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Ann Thorac Surg 1997;64:1108-1112
© 1997 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Aortic Valve Conservation in Acute Type A Dissection

Department of Cardiac Surgery, Oxford Heart Centre, Oxford, England

Accepted for publication April 23, 1997.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. We consider operative survival as the primary objective in acute type A dissection and believe that virtually all native aortic valves can be conserved. We sought to answer the question: "Does glue repair improve the long-term stability of proximal aortic repair?"

Methods. We retrospectively studied 64 patients with an acute type A dissection, an ascending aortic tear, and aortic regurgitation operated on by the same surgeon between 1988 and 1996. Three had Marfan's syndrome and 2 had a bicuspid valve. The valves in all patients without Marfan's syndrome were repaired with gelatin-resorcinol-formol glue. The valve and root were reinvestigated by echocardiography. Some patients underwent nuclear magnetic resonance imaging.

Results. There were four hospital (6%) and three late deaths. Aortic root reoperation was required in 2 of the 60 survivors (3.3%) and operation on the distal aorta in 2. Root reoperations were required within 3 years. The remaining proximal repairs remained stable.

Conclusions. The native aortic valve can be conserved in most patients, and glue repair is durable. Simple root repair is associated with a low operative mortality.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
The priority in operations for an acute type A dissection is operative survival. This is partly dependent on the interval between dissection and treatment but is predominantly dependent on the effectiveness of the surgical intervention [1, 2]. The operation aims to prevent aortic rupture, correct aortic regurgitation, and obliterate the distal false lumen. In 70% of patients the intimal tear is within 2 to 3 cm of the valve (Stanford type A dissection) and involves 50% to 70% of the aortic circumference [3]. These patients suffer prolapse of the right and noncoronary aortic cusps with aortic regurgitation. Up to 10% of patients with a non-Marfan's dissection have a bicuspid valve (versus 1% to 2% in the general population) [4]. Marfan's syndrome accounts for 3% to 5% of the acute type A dissections and in high-risk families may occur in an aortic root of 4.0 cm [5].

In most patients the aortic valve is functionally normal before dissection. Native valve conservation is therefore preferable and is achieved in conjunction with ascending aortic replacement. A valve procedure is seldom required for primary arch tears. The actual incidence of valve repair versus replacement varies considerably between centers. In a combined series of 170 patients from Stanford and Duke Universities (1991), ascending aortic replacement alone was performed in 95 patients and only 75 required a valve procedure [6]. Of these, half underwent aortic valve replacement but with a similar incidence of late reoperations in repair and replacement groups. More recently the experienced groups at Mount Sinai Medical Center (New York) and in Zurich have reported valve conservation rates of 74% and 56%, with operative mortalities of 13.6% and 22%, respectively [7, 8]. However, some of these patients did not have significant aortic regurgitation and survival was similar or better in those who underwent root replacement with a composite graft. Ergin [7] and Svensson [9] and their colleagues, as well as others, now advocate the more frequent performance of root replacement in patients with dissection. Despite this, we consider conservation of the native valve to be possible and preferable in the great majority of patients and believe that this strategy reduces hospital mortality. This prompted us to review our experience in patients with acute type A dissection and aortic regurgitation operated on in the era of biological glue [10]. We sought to answer the question: "Does gelatin-resorcinol-formol glue (GRF) provide a durable aortic root repair without the need to remove all dissected tissues?"

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Between 1988 and July 1996, 64 patients with an acute type A dissection, an ascending aortic tear, and aortic regurgitation were operated on by one surgeon (S.W.), and they form the basis of this study. During this period the same surgeon also operated on 8 patients with primary arch tears and no aortic regurgitation, so that root repair was not necessary. Fifty-two patients were male, and 12 were female; ages ranged from 37 to 81 years (mean, 63 ± 9 years). Three patients had Marfan's syndrome, and 2 had a bicuspid aortic valve without significant aortic stenosis. Forty-six patients had hemopericardium. Twenty-seven patients presented with circulatory deterioration resulting from cardiac tamponade. Four were resuscitated by cardiac massage and 1, by pericardiocentesis. Two patients presented with left hemiparesis, and 1 had previously undergone a coronary artery bypass operation. Four had received streptokinase for suspected myocardial infarction. Preoperative diagnosis was established by computed tomography and transthoracic or transesophageal echocardiography. We avoided catheter investigations. Because of wide variations in the hemodynamic status of patients, aortic regurgitation was designated as either present or absent, but not graded. Patients without aortic regurgitation are not discussed further.

Operative Methods
All patients underwent emergency operation upon confirmation of the diagnosis. In each patient, cardiopulmonary bypass was established with arterial return through the femoral artery with the most prominent pulse. All patients received a cerebral protection cocktail of nimodipine (1 mg/h), thiopentone (6 mg/kg loading dose, then 6 mg • kg^-1 • h^-1), and mannitol (500 mg/kg). Femoral cannulation was obtained before the pericardium was opened. Venous drainage was then established with a two-stage cannula inserted through the right atrial appendage. Free aortic rupture occurred upon relief of the pericardial tamponade in 2 patients. Cooling to 22°C was begun immediately, and in 1 patient, cerebral malperfusion was discovered when the nasopharyngeal temperature remained at 36°C. After 15 minutes of normothermic cerebral ischemia with the aortic root already open, the arterial cannula in this patient was switched to the aortic arch. Cooling then proceeded as expected.

After beginning cardiopulmonary bypass, a vent was inserted into the apex of the left ventricle and an aortic cross-clamp applied between 2 and 3 cm proximal to the innominate artery. The cross-clamp site was later excised during open-ended distal anastomosis. The aorta was then opened and the heart arrested with cold potassium cardioplegia (St. Thomas' solution) delivered anterograde into the coronary ostia. In the patient with coronary grafts, the proximal anastomoses were mobilized and reimplanted into the aortic graft. Irrespective of the site of the primary tear, the aorta was transected at the level of the sinotubular junction, leaving between 0.5 and 1 cm above the coronary ostia. Dissection was found in the tissues around the right coronary ostium in all 64 patients, whereas only 7 patients had pericoronary dissection around the left coronary ostium.

All blood clot was removed assiduously from the aortic false lumen and the aortic wall reconstituted with GRF glue. The aortic sinuses were carefully remodeled over 3 to 5 minutes while the glue set. Care was taken to obliterate the entire space between the dissected layers. Aortic root replacement with a valved conduit was undertaken electively in all 3 Marfan's patients. The coronary buttons were mobilized out of the native aorta and reimplanted into the valved conduit. All 61 non-Marfan aortic roots were repaired, including the bicuspid valves. With the aortic sinuses reconstituted with glue, the sinotubular junction was measured with a valve sizer and a slightly smaller (2 to 5 mm) Hemashield (Meadox Medicals, Oakland, NJ) graft chosen for ascending aortic replacement. The anastomosis was performed with continuous 4-0 Prolene (Ethicon, Somerville, NJ), without a Teflon buttress. The suture line was carried deep into the right coronary sinus and close to the superior rim of the left and right coronary ostia. In most patients the repair was completed within the 20 minutes required to cool to 22°C. The patient was then tipped head down and the circulation arrested. We did not use retrograde cerebral perfusion. The aortic cross-clamp was removed and the aorta transected at the root of the innominate artery. The false lumen in the proximal aortic arch was obliterated with glue, using a Foley urinary catheter balloon to distribute pressure evenly and prevent glue embolism. Five minutes were allowed for the glue to dry, after which the distal anastomosis was performed with a circumferential rim of Teflon felt. Where the tear extended into the arch in 4 patients, this was excised and hemiarch replacement performed. Air was then removed from the aortic arch, Dacron graft, and left ventricle and perfusion recommenced with full rewarming. The mean duration of total circulatory arrest was 20 minutes (standard deviation, ±8). The myocardial ischemic time was 46 minutes (standard deviation, ±13). Further air was removed at full rewarming and cardiopulmonary bypass discontinued. The mean duration of perfusion was 64 minutes (standard deviation, ±18, excluding circulatory arrest time). The mean duration of operation was 177 minutes (standard deviation, ±9, including aortic root replacements).

Follow-up and Investigations
All patients were started or continued on a regimen of beta-blockers and reviewed at 3-month and then 6-month intervals. Aortic valve function in all patients was investigated by echocardiography at follow-up. Nuclear magnetic resonance imaging (NMR) was performed at intervals of between 6 weeks and 1 year after dissection repair in 24 patients to determine the status of the aortic root and distal false lumen. However, for economic reasons, NMR studies were not performed in all patients. Follow-up and data collection were carried out independent of the operating surgeon, and all surviving patients were traced for the purpose of the investigation.

Statistical Analysis
Both survival times and times free from reoperation in months were calculated from the time of the first operation to the end point of August 1996 using Kaplan-Meier tables and curves.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
The surgeon considered that a competent aortic valve was achieved by root repair with GRF glue in all 61 patients without Marfan's syndrome. A postoperative echocardiogram showed residual mild to moderate aortic regurgitation in 1 patient, and this proved to be progressive, eventually requiring valve replacement (see section on Late Valve Status).

Morbidity and Mortality
Reoperation for the management of diffuse bleeding was required in 1 patient. Three of the 61 patients without Marfan's syndrome died in the hospital. One with severe diffuse coronary artery disease and a second with a detached right coronary artery and preoperative myocardial infarction died of left ventricular failure in the operating room. The third patient suffered ventricular fibrillation on the second postoperative day and died of diffuse cerebral injury on day 20.

One patient with Marfan's syndrome was readmitted to the hospital with mediastinitis and died from the consequences of graft infection on day 48. Four of the 64 patients died, for an overall perioperative mortality of 6%. There were no hospital deaths resulting from bleeding or distal aortic rupture, but 1 patient who had had root repair died suddenly at home 3 months after operation. No autopsy was obtained.

Preoperative left hemiparesis persisted in 1 patient but resolved completely in the second. There were four new permanent neurological events: 3 cases of hemiparesis and 1 of monoplegia. The patient with prolonged cerebral malperfusion recovered completely and returned to work as an accountant. One patient required temporary hemodialysis for renal failure.

Late Valve Status
Echocardiography and NMR (in 44% of patients) findings indicated that the root repaired with GRF glue does not change with time (Fig 1). In 55 of the 61 patients who underwent aortic root repair, the integrity of the aortic valve and sinuses remained unchanged between 6 months and 8 years postoperatively and none had more than trivial aortic regurgitation. None of these patients required anticoagulants, and there were no thromboembolic events.

View larger version (179K): [in this window] [in a new window]   Fig 1. . Nuclear magnetic resonance image of the aortic root 12 months after repair of an acute type A dissection. There is no dilatation of the retained aortic sinuses.

Late reoperation was required for the management of an aortic arch aneurysm in the patient who suffered cerebral malperfusion, with presumed tension in the false lumen at the first operation. Replacement of the aortic arch and proximal descending thoracic aorta was performed, but diffuse cerebral injury resulted in death 16 days later. This patient's aortic valve was fully competent, with normal sinuses. Computed tomography and autopsy revealed the presence of widespread cerebral embolism. One 76-year-old woman with very poor respiratory function had massive aneurysm formation in the descending thoracic aorta and an atherosclerotic abdominal aortic aneurysm. She underwent combined thromboexclusion and abdominal aneurysm repair (Fig 2). Nuclear magnetic resonance imaging in 24 patients showed obliteration of the dissection in the aortic sinuses in 23 (96%) but persistence of part or all of the distal false lumen in 19 (79%). The first patient (age, 87 years) in the series died after an abdominal operation for complications of diverticular disease 8 years after aortic repair. Autopsy showed the valve and sinuses to be normal, though echocardiography showed mild aortic regurgitation. Figures 3 and 4 show actuarial survival and freedom from dissection-related reoperation.

View larger version (101K): [in this window] [in a new window]   Fig 2. . Nuclear magnetic resonance scan of the thorax 3 years after repair of an acute type A dissection. (A) The aortic root is normal in appearance. (B) There is massive dilatation of the false channel in the descending thoracic aorta.

View larger version (13K): [in this window] [in a new window]   Fig 3. . Actuarial survival after operation for an acute type A dissection. (Cum = cumulative; n = number of patients at risk.)

View larger version (14K): [in this window] [in a new window]   Fig 4. . Freedom from aortic root reoperation after an acute type A dissection. (n = number of patients at risk.)

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

Although composite graft aortic root replacement and radical root repair (with mobilization and reimplantation of dissected coronary arteries) can be achieved with an acceptable operative mortality by experienced groups, most patients are operated on under emergency conditions by surgeons with limited experience in aortic root operations. Dissected pericoronary tissues may be very fragile, even in patients without Marfan's syndrome. Given the added difficulties posed by diagnostic delay, visceral malperfusion, and established coagulopathy, with or without the misuse of thrombolysis, we emphasize that operative survival is of paramount importance [14, 15]. An expeditious and simple operation is most likely to achieve this, as long as the patient does not have Marfan's syndrome.

It has been suggested that it is possible to preserve the native aortic valve using conservative techniques in 70% to 80% of patients without Marfan's syndrome but that 20% of these will go on to require aortic valve replacement within 10 years because of progressive aortic regurgitation [16, 17]. These results have come predominantly from experienced centers but without access to GRF glue. In Europe, evidence is accumulating to suggest that the use of glue provides long-term stability in reconstituted dissected aorta, with no demonstrable adverse effects [18, 19]. The surgical approach described here is simple, expeditious, and durable and associated with a low operative mortality. Our experience indicates that virtually all aortic valves that are competent before dissection can be restored to a satisfactory functional state by glue repair and remodeling of the sinotubular junction using a vascular graft of appropriate size. Teflon felt is no longer required for the root repair, because the GRF glue enhances the suture-holding capacity and plugs the needle holes. The open-ended distal anastomosis (mandatory in our view) allows glue reconstruction of the aortic arch [19]. Complete transection at the sinotubular junction and beyond the site of aortic cross-clamping is an important prerequisite for accurate glue repair, after which the operation simply involves the interposition of an impervious tube graft [20].

The method has the advantage of great simplicity, with a short duration of perfusion and total circulatory arrest at 22°C. For this reason, we do not use retrograde cerebral perfusion. Conservation of the native aortic valve also avoids the long-term risks posed by anticoagulation.

Failure of valve repair in this series occurred as a result of failure to obtain a competent repair in 1 patient and failure to obliterate the false lumen, resulting in aneurysm formation, in the second. Although this man did not have Marfan's syndrome, his dissection occurred when he was 44 years old, indicating the presence of cystic medial necrosis. In retrospect, this patient might have been better served by aortic root replacement. The recent strategy of aortic root repair in type A dissection patients advocated by David and Feindel [21] avoids the use of a prosthesis in young patients, but this method should be assessed carefully before its widespread adoption. Although Gott and colleagues [22] and Miller and colleagues [23] have demonstrated excellent long-term results from elective aortic root replacement in Marfans patients, the survival curves in those who are operated on after dissection remain dismal, with a high incidence of reoperation. This stems from failure to obliterate the distal false lumen and the propensity for aneurysm formation, also demonstrated in our NMR follow-up studies [24]. Even aggressive, complete aortic arch replacement, which carries a 23% mortality in expert hands, fails to obliterate the false lumen in more than half of the patients [25, 26].

Debate continues as to whether glue repair is superior to classic resuspension using layers of Teflon felt [27]. In addition to our experience, the long-term integrity of aortic root repair was recently reported by Séguin and colleagues [28], who employed fibrin glue. In 15 consecutive patients with severe aortic insufficiency, follow-up by clinical examination and computed tomography showed no more than trivial aortic regurgitation with no residual dissecting process in the aortic sinuses.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Mr Westaby, Department of Cardiac Surgery, Oxford Heart Centre, John Radcliffe Hospital, Oxford, England OX3 9DU

This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/annals

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

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