution. MRI was a very useful technique for long-term monitoring and to identify prognostic indexes of evolution.     

Accuracy of biplane and multiplane transesophageal echocardiography in diagnosis of typical acute aortic dissection and intramural hematoma

Objectives. The purpose of this study was to evaluate the diagnostic accuracy of biplane and multiplane transesophageal echocardiography in patients with suspected aortic dissection, including intramural hematoma.Background. Transesophageal echocardiography is a useful technique for rapid bedside evaluation of patients with suspected acute aortic dissection. The sensitivity of transesophageal echocardiography is high, but the diagnostic accuracy of biplane and multiplane transesophageal echocardiography for dissection and intramural hematoma is less well defined.Methods. We studied 112 consecutive patients at a major referral center who had undergone biplane or multiplane transesophageal echocardiography to identify aortic dissection. The presence, absence and type of aortic dissection (type A or B, typical dissection or intramural hematoma) were confirmed by operation or autopsy in 60 patients and by other imaging techniques in all. The accuracy of transesophageal echocardiography for ancillary findings of aortic dissection (intimal flap, fenestration and thrombosis) was assessed in the 60 patients with available surgical data.Results. Of the 112 patients, aortic dissection was present in 49 (44%); 10 of these had intramural hematom (5 with and 5 without involvement of the ascending aorta). Of the remaining 63 patients without dissection, 33 (29%) had aortic aneurysm and 30 (27%) had neither dissection nor aneurysm. The overall sensitivity and specificity of transesophageal echocardiography for the presence of dissection were 98% and 95%, respectively. The specificity for type A and type B dissection was 97% and 99%, respectively. The sensitivity and specificity for intramural hematoma was 90% and 99%, respectively. The accuracy of transesophageal echocardiography for diagnosis of acute significant aortic regurgitation and pericardial tamponade was 100%.Conclusions. Biplane and multiplane transesophageal echocardiography are highly accurate for prospective identification of the presence and site of aortic dissection, its ancillary findings and major complications in a large series of patients with varied aortic pathology, Intramural hematoma carries a high complication rate and should be treated identically with aortic dissection.     

The surgical treatment of aneurysms of the ascending aorta with associated aortic insufficiency. Total replacement with reimplantation of the coronary arteries]

We reviewed our experience with replacement of the ascending aorta and aortic valve with a composite graft and reimplantation of coronary arteries to the tube graft during 8 years interval from April, 1982, to April 1990. 24 patients underwent repair, the mean age was 49.83 years. Annuloaortic ectasia was the most common indication (58.33%), followed by aortic dissection (acute or chronic). Emergency operation was carried out in nine patients with aortic dissection (37.5%) and elective in 15. The mean duration of cardiopulmonary bypass was 118 +/- 4 minutes and of aortic clamping 83.85 +/- 2 minutes. Hospital mortality was 4.17%, reoperation for hemorrhage was 12.5% and perioperative morbidity for other causes was 34.7%. There were one late death. 20 patients were follow-up with a total of 638 patients-months (two patients excluded with insufficient follow-up and one late death). At last follow-up 14 patients were in functional class I. Eight year actuarial survival for the 24 patients was 91%. We believe that replacement of the ascending aorta and aortic valve with a composite graft and coronary arteries reimplantation to the tube graft is more than one satisfactory alternative to supracoronary graft replacement and aortic valve replacement. It offers the advantage of excluding all abnormal aortic tissue, eliminating the risk for later development of complications in the non excluded disease aorta. It supposes the method of choice for patients with anuloaortic-ectasia, aneurysms of the sinuses of Valsalva with aortic insufficiency, and aortic dissection with proximal affectation of coronary arteries and aortic valve.     

Results of video-assisted mitral surgery in a non-selected population

A prospective 'analysis of operative risk and results in video-assisted mitral valve surgery performed in a non selected population is reported. Seventy two consecutive patients (1997-2004) with mean age 60 +/- 12 years underwent a video-assisted mitral valve procedure using a femoral CPB. A transthoracic direct aortic clamping was done in 28 patients (TT) and an endo-aortic occlusion balloon was used in 44 patients (Endo). The surgical approach was a right lateral minithoracotomy in all cases; 16 patients had a previous cardiac surgery. The expected mitral operation (39 repairs, 33 replacements) was done in all cases, without conversion. There were 4 early deaths (1 st month), all in Endo group: 1 aortic dissection, 1 heart failure and 2 sudden deaths. Postoperative complication occurred in 17 patients with 5 reoperations for hemostasis of the thoracic wall. Cumulative rate of mortality and morbidity was 29% in Endo and 28% in TT (ns). Hospital stay was 8 +/- 2 days. At discharge, 4 patients had a residual grade 2 echocardiographic mitral regurgitation after valve repair. In January 2005, with a 1.8 years follow-up, there were 4 late deaths, 3 patients underwent a valve reoperation, 2 patients were still in NYHA class 3 and 5 patients had a residual grade 1 or 2 mitral regurgitation. The 3-year actuarial survival was 86 +/- 10% and the 3-year probability to be free of reoperation was 95 +/- 6%. In mitral valve surgery, video-assisted approach is reliable, the operative risk is controlled and midterm results are not compromised. Video-assisted mitral valve surgery is a new less invasive standard; it is the procedure of choice in valve replacement, in reoperation and in non complex valve repair with good cosmetic results.     

Long-term results of the bentall operation versus separate replacement of the ascending aorta and aortic valve

BACKGROUND AND AIMS OF THE STUDY: Aortic valve disease associated with ascending aorta dilatation can be treated either by separate replacement of the aortic valve and ascending aorta, or by a composite valved graft. METHODS: Between 1974 and 1999, 117 patients underwent a Bentall operation (BP), and 63 a separate replacement procedure (SP) of the ascending aorta and aortic valve. Anatomic lesions were dystrophic aneurysm in 79 patients, annuloectasia in 65, chronic dissection in 14, acute dissection in 18, and other etiology in four. Mean follow up was 3.45+/-3.47 and 8.75+/-6.8 years in the BP and SP groups, respectively. RESULTS: Early mortality was 7.7% in the BP group versus 11% in the SP group (p = NS). Actuarial survival at 10 years postoperatively in these groups was respectively 77.7+/-5.6% versus 75.8+/-6.9% (p = NS). However, freedom from late complication of the ascending aorta was significantly different (97.3+/-1.9% versus 68.3+/-9.0% at 10 years postoperatively). SP was identified as a risk factor for late complication of the ascending aorta by multivariate analysis (p = 0.01; odds ratio = 9). No statistical difference was observed on late reoperation rates. CONCLUSION: Separate replacement of the ascending aorta and aortic valve carries a higher complication rate for the remaining ascending aorta on long-term follow up when compared with the Bentall procedure. However, there were no differences in terms of late mortality.