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Ann Thorac Surg 1998;66:388-395
© 1998 The Society of Thoracic Surgeons
a Florida Heart Institute, Orlando, Florida, USA
Address reprint requests to Dr Stowe, Cardiovascular Surgeons, PA, 217 Hillcrest St, Orlando, FL 32801
Presented at the Forty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Naples, FL, Nov 6–8, 1997.
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Abstract |
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 Top Abstract IntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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Methods. We conducted a retrospective analysis of records of 117 consecutive patients who underwent 118 procedures between March 1987 and September 1997, for graft replacement of the ascending or transverse aortic arch with or without aortic valve reconstruction or replacement. There were 67 men (57.3%) and 50 women (42.7%). The mean age was 61.4 years (range, 16 to 81 years). Aortic abnormalities were medial degeneration in 59 patients (50.0%), dissection in 28 patients (23.7%), atherosclerosis in 16 patients (13.6%), Marfan’s syndrome in 8 patients (6.8%), and other in 7 patients (5.9%).
Results. The ascending aorta alone was replaced in 58 patients (49.2%), ascending and arch aorta in 56 patients (47.5%), and isolated arch aorta in 4 patients (3.4%). Twenty-six patients (22.0%) required aortic valve reconstruction, 17 patients (14.4%) had separate aortic valve replacement, and 37 patients (31.4%) received a valve conduit. Overall hospital mortality rate was 3.4% (4 of 117 patients). Postoperative complications included myocardial infarction in 3 patients (2.5%), stroke in 7 patients (5.9%), pulmonary insufficiency in 22 patients (18.6%), renal insufficiency in 4 patients (3.4%), and reoperation for bleeding in 8 patients (6.8%). There were no deep sternal wound infections. Follow-up was completed for 112 (99.1%) of 113 survivors and ranged from 1 month to 10.6 years (mean, 39.5 months). Actuarial survival for patients discharged from the hospital was 87.9% ± 3.7% (standard error of the mean) at 3 years and 79.7% ± 5.8% at 6 years.
Conclusions. Graft replacement of the ascending and transverse aortic arch, although technically demanding, can be performed with low hospital mortality and morbidity rates.
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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This study is a retrospective analysis of the early and late results in 117 consecutive patients who underwent 118 surgical procedures to the ascending and transverse aortic arch. It focuses on the use of refined surgical techniques to improve early and late results.
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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Patient risk factors in the series included hypertension (diastolic blood pressure higher than 90 mm Hg) in 75 patients (63.6%), hypercholesterolemia (cholesterol level higher than 200 mg/dL) in 23 patients (19.5%), diabetes mellitus (insulin and noninsulin-dependent) in 8 patients (6.8%), smoking history in 51 patients (43.2%), cerebrovascular disease in 10 patients (8.5%), renal insufficiency (creatinine level at least 2.0 mg/dL) in 5 patients (4.2%), peripheral vascular disease in 8 patients (6.8%), and chronic obstructive pulmonary disease in 29 patients (24.6%).
Thirteen patients (11.0%) had at least 1 myocardial infarction before operation. Six patients (5.1%) had a history of recent myocardial infarction (within 3 months) and 7 patients (5.9%) had a remote myocardial infarction (more than 3 months before operation). There were 24 patients (20.3%) who had a history of congestive heart failure, 7 patients (5.9%) who were in cardiogenic shock, and 10 patients (8.5%) who presented with cardiomyopathy. The patient’s preoperative functional status was ranked according to the New York Heart Association classification system. Seventeen patients (14.4%) were in class I, 55 patients (46.6%) in class II, 34 patients (28.8%) in class III, and 12 patients (10.2%) in class IV. The clinical characteristics of the patient population are summarized in Table 1.
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Preoperative diagnostic assessment was performed with cineangiography, aortography, computed tomographic scan, magnetic resonance imaging, transesophageal echocardiography, or a combination thereof to confirm the diagnosis.
Operative technique
Patients were operated on through a median sternotomy using total cardiopulmonary bypass. The method of venous cannulation was right atrial, bicaval, or femoral vein, and arterial cannulation was distal ascending aorta, transverse arch, or femoral artery. Femoral arterial cannulation was abandoned in 1993 to avoid retrograde embolization of atherosclerotic debris. Cannulation of the aneurysm, distal ascending aorta, or proximal aortic arch was preferred when feasible. The cannula insertion site was selected according to the area that had the least atherosclerotic or thrombotic material, which was determined after visual inspection of the aorta or by transesophageal echocardiography, which has been used since 1991. Systemic cooling to 28°C was used during cardiopulmonary bypass unless hypothermic circulatory arrest was indicated, in which case the patient was cooled to 16°C rectally. Since the inception of retrograde cerebral perfusion in 1992, bicaval venous cannulation has been used to allow retrograde cerebral perfusion through the superior vena cava. Patients received 1,000 mL of crystalloid cardioplegic solution by antegrade root injection and retrograde coronary sinus perfusion. Additional cardioplegia was given intermittently at 20-minute intervals. Left radial and pulmonary artery catheters were inserted for monitoring. Continuous electroencephalographic four-channel monitoring was performed in all patients undergoing circulatory arrest.
The selection of the surgical procedure was determined by the extent of aortic abnormality, involvement of the coronary sinuses, and the condition of the aortic valve apparatus. Three approaches were used for replacement of the aortic valve, aortic root, and ascending aorta. In addition, hemiarch or total aortic arch replacement of the transverse aorta was performed when indicated. The classic Bentall [15], Cabrol [16], or homograft root procedure was used for composite graft replacement of the aortic valve, aortic root, and ascending aorta. A separate ascending graft and isolated aortic valve replacement was performed when the coronary sinuses were not involved with an aneurysm or dissection. A third alternative, replacement or primary repair of the ascending aorta using graft material, was accomplished with or without aortic valve reconstruction. When aortic valve reconstruction was indicated, standard resuspension techniques or the David procedure [17] was used. These three approaches were applied in combination with hemiarch or total transverse aortic arch replacement (Table 2).
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Our technique for reimplanting the coronary ostia to the ascending graft in total root replacement has evolved. Initially the coronary ostia were reimplanted using the classic Bentall operation (Fig 1) or the Cabrol technique (Fig 2). The Bentall technique was used in 21 patients (17.8%) and the Cabrol technique in 7 patients (5.9%). A combination of the two techniques was used in 9 patients (7.6%). The preferred procedure was the Bentall button technique for reimplanting the coronary ostia using a double row of 5-0 monofilament with a thin strip of pericardium beneath the suture line for strength and hemostasis (Fig 3). When saphenous veins were used for coronary artery bypass grafting, they were implanted directly to the ascending Dacron graft. Concomitant mitral valve replacement was performed through a standard right lateral left atrial incision.
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-aminocaproic acid.
Operative data
The operation was performed electively in 98 patients (83.1%), urgently in 4 patients (3.4%), and on an emergency basis in 16 patients (13.5%). Patients operated on within 24 hours of diagnostic studies because of aneurysmal symptoms and rapid clinical deterioration were considered urgent. Patients operated on the same day of diagnostic studies who did not respond to aggressive clinical measures, with aneurysm rupture or impending rupture, were considered emergency cases. All other patients in the series were considered elective.
Aortic abnormality was medial degeneration in 59 patients (50.0%), dissection in 28 patients (23.7%) (17 acute and 11 chronic), atherosclerosis in 16 patients (13.6%), Marfan’s syndrome in 8 patients (6.8%), and other abnormalities in 7 patients (5.9%). The ascending aorta alone was replaced in 58 patients (49.2%), ascending and arch aorta in 56 patients (47.5%), and isolated aortic arch in 4 patients (3.4%). Twenty-six patients (22.0%) required aortic valve reconstruction, 17 patients (14.4%) had isolated aortic valve replacement, and 37 patients (31.4%) received a valve conduit. Two patients (1.7%) had concomitant mitral valve replacement and 27 patients (22.9%) had coronary artery bypass grafting. Five patients (4.2%) had an additional vascular procedure at the time of the operation.
The mean cardiopulmonary bypass time was 146.8 ± 41.0 minutes (range, 46 to 294 minutes). The mean aortic cross-clamping time was 97.0 ± 34.6 minutes (range, 19 to 207 minutes). The mean duration of circulatory arrest (n = 66) was 35.9 ± 11.7 minutes (range, 16 to 69 minutes), and the mean period of retrograde cerebral perfusion time (n = 50) was 34.4 ± 11.3 minutes (range, 4 to 63 minutes).
Data sources
Perioperative data were obtained by retrospective review of the patient’s hospital record, catheterization reports, cine angiograms, aortograms, computed tomographic scans, magnetic resonance imaging, and transesophageal echocardiography. Follow-up information was obtained through comprehensive questionnaires and by telephone interview with surviving patients, family members, or the patient’s personal physician. Follow-up data included activity level, current symptoms, diagnostic tests, occurrence of late cardiovascular events, and medications being taken. Patients were asked to describe their functional capacity and were ranked according to the New York Heart Association classification system. The National Death Index and the Office of Vital Statistics were contacted when necessary to obtain death certificates and cause of death. Autopsy reports, when available, furnished additional information.
A patient registration form and a patient follow-up form were completed for each participant in the study. These data collection instruments provided standardized reporting of each patient’s clinical status before and after the operation. A 99.1% follow-up rate was obtained in the present study.
Statistical analysis
Data are presented as frequency distributions and simple percentages. Values of continuous variables are expressed as mean ± standard deviation. Univariate analysis of selected preoperative and postoperative discrete variables was accomplished by 
2 test, the continuity-adjusted 2 analysis, or a two-tailed Fisher’s exact test with the appropriate degrees of freedom to test for the equality of proportions in categorical variables.
Patient survival was expressed by actuarial analysis according to the method of Cutler and Ederer [19] using time zero as the date of operation and late death as the end point (with variability expressed as the standard error of the mean) and by linearized occurrence rates. Data collected were subjected to both quantitative and qualitative analysis using the biostatistical capabilities of the Patient Analysis and Tracking Systems (PATS; Axis Clinical Software, Inc, Portland, OR). A significant difference between measurements was defined as p less than or equal to 0.05.
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Results |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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Placement of the intraaortic balloon pump was required in 6 patients (5.1%), 4 (3.4%) of whom had it placed preoperatively and 2 (1.7%) postoperatively. None of the patients requiring the intraaortic balloon pump had a major complication. The overall incidence of postoperative morbidity was low, with most patients (67.8%; n = 80) experiencing no hospital complications. There were 49 patients (41.5%) who had an operation and received no blood products. The average postoperative length of stay was 11.1 ± 8.4 days (range, 3 to 51 days).
Hospital mortality rate
The hospital mortality rate included death occurring during the operation or the hospitalization in which the procedure was performed or death occurring after discharge but within 30 days of the surgical procedure, unless the cause was unrelated to the operation. The overall hospital mortality rate for the series was 3.4% (4 of 117). The mortality rate for replacement of the ascending aorta was 1.7% (1 of 58) and for the ascending and arch aorta was 5.4% (3 of 56). There were no hospital deaths in the arch aorta cohort. The mortality rate for aortic dissection was 7.1% (2 of 28); both deaths occurred in acute cases. A comparison of the acute and chronic dissection mortality rates was not significantly different.
The mortality rate of elective procedures was 2.0% (2 of 98), the mortality rate of emergency procedures was 12.5% (2 of 16). There were no deaths in urgent cases. Within-group comparison of the mortality rates for these categories were not significant. There have been no hospital deaths in this series since September 1994, during which period 48 patients (40.7%) have had operations. Data on the 4 hospital deaths are presented in Table 3.
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Comment |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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Increased experience, refinement in surgical techniques, better myocardial and cerebral protection, improved prosthetic materials, better intraoperative monitoring, and control of hematologic factors have contributed to enhanced results. In addition, patient selection and continuous evaluation of early and long-term outcome have improved our results.
The overall hospital mortality rate of 3.4% in this series is low. The mortality rate of elective procedures of 2.0% (2 of 98) and of emergency procedures of 12.5% (2 of 16) compared favorably to those of other studies [21–23]. In this series there was a reduction in the hospital mortality rate over the past 3 years, with no deaths occurring in the last 48 patients. Two of the 4 hospital deaths occurred in patients with acute dissections. One of these 2 presented with paraparesis, and both subsequently died of multisystem failure. The remaining 2 were elective cases, 1 a reoperation. Both had intraoperative cerebrovascular accidents that were fatal. In this series 80 patients (67.8%) had no hospital complications. We attribute this improvement in mortality and morbidity rates to increased experience, the application of refined operative techniques, and aggressive preoperative and postoperative management.
Careful preoperative evaluation of pulmonary function and appropriate medical treatment before surgical intervention has allowed us to treat potential respiratory problems more effectively. The use of less invasive studies, such as magnetic resonance imaging and transesophageal echocardiography, avoids contrast material in patients with marginal renal function. In cases of acute dissection, these diagnostic techniques allow for more rapid surgical intervention. In addition, the use of transesophageal echocardiography intraoperatively aids in selecting the aortic cannulation site, documenting the success of aortic valve repair, assessing the adequacy of deairing techniques, and evaluating ventricular function when cardiopulmonary bypass is discontinued.
The use of retrograde cardioplegia through the coronary sinus improves myocardial protection, allows for additional injections at intervals throughout the surgical procedure without interrupting the operation, and has reduced cross-clamp times. The avoidance of femoral retrograde arterial perfusion reduces the risk of embolization from the distal aorta. The incidence of stroke in femoral cannulation was 8.1% (3 of 37) and for aortic cannulation was 4.9% (4 of 81) in this series (p = 0.38). Retrograde cerebral perfusion flushes air and debris from the brachiocephalic vessels and may provide nutrients and oxygen to the brain during circulatory arrest. Further investigation is warranted to document these benefits.
Incremental refinements in proven surgical techniques, such as the exclusion method for graft insertion, the use of double suture lines, and buttressing the anastomosis of friable tissues with either Teflon felt or pericardial strips minimizes the risk of postoperative bleeding. Softer, collagen-impregnated grafts with improved tissue conformability have also assisted in suture line hemostasis. The Bentall button technique for reimplanting the coronary ostia as opposed to the classic Bentall or Cabrol technique avoids reported complications of false aneurysm formation [24] and graft thrombosis [5, 20]. None of these complications were observed in the present series. We prefer the Bentall button technique because it is more anatomically correct and prevents suture line tension. The elephant trunk method for transverse aortic arch replacement in patients with descending and thoracoabdominal aneurysms allows for easier proximal aortic control with less sharp dissection if patients must return for a second aortic procedure.
At discharge from the hospital, 20 patients (17.5%) had distal aortic aneurysm disease in the descending or thoracoabdominal aorta. Seven patients (5.9%) required a second operation for the presence of distal disease. There were no hospital deaths in this cohort. In the remaining 13 patients, 4 died of rupture of the distal aorta. Two patients refused additional operation and 2 were inoperable because of pre-existing severe chronic obstructive pulmonary disease. The remaining 9 patients are undergoing follow-up with serial computed tomographic scans, 2 of whom are scheduled for operation.
The reduction of blood use and patient exposure to blood-borne pathogens such as human immunodeficiency virus and hepatitis virus have been a major concern. The application of blood conservation techniques has significantly influenced outcomes in ascending aorta and aortic arch operations [25].
Our protocol includes collecting autologous blood products preoperatively when feasible. Intraoperatively, cell-saving devices are used routinely to collect and reinfuse blood lost during the operation. When platelet transfusion is indicated, single-donor, pooled products are used to reduce exposure to potential pathogens. Aprotinin and -aminocaproic acid in combination with other methods of blood preservation have also had a beneficial effect. In the past 4 years, patient exposure to blood products has been significantly reduced (p < 0.018) with 49 patients (41.5%) having received no blood products during the operation and hospital stay.
The long-term clinical and enhanced functional improvement in patients in the present series has been impressive, with 98.9% of survivors in New York Heart Association class I or II. These results suggest that surgical treatment is viable for ascending and transverse aortic arch disease. The actuarial survival at 3 years of 87.9% ± 3.7%, and 79.7% ± 5.8% at 6 years supports a continued aggressive program of surgical intervention for these patients.
This study clearly demonstrates that surgical treatment of the ascending and transverse aortic arch can be accomplished with low hospital mortality and morbidity rates without excluding high-risk patients. Although the procedure is technically demanding, the outcome in the present series has been favorable. This operation has been made safer, costs have been reduced, and outcomes have been substantially improved. Patients in the present study have had fewer late cardiovascular events, excellent functional improvement, and enhanced long-term survival.
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Acknowledgments |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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