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Ann Thorac Surg 1997;64:986-992
© 1997 The Society of Thoracic Surgeons
Division of Cardiothoracic Surgery, Washington University School of Medicine, and the Heart Center, Missouri Baptist Medical Center, BJC Health System, St. Louis, Missouri
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentReferences |
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Methods. Eighty-one patients (age range, 14 to 78 years) underwent reoperations on the aortic root or the ascending aorta during a 14.5-year interval ending October 1996. The previous operations were aortic valve procedure (28%), coronary artery bypass grafting (25%), aortic root replacement (24%), ascending aortic replacement (19%), and miscellaneous (5%). Twenty-two patients (27%) had had two or more previous operations. The principal indications for reoperation were true or false aneurysm (35%), acute or chronic dissection (28%), and malfunction of an aortic valve substitute (27%). The reoperations performed were aortic root replacement (composite graft, allograft, or autograft) in 48 patients and graft replacement of the ascending aorta in 33 patients. Concomitant procedures included aortic arch replacement in 43 patients (55%) and coronary artery bypass grafting in 33 patients (41%).
Results. The 30-day mortality rate was 8.6% (7 patients). It was 8.3% for aortic root replacement and 9.1% for ascending aorta replacement (p > 0.05). Using stepwise multivariate logistic regression analysis of 23 variables, preoperative functional class III/IV (p = 0.047) and duration of cardiopulmonary bypass (p = 0.007) were significant independent predictors of early death. The mean duration of follow-up was 3.6 years. The 1-year, 5-year, and 10-year survival rates were 89%, 81%, and 69%, respectively. Freedom from reoperation on the heart or ascending aorta was 98%, 92%, and 69%, respectively. Reoperation for false aneurysm (p = 0.050) and the presence of coexisting coronary artery disease requiring bypass grafting (p = 0.010) were the only significant predictors of late mortality.
Conclusions. Reoperations on the aortic root and the ascending aorta can be accomplished with acceptable early mortality and satisfactory long-term results. More frequent resection of the aneurysmal or dissected segments of the ascending aorta and aortic root at the initial operation may reduce the need for subsequent reoperation.
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Introduction |
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During the last decade, important advances in the perioperative management of patients with aneurysmal disease and dissection that involves the aortic root and the ascending aorta have substantially reduced the risks of operation and have improved the long-term outcome. As a consequence, the number of procedures performed on these segments of the thoracic aorta has increased. Although the incidence of complications requiring reoperation appears to have decreased, the total number of patients at risk for the development of complications that may require reoperation has, in all probability, increased. The more frequent use of aortic allografts and pulmonary autografts to replace diseased aortic valves and aortic roots as well as the increased use of valve-sparing operations has also increased the population of patients who may be at risk for the development of complications that may require reoperation. The aging of the population of patients who are undergoing cardiac surgical procedures such as coronary artery bypass grafting and valve replacement has resulted in an increase in the number of patients who have degenerative diseases of the aorta and are thus at risk for intraoperative injury to the aorta that may require treatment at a later operation. The increasing use of echocardiography and computed tomography in the evaluation of patients after operations on the aortic root and the ascending aorta has identified abnormalities in asymptomatic or minimally symptomatic patients that may require reoperation.
Taken together, these observations suggest that the frequency of reoperations on the aortic root and the ascending aorta will likely increase. This has been our experience during the last 5 years. In this report, we present our experience with reoperations on the aortic root and the ascending aorta during a 14
-year interval.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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The clinical characteristics of the patients are shown in Table 1
. The majority of the previous operations involved aortic valve replacement or repair (23 patients), coronary artery bypass grafting (20 patients), aortic root replacement (19 patients), or ascending aorta replacement (15 patients). Patients undergoing aortic arch operations alone were excluded from this series. Twenty-two patients had had two or more (6 patients having had three) operations on the heart, the aortic root, or the ascending aorta. The procedures shown in Table 1 represent the most recent operation. The interval between the last procedure and the current reoperation ranged between 10 days and 18.5 years and averaged 6 years. Thirty-three patients (41%) were in New York Heart Association functional class III or IV preoperatively, and 43 (53%) had moderate or severe aortic regurgitation.
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. The presence of a true or false aneurysm, acute or chronic aortic dissection, and malfunction of an aortic valve substitute were the principal ones. In 11 of the 12 patients with true aneurysms and in 9 of the 23 patients with dissection, inadequate repair during the previous operation resulted in recurrence and the need of reoperation. Three patients with aortic allografts and 3 with pulmonary autografts required reoperation because of major aortic regurgitation. In 1 patient with a pulmonary autograft, a false aneurysm developed. Five patients required reoperation for prosthetic valve endocarditis. In 1 patient, coarctation of the ascending aorta developed after insertion of a composite graft. Among the 9 patients with Marfan's syndrome, 1 had undergone three previous operations for treatment of an ascending aortic dissection, and 2 had undergone previous composite graft replacement of the aortic root two or three times.
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). Replacement of the ascending aorta with a Dacron graft was done in the other 33 patients. Concomitant procedures included replacement of all or part of the aortic arch in 43 patients, coronary artery bypass grafting in 21 patients, aortic arch replacement and coronary artery bypass grafting in 12 patients, and aortic or mitral valve replacement in 8 patients. Three patients undergoing concomitant aortic arch replacement also had resection and graft replacement of the proximal descending thoracic aorta.
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To avoid ventricular fibrillation and distention, the perfusate temperature is not reduced if aortic regurgitation is present. If the right atrium can be mobilized, a second venous cannula is inserted into the superior vena cava. The left heart is vented through the right superior pulmonary vein or through the pulmonary artery. The ascending aorta is isolated circumferentially to permit placement of a clamp. Cooling of the perfusate is then initiated. A balloon-tipped cannula is placed into the coronary sinus through a pursestring suture in the wall of the right atrium. If the aortic valve is competent, the initial dose of cold blood cardioplegic solution is administered into the ascending aorta after placement of the aortic clamp. Subsequent infusions of cardioplegic solution are administered into the coronary sinus or directly into the coronary arteries, when possible, every 20 to 25 minutes. Topical cooling with iced slush or a cooling jacket are also used for additional myocardial protection.
If the ascending aorta cannot be isolated and if there is no aortic regurgitation, profound cooling is initiated. When the nasopharyngeal temperature reaches 12° to 14°C and the electroencephalogram is isoelectric, circulatory arrest is established. If the ascending aorta can then be isolated and clamped and resection of the aortic arch is not indicated, rewarming can be initiated and the procedure completed. If replacement of the aortic arch is necessary, it is performed at this time. As the anastomosis between the aortic arch and the Dacron graft is being completed, cold (6°C) blood is infused into the superior vena cava cannula to facilitate removal of air and debris from the branchiocephalic vessels. If dissection or severe atherosclerosis is present, flow is reestablished in the antegrade direction by insertion of an aortic cannula into the aortic graft or into an 8-mm collagen-impregnated Dacron graft that is sutured to the aortic graft [7].
If moderate or severe aortic regurgitation is present and the ascending aorta cannot be clamped, other approaches are necessary. If the sternum cannot be safely divided, partial division of the sternum and cannulation through the apex of the ventricle may permit sufficient cooling to safely establish circulatory arrest [8]. If the sternum can be divided, cooling is initiated. Circulatory arrest is established. The ascending aorta or the previously inserted aortic graft is incised, and perfusion cannulas are inserted directly into the innominate and left carotid arteries. Occlusion catheters are placed in the left subclavian artery and in the descending thoracic aorta. Cold (6° to 10°C) perfusion of the innominate and carotid arteries and the distal aorta is initiated, and the aortic arch is replaced as just described.
Replacement of the ascending aorta or the aortic root is completed during the period of rewarming. If root replacement is required, the coronary arteries are excised with a small cuff of aortic tissue and are anastomosed to the ascending aortic graft. If this is not possible, short segments of 8-mm collagen-impregnated Dacron grafts are sutured to the aortic tissue surrounding the coronary ostia and to the ascending aortic graft. This was necessary in 9 (19%) of the 48 patients having aortic root replacement. Previously placed saphenous vein grafts are reimplanted into the new aortic graft using a cuff of aorta or a Dacron graft. New saphenous vein grafts are sutured to the new aortic graft.
The mean duration of cardiopulmonary bypass for the 81 patients was 187 ± 78 minutes, and the mean duration of aortic clamping was 145 ± 59 minutes. Hypothermic circulatory arrest was required in 45 patients (56%). The mean duration of arrest was 40 minutes (range, 9 to 119 minutes). In this series, 2 patients, neither of whom were undergoing circulatory arrest, received aprotinin.
Follow-up
Follow-up information was obtained between March and October 1996 by examination of the patients or by correspondence (telephone or mailed questionnaire) with the patients and their referring physicians. Information was available for all but 3 of the hospital survivors. The mean duration of follow-up was 3.6 years (range, 1 month to 12.5 years).
Statistical Analysis
Group statistics were expressed as the mean ± one standard deviation. The end points examined were 30-day mortality, late mortality, subsequent reoperation on the ascending aorta or the aortic root, and the development of prosthetic valve endocarditis, thromboembolism, or complications related to anticoagulant therapy. Standard definitions were used for these events [9]. The Stata (Stata Corporation, College Station, TX, 1989) and the BMDP (University of California, CA, 1992) statistical software packages were used. Comparisons for univariate analyses were performed with the standard t test, 
2, or Fisher's exact test, when appropriate. Stepwise forward logistic regression analysis (Stata) was used to determine the independent predictors of early mortality. Survival analysis was performed using the Kaplan-Meier method (BMDP), and survivor groups were compared using the log-rank test (BMDP). Multivariate analysis of late survival adjusted for preoperative and operative variables was performed using the Cox proportional hazard method (BMDP). The variables used for analysis of 30-day mortality are shown in Tables 4 and 5. For late death, the variables analyzed were age, sex, reoperation for false aneurysm, history of two or more previous operations, presence of Marfan's syndrome, aortic root replacement, aortic regurgitation, aortic dissection, and concomitant coronary artery bypass grafting or aortic arch replacement. A p value of less than 0.05 was considered significant.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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In the univariate analysis, New York Heart Association class III/IV, a short interval between operations, and prolonged duration of cardiopulmonary bypass were associated with increased mortality (see Tables 4, 5
). In the multivariate analysis, preoperative functional class III/IV (p = 0.047) and prolonged duration of cardiopulmonary bypass (p = 0.007) were independent risk factors for 30-day mortality.
MORBIDITY.
Five patients (6%) required early reoperation for bleeding. Four patients required intraaortic balloon pumping postoperatively for low cardiac output. One patient sustained a perioperative myocardial infarction, and 1 required insertion of a permanent pacemaker. Three patients required prolonged assisted ventilation, and 2 had development of acute renal failure requiring dialysis. Two patients (2.5%) sustained a permanent neurologic deficit, 2 experienced confusion and delirium, which resolved, and 1 sustained a retinal artery embolus.
Late
SURVIVAL.
There have been ten late deaths during follow-up, which extends to 12.5 years. Among the survivors, the 1-year, 5-year, and 10-year survival rates for the entire group were 89%, 81%, and 69%, respectively (Fig 1). The survival rates did not differ significantly between patients having aortic root replacement and those having replacement of the ascending aorta. For patients having aortic root replacement, there were no significant differences in survival between those who had insertion of a composite graft, an aortic allograft, or a pulmonary autograft. Using the Cox proportional hazard method, the presence of a false aneurysm (p = 0.05) and the presence of coexisting coronary artery disease requiring bypass grafting (p = 0.01) were the only significant independent predictors of late mortality.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Previous studies have identified the common technical problems leading to reoperation and other complications requiring reoperation. For patients having operation for aortic dissection, these include, use of localized aortoplasty, replacement of only a small segment of the ascending aorta with a tube graft, use of tube graft replacement in patients with dilated sinuses of Valsalva, and development of false aneurysms at anastomotic sites [15]. For patients with Marfan's syndrome or annuloaortic ectasia, failure to replace the dilated aortic sinuses at the time of valve replacement or resection of an ascending aortic aneurysm or dissection and use of the inclusion wrap technique have been associated with an increased incidence of reoperation [3, 4, 10–13, 16, 17]. For patients with aneurysms of the ascending aorta who require aortic valve replacement or coronary artery bypass grafting, failure to resect the aneurysm increases the probability of a subsequent operation [10].
In our series, all of these problems were encountered among the patients who required reoperation. In addition, we had patients who had reoperation because of failure of previously inserted aortic root allografts and pulmonary autografts. The number of patients requiring reoperation for this complication will likely grow because of the increasing use of these grafts for the treatment of disorders of the aortic valve and the aortic root. The management of patients with allograft failure varies. In several, we just replaced the valve; those patients were not included in the study. Infection of the prosthetic valve or graft remains an important, although relatively infrequent cause of reoperation [16].
In our series, more than half of the patients requiring reoperation had had previous operations on the aortic valve or coronary artery bypass grafting (see Table 1). The majority of these patients had aneurysmal disease of the aorta that was present at the initial operation and was not treated or had development of dissections or false aneurysms during or early after the previous operation. These findings suggest that more aggressive management of aortic disease at the time of aortic valve replacement or coronary artery bypass grafting should reduce the need of reoperation. The low operative risk currently associated with elective ascending aorta replacement, even in conjunction with valve replacement or coronary artery bypass grafting, justifies this recommendation [18].
Long-term survival after reoperation has been satisfactory (81% at 5 years and 69% at 10 years). Comparison with results from other studies is difficult because of the heterogeneity of the patients in the various surgical series. In our study, reoperation for false aneurysm and the need of coronary artery bypass grafting at reoperation were the only significant predictors of late mortality. Actuarial freedom from reoperation on the ascending aorta or the aortic root was 69% at 10 years. Two of the four reoperations were for complications related to the previously inserted aortic graft, and two were for treatment of aneurysms that developed adjacent to the previously inserted grafts.
The mean interval of approximately 6 years between the current reoperation and the last surgical procedure emphasizes the importance of continued surveillance of patients after cardiac, valvular, and thoracic aortic surgical procedures. Although periodic examination of all such patients by cardiothoracic surgeons is not possible, it is our belief that those patients with diseases or surgical procedures that render the patient at increased risk for the development of complications that may require operation should be examined at regular intervals by cardiothoracic surgeons or other cardiovascular specialists who are familiar with the disease processes and the surgical procedures. This includes patients with Marfan's syndrome, patients who have undergone ascending aorta or aortic root replacement, and patients with valvular or coronary artery disease who had enlarged or other wise abnormal aortas at the time of the initial operation that were not replaced or were treated by other methods such as wrapping or aortoplasty. The need for reoperation as late as 18.5 years after the previous operation in our series supports this position.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Address reprint requests to Dr Kouchoukos, 3009 N Ballas Rd, Suite 266C, St. Louis, MO 63131.
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M. A.A.M. Schepens, K. M. Dossche, and W. J. Morshuis Reoperations on the ascending aorta and aortic root: pitfalls and results in 134 patients Ann. Thorac. Surg., November 1, 1999; 68(5): 1676 - 1680. [Abstract] [Full Text] [PDF]
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L. G. Svensson and R. S. D'Agostino "J" incision minimal-access valve operations Ann. Thorac. Surg., September 1, 1998; 66(3): 1110 - 1112. [Abstract] [Full Text] [PDF]
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L. G. Svensson and R. S. D'Agostino Minimal-access aortic and valvular operations, including the "J/j" incision Ann. Thorac. Surg., August 1, 1998; 66(2): 431 - 435. [Abstract] [Full Text] [PDF]
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