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Ann Thorac Surg 1996;62:463-468
© 1996 The Society of Thoracic Surgeons
Division of Cardiac Surgery, Brigham and Women's Hospital and the Department of Surgery, Harvard Medical School, Boston, Massachusetts
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Abstract |
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 TopFootnotes Abstract IntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Methods.One hundred fifteen consecutive patients who underwent ascending aortic aneurysm repair from January 1, 1990, to July 1, 1995, were retrospectively reviewed, excluding those with acute ascending aortic dissection. The mean age was 59 years; 55% were male. Concomitant procedures included coronary artery bypass in 23 (20%) and arch repair in 12 (10%). In group 1, 54 patients had replacement of the aortic valve, root, and ascending aorta with a valve-graft conduit using the "Bentall" technique, and of these 19 (35%) had Marfan's syndrome. In group II, 44 patients had separate aortic valve repair or replacement and supracoronary ascending aortic replacement. In group III, 17 patients had supracoronary ascending aortic replacement, without aortic valve operation. Operative techniques included frequent use of (1) intraoperative transesophageal echocardiography or epiaortic ultrasound scanning of the ascending and descending thoracic aorta to help guide arterial cannulation, avoid atherosclerotic embolization, and assess the repair; (2) antegrade and retrograde multidose cold blood cardioplegia for myocardial protection; (3) exclusion and button anastomotic techniques to ensure secure suture lines; (4) antifibrinolytic agents and collagen-impregnated aortic grafts to reduce bleeding; and (5) deep hypothermic circulatory arrest and the open distal anastomotic technique in patients with distal ascending and arch aortic disease.
Results.Operative mortality overall was 2/115 (1.7%). Mortality was 1/54 (1.8) in group I and 1/44 (2%) in group II, and there was no mortality in group III. The overall postoperative morbidity was 3% due to bleeding, 2% due to stroke, and 1% due to myocardial infarction. The length of stay in the past year has decreased to less than 7 days.
Conclusions.The current risk for ascending aortic aneurysm repair is low (<2%) whether or not the aortic root or valve also needs repair, regardless of the cause of the aneurysm.
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Introduction |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Patients and Methods |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Overall, there were 63 men and 52 women with a mean age of 59 years (range, 27 to 81 years). In group I there were 54 patients, with a mean age of 50 years, of whom 63% were male and 19 (35%) had classic Marfan's syndrome. In group II there were 44 patients, with a mean age of 66 years, of whom 52% were male. In group III, there were 17 patients, with a mean age of 68 years, and only 35% were male. A history of hypertension, smoking, and high cholesterol was more frequent in patients in group III. Prior cardiac operations had been performed on 15% of the patients, and 20% had significant coronary artery disease requiring concomitant coronary artery bypass grafting. Forty-five percent were class III or IV. Elective operations were carried out in 79%, urgent in 16%, and emergent in 5% (6 patients).
The cause of the aneurysms was determined by reviewing the pathologic examination of the aortic biopsy and the clinical findings. The overall cause of the aortic aneurysms is presented in Figure 1
. The cause for each group is outlined in Table 1. In group I, 54% of the aneurysms were myxomatous, including 19 (35%) with Marfan's syndrome and 10 (19%) with annuloaortic ectasia but without the other features of Marfan's syndrome. Only 19% of the aneurysms in group I were due to atherosclerosis, whereas 45% of those in group II and 71% of those in group III were due to atherosclerosis.
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In those cases in which the distal ascending aorta was diseased, cross-clamping of the diseased aorta was avoided, provided that the degree of aortic valve regurgitation did not result in ventricular distention during the cooling period. These patients were cooled to 15°C, deep hypothermic circulatory arrest was established, and an open distal aortic anastomotic technique was performed. In those patients with a diseased distal ascending aorta and significant aortic valve regurgitation causing ventricular distention, the ascending aorta was cross-clamped and an open distal aortic anastomosis was performed later, once the patient was adequately cooled. After completion of the distal aortic anastomosis, the perfusion cannula was reinserted into the prosthetic graft and arterial perfusion was restarted antegrade, the distal aorta and graft was deaired, the aortic graft was clamped proximal to the perfusion cannula, and the patient was rewarmed.
We used the St. Jude Medical (St. Paul, MN) valve graft/conduit, except in those cases where a homograft root was used. Before the introduction of the collagen-impregnated Hemashield (Meadox Medicals, Oakland, NJ) aortic graft beginning approximately in 1992, the prosthetic graft was soaked in albumin and then autoclaved. The valve-graft conduit was inserted in the aortic annulus with everting pledgeted mattress or simple sutures. The type of valve used for replacement and the incidence of repair are noted in Figure 2. The technique of coronary reimplantation in 45/54 (83%) of the Bentall procedures was the button technique, in which both coronary ostia are excised from the adjacent aneurysmal aorta and mobilized as buttons and anastomosed with continuous full-thickness sutures to the side of the prosthetic graft. Only 3/54 (6%) had the classic Bentall approach, in which the coronary orifices are not excised from adjacent aorta before reimplantation [4], and 6/54 (11%) had the Cabrol procedure, in which a separate smaller-diameter prosthetic tube graft is used to indirectly reattach the coronary arteries to the aortic graft [5].
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Concomitant procedures were performed in 32% of patients, including 23 (20%) who had coronary bypass grafting and 12 (10%) who also had at least a portion of the aortic arch replaced (Table 3). There were 17 patients who required reoperative mediastinotomy.
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-aminocaproic acid (Amicar) was used as an antifibrinolytic and antiplatelet aggregating agent, including in patients undergoing hypothermic arrest. Patients with St. Jude bileaflet mechanical aortic valves were anticoagulated to an international normalized ratio of 2.5, and patients with porcine valves were not anticoagulated at all unless for transient atrial fibrillation. Most patients were evaluated with follow-up thoracic aortic magnetic resonance imaging or computed tomographic scan at yearly intervals.
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Results |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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. The overall hospital mortality was 2/115 (1.7%). There was one death among 54 patients in the Bentall group (1.8%). This patient was a 77-year-old woman who required concomitant partial aortic arch replacement and coronary bypass for an atherosclerotic aneurysm and died of multisystem organ failure 15 days postoperatively. In group II, there was one death in 44 patients (2%). This patient was a 70-year-old woman with an atherosclerotic aneurysm who died of brain death, probably due to atheromatous emboli to the brain from retrograde femoral arterial perfusion or aortic cross-clamping. There was no mortality in group III. The incidence of reoperation for bleeding, nonfatal stroke, and nonfatal myocardial infarction was 3%, 2%, and 1% respectively. One patient who suffered a perioperative stroke was a 74-year-old woman in group III who required ascending and proximal arch aortic replacement for an atherosclerotic aneurysm and required debridement of the arch and partial arch replacement using an open distal anastomotic technique under hypothermic circulatory arrest and retrograde cerebral perfusion. A mild cerebellar stroke occurred. The other patient who suffered a cerebral complication was a 41-year-old man in group I in whom a transient ischemic attack developed while he was at home 2 weeks postoperatively after repair of an atherosclerotic aneurysm.
The only patient who suffered a perioperative myocardial infarction was a 54-year-old woman with an atherosclerotic aneurysm who had a Bentall procedure, using the Cabrol technique of coronary reimplantation. The right coronary artery was nondominant, and the right limb of the Cabrol graft thrombosed and then appeared to embolize thrombus to the left anterior descending and circumflex coronary arteries, causing left ventricular ischemia. The patient required reoperation, had two coronary bypass grafts placed to the left coronary circulation, and recovered gradually.
All 5 patients who either died (2) or suffered perioperative nonfatal stroke or myocardial infarction (3) had aneurysms that were due to atherosclerosis.
There have not been any late reoperations required for a recurrent ascending aortic aneurysm, but several patients have required repair of enlarging aneurysms of the aortic arch or descending thoracic aorta. In the Bentall group 1 patient later required an arch aneurysm resection. In group II, 1 patient required descending thoracic aortic aneurysm repair, and in group III, 4 patients later required descending thoracic aortic aneurysmectomy. Overall, about a third of the patients received no blood transfusions. In the past 2 years there has been a marked reduction in the length of stay, with many patients coming in the day of operation for elective aneurysm resection and discharged within 7 hospital days.
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Comment |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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For the Bentall-type operations we believe that the coronary button reimplantation technique is the most reliable method for prevention of bleeding and false aneurysm formation, especially in patients with Marfan's syndrome, as suggested by Kouchoukas and associates [8]. Creation of the buttons and mobilization of the coronary arteries allows the coronary orifices to be directly attached to the aortic graft, and for the anastomoses to be performed under minimal tension using full-thickness suturing techniques. If additional support is required, autologous aortic tissue rather than prosthetic collars has been our preferred material as a bolster. In past years when patients with Marfan's syndrome were treated by the "classic" nonbutton Bentall technique, the coronary reimplantation was made directly to the side of the aortic graft, but often was under tension and full-thickness suturing was not guaranteed, leading to a greater risk of late dehiscence of the anastomosis and pseudoaneurysm formation [9]. The Cabrol coronary reimplantation technique [5] is now rarely used on our service because the button technique appears more stable and associated with fewer complications, such as the graft thrombosis and embolization problem we observed. Although a valve-graft conduit has usually been recommended for Marfan's patients to exclude the diseased sinus tissue and aortic valve, newer operations in which the native aortic valve leaflets are preserved are being evaluated by David and Feindel [6]. This is a particularly intriguing option when there is minimal aortic regurgitation or aortic regurgitation due to annuloaortic ectasia with normal leaflets. The Bentall technique is also used in non-Marfan's patients when there is significant displacement of the coronary ostia from the aortic annulus and the aortic sinuses are quite dilated below the coronary ostia. If there is no coronary displacement, we have preferred the more conservative operation of separate valve repair or replacement and supracoronary aortic graft or aortic graft.
We also believe the exclusion type aortic anastomotic technique popularized by Crawford and Crawford [10] is the technique of choice to prevent bleeding intraoperatively and especially to prevent late false aneurysms at aortic anastomoses. In particularly fragile aortas, the anastomosis can be buttressed or wrapped with Teflon strips, autologous pericardial strips, or autologous native aorta to reinforce fragile suture lines.
The use of deep hypothermic arrest in the treatment of ascending aortic aneurysm remains a controversial concept if there is a reasonable neck proximal to the innominate artery. Although the clampless open distal anastomotic technique is now widely accepted for dissections of the aorta [11], it is not generally done for straightforward aneurysms of the ascending aorta unless there is severe atherosclerotic disease diagnosed by preoperative study, or by intraoperative palpation, epiaortic ultrasound, or transesophageal echocardiography. Clamps can produce dissections of the aorta beyond the anastomosis, and the presence of intimal disease can be subtle and difficult to appreciate, so open distal anastomosis of all aneurysms using deep hypothermic techniques may be a consideration. We have used the open distal anastomosis technique if there is any question about the aneurysm abutting the arch vessels or another local situation that would suggest that a clamp technique may produce some injury to the intima. Deep hypothermic arrest is instituted with intermittent retrograde cerebral perfusion and aortic clamping is avoided. Two perioperative strokes in this series, one fatal, occurred in patients with atherosclerotic aneurysms in whom the distal aorta was clamped. We used the open distal anastomotic technique in 23/115 patients (17%) and there was one death and one stroke among these patients, but neither occurred among the patients who did not have the native aorta clamped before completion of the distal aortic anastomosis. In 7/23 patients (30%) we used retrograde cerebral perfusion, an increasingly used technology to perfuse the brain and flush out debris and air from the cerebral vessels during circulatory arrest [12].
Graft technology has changed surgery of the ascending aorta by making the operation technically easier and decreasing blood loss. The collagen-impregnated Hemashield woven aortic graft by Meadox is an important advance because it sutures and handles easily, yet "pore" bleeding is limited.
Use of aprotinin for aortic aneurysm operations is controversial, because of concern regarding a possible increased risk of intravascular thrombosis, particularly for those cases requiring deep hypothermic circulatory arrest [13]. We have used Amicar for routine operations and for those that had deep hypothermic circulatory arrest. Aprotinin has been used for all reoperations, but not with hypothermic arrest, and we have not noted any problems, particularly with renal function. Blood use decreased dramatically: only 4/115 required a reoperation for bleeding and about 30% of patients received no blood transfusion during the hospital courses.
Echocardiography has become important, particularly in the latter years of this series, to ascertain when to use and when not to use retrograde femoral cannulation due to descending thoracic atherosclerotic material. We believe that in the past, embolic injuries of the brain have been caused by retrograde perfusion of this material into the cerebral vessels. Echocardiography has also been helpful in establishing whether or not dissection has occurred after an aortic grafting operation [14]. In addition, the heart can be evaluated for residual air and for valvular and ventricular function. In group II some patients had mild to moderate aortic regurgitation without sinus enlargement, which was thought to be due to the aneurysm causing outward displacement of the valve commissures. The aortic valve regurgitation was corrected by resection of the aneurysm and down-sizing the graft to reduce the aorta at the sinotubular area, as suggested by David and Feindel [15]. Two patients in group III with forme fruste of Marfan's syndrome were treated by sculpturing the graft, leaving the coronary orifices in the sinus and preserving the valve similar to a technique reported by Miller and associates [16].
Using newer graft and ultrasound technology, antifibrinolytic agents, better anastomotic suturing methods of both aorta and coronary buttons, and improved myocardial and cerebral protection, operation for repair of ascending aortic aneurysms has been made safer and more dependable. Blood use appears to have decreased dramatically and the need for reoperation for recurrence has been negligible. Thus patients with 5-cm ascending aortic aneurysms, similar to the size recommended for abdominal aortic aneurysms, should be able to undergo surgical resection of the aneurysm with as low a risk as that in the abdomen. A combination of all of these technical advances has led to decreased mortality and morbidity, hence decreased length of stay and cost, which are important factors in the present cost-conscious medical environment.
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Acknowledgments |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Footnotes |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Address reprint requests to Dr Cohn, Division of Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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