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Ann Thorac Surg 1999;67:2010-2013
© 1999 The Society of Thoracic Surgeons

Preservation of the aortic valve in acute type A dissection complicated by aortic regurgitation

^a Division of Cardiac Surgery, University of Verona, Verona, Italy

Address reprint requests to Dr Pessotto, Department of Cardiac Surgery, University of Verona, OCM Borgo Trento, P.le Stefani 1, 37126, Verona, Italy

Presented at the Aortic Surgery Symposium VI, April 30–May 1, 1998, New York, NY.

	Abstract

Top Abstract Introduction Patients and methods Results Conclusions References

 
Background. The aim of the present study was to verify the efficacy of preserving the aortic valve in patients with acute type A aortic dissection complicated by significant aortic regurgitation.

Methods. From January 1979 to December 1996, 178 patients (125 males; mean age 57 ± 9 years) underwent emergency surgery for acute type A aortic dissection, with an overall operative mortality rate of 21%. Based on a retrospective analysis of the preoperative angio- or echocardiographic findings, the 141 survivors were divided into 2 groups: Group 1 (G1) included 80 patients (57%) with no or mild aortic regurgitation, and Group 2 (G2) the remaining 61 patients with moderate-to-severe aortic regurgitation. The native aortic valve was preserved by means of a uniform technique consisting of reconstruction of the aortic root and sinotubular junction in 99 patients (70%) [68 in G1 (85%) and 31 in G2 (51%)]. Forty-two patients required aortic valve (8 patients; 6%) or total root replacement (34 patients; 24%).

Results. At a mean follow-up of 4 ± 3.6 years (range, 6 months to 19 years), 19 of the 99 patients with a preserved aortic valve developed moderate-to-severe aortic insufficiency [19%; 7/68 in G1 (10%) and 12/31 in G2 (39%)]. Multivariate analysis revealed that moderate-to-severe preoperative aortic valve insufficiency was a significant risk factor for development of postoperative aortic valve regurgitation (p= 0.008). Reoperation was necessary in 7 G1 patients (10%) and in 8 G2 patients (26%), with an actuarial freedom from reoperation at 5 and 10 years of 93% ± 7% and 80% ± 9% in G1 patients, and 81% ± 8% and 40% ± 15% in G2 patients (p = 0.045).

Conclusions. Preservation of the aortic valve and aortic root is recommended in patients with acute type A aortic dissection and absent or mild aortic insufficiency. Patients presenting with moderate-to-severe aortic regurgitation and treated conservatively present an increased risk of recurrent valvular insufficiency.

	Introduction

Top Abstract Introduction Patients and methods Results Conclusions References

 
Surgical results in patients with acute Stanford type A aortic dissection have substantially improved in recent years [1, 2]. Thus, although immediate operative survival still remains the main priority, more recent technical modifications have been directed toward reducing the incidence of late complications to increase long-term survival and reduce the necessity of late reoperations [1–6].

An aggressive surgical approach with total root replacement has been demonstrated to improve long-term results in particular subsets of patients, such as those with Marfan syndrome or a dilated aortic root [4, 5, 7]. However, while preservation of the native aortic valve and root is recommended in the majority of patients with a continent or mildly insufficient aortic valve, the best method of management of those presenting with significant aortic valve regurgitation is still debated [5, 8–12]. The present study was undertaken to review our results after repair of acute type A aortic dissection to assess the efficacy of a conservative approach in those cases complicated by significant aortic valve regurgitation.

	Patients and methods

Top Abstract Introduction Patients and methods Results Conclusions References

 
From January 1979 to December 1996, 178 patients, 125 males and 53 females, with a mean age of 57 ± 9 years (range, 18 to 88), underwent emergency operation for acute Stanford type A aortic dissection. One hundred and twenty-eight patients (72%) were treated by replacement of the ascending aorta and varying portions of the aortic arch with a Dacron prosthesis; 36 (20%) required composite replacement of the aortic valve and root; 7 (4%) underwent separate aortic valve replacement, and another 7 patients underwent simple intimal tear resection and direct aortic reconstruction, early in our experience. The overall hospital mortality rate was 21%, and was not correlated with the type of surgical procedure employed [13].

The 141 survivors, 100 males and 41 females with a mean age of 58 ± 12 years, were divided into 2 groups based on the degree of aortic valve regurgitation present at the time of operation. Data were obtained by retrospective analysis of the preoperative angiographic (65%) or echocardiographic (35%) findings, and by the description of the aortic valve leaflets and the aortic root in the operative notes. Because all preoperative examinations were done on an emergency basis with the main purpose of confirming the diagnosis of aortic dissection, the degree of aortic insufficiency could only be classified as absent, mild-to-moderate or moderate-to-severe. Thus, as indicated in Table 1 , group 1 (G1: 80 patients; 57%) included 68 patients with either absent (56 patients; 70%) or mild-to-moderate aortic regurgitation (12 patients; 15%); 6 patients with aortic stenosis (7.5%), and 6 with a previously implanted aortic valve prosthesis (7.5%), group 2 (G2) included 61 patients with a moderate-to-severe aortic regurgitation (43%).

Using this technique, 99 patients (70%) had a conservative procedure with preservation of the aortic root and aortic cusps: these included all 68 G1 patients with absent or mild preoperative aortic regurgitation (85%) and 31 G2 cases (51%). Indications for valve or root replacement were: aortic valve stenosis (6 G1 patients, 4%); prior aortic valve replacement (6 G1 patients, 4%); annuloaortic ectasia (18 G2 patients, 13%); Marfan syndrome (9 G2 patients, 6%), and damaged aortic leaflets (3 G2 patients, 2%).

Postoperative follow-up was obtained by recall of the patients to our center and careful reevaluation of all postoperative echocardiographic examinations performed at the referral cardiology department. Aortic insufficiency was graded as grade I, II, III and IV. Patients with severe aortic insufficiency (grade III to IV) underwent complete cardiac catheterization and were referred for elective reoperation.

Statistical analysis
Continuous data are expressed as mean ± standard deviation. Comparisons between categoric parameters were assessed by chi-square or Fisher’s exact test. Actuarial survival and event-free estimates were determined with the Kaplan-Meier method with variability expressed with 70% confidence limits. The curves were compared by the Mantel-Haenszel test. Eight parameters, including age, sex, date of operation, site of the intimal tear, hemopericardium, hypertension, degree of preoperative aortic regurgitation and use of the French glue were analyzed by univariate analysis followed by a Cox model multivariate analysis with respect to postoperative recurrent aortic valve regurgitation. A p value less than 0.05 was considered to be statistically significant.

	Results

Top Abstract Introduction Patients and methods Results Conclusions References

 
Follow-up of the 141 discharged patients was 98% complete and totaled 692 patient-years (mean 5 ± 4 years, ranging from 6 months to 19 years). Overall there were 26 late deaths (18%), with an actuarial survival rate of 88 ± 4%, 72 ± 7% and 40 ± 12% at 5, 10 and 15 years, respectively (Fig 1 ). Causes of late death were stroke (n = 6), sudden death (n = 5), malignancy (n = 3), new dissection (n = 2), respiratory insufficiency (n = 2), sepsis (n = 2), reoperation (n = 1), myocardial infarction (n = 1), heart failure (n = 1), renal failure (n = 1), and unknown (n = 2). No patient died of congestive heart failure due to aortic insufficiency. Actuarial survival rates were not statistically different for patients who required aortic valve replacement versus those with a conservative procedure (Fig 1).

View larger version (24K): [in this window] [in a new window]   Fig 1. Actuarial survival of all discharged patients (All pts), of all patients with an aortic prosthesis (AVR) and that of G1 and G2 patients.

View larger version (21K): [in this window] [in a new window]   Fig 2. Actuarial freedom from recurrent significant aortic valve regurgitation (AR) for G1 and G2 patients.

Two of the 42 patients who underwent initial aortic valve replacement were reoperated for dysfunction of a mechanical prosthesis (5%), because of pannus overgrowth in one patient, and proximal pseudoaneurysm formation in another. In the group with aortic valve replacement, actuarial freedom from reoperation was 100% at 5 years and 88 ± 9% at 10 years.

	Conclusions

Top Abstract Introduction Patients and methods Results Conclusions References

 
Aortic valve insufficiency complicates 40 to 60% of acute type A aortic dissections [8, 9, 11]. Excluding the 20 to 30% of patients with Marfan syndrome or a dilated aortic root in whom total root replacement is recommended, the others can be treated preserving the native aortic valve [4, 5].

Similar to the experience reported by Mazzucotelli and associates, retrospective analysis of our series revealed that approximately one-quarter of our patients who survived repair presented preoperatively with moderate-to-severe acute aortic insufficiency and a non-dilated aortic root [8]. These patients developed acute aortic regurgitation in a previous functionally normal aortic valve as a consequence of the proximal extension of the dissecting process with loss of commissural support and prolapse of the valve leaflets [4, 11]. Based on this physiopathological mechanism, we treated aortic valve regurgitation by simple reconstruction of the native aortic root and sinotubular junction, thus resupporting the valve commissures. Using this technique, patients presenting with absent or mild aortic regurgitation had better long-term results than those with preoperative moderate-to-severe aortic insufficiency in terms of late recurrent grade III-IV valve regurgitation. Interestingly, the degree of preoperative valvular insufficiency was the only predictive variable for late aortic regurgitation using multivariate analysis.

In fact, 10% of patients presenting with absent or mild aortic regurgitation developed grade III to IV aortic insufficiency versus 39% of those presenting with moderate-to-severe aortic insufficiency. These findings confirm the experience reported by Mazzucotelli and associates, who found that 37% of patients initially presenting with grade III to IV aortic regurgitation required subsequent reoperation [8]. Some authors have suggested that the long-term stability of the repaired aortic root can be improved with the use of gelatin-resorcinol-formol glue, but the degree of preoperative aortic regurgitation was not graded in their report and their results were not confirmed by others [3, 11]. In our experience, we could not find any statistical difference in long-term results between cases repaired with and without the French glue.

Most of the reoperated patients developed aneurysmal dilatation of the aortic root with severe aortic regurgitation, and required total root replacement with a composite graft. For this reason, patients presenting with acute dissection complicated by significant aortic regurgitation appear at risk of future root dilatation and recurrent valve insufficiency, and should be carefully evaluated for even discrete aortic root ectasia, because composite root replacement may prevent future reoperations. On the other hand, even though a more aggressive approach with radical replacement of the aortic root in all patients presenting with moderate-to-severe aortic regurgitation can prevent reoperations, such an approach introduces some drawbacks, such as the necessity for long-term anticoagulation, which can prevent thrombosis of the false lumen, and all of the other risks associated with use of an aortic valve prosthesis. Considering that 61% of patients presenting with severe aortic regurgitation are free from significant aortic insufficiency, and that 74% of them are free from reoperation at a mean follow-up of 4 ± 3.6 years after valve repair, and taking into account the very low risk of reoperation, preserving the native aortic valve still appears an attractive option even for this challenging group of patients.

In conclusion, this study confirms that the native aortic valve can be efficaciously preserved in all patients with acute Stanford type A aortic dissection presenting with absent or mild aortic regurgitation. Patients presenting with moderate-to-severe aortic insufficiency and a normal aortic root can be treated conservatively, but present an increased risk of recurrent aortic regurgitation with a low operative risk at elective reoperation.

	References

Top Abstract Introduction Patients and methods Results Conclusions References

 

1. Svensson L.G., Crawford E.S., Hess K.R., et al. Dissection of the aorta and dissecting aortic aneurysms. Improving early and long-term surgical results. Circulation 1990;82:IV-24-IV-38.
2. Fann J.I., Smith J.A., Miller D.C., et al. Surgical management of aortic dissection during a 30-year period. Circulation 1995;92:II-113-II-121.
3. Weinschelbaum E.E., Schamun C., Caramutti V., et al. Surgical treatment of acute type A dissecting aneurysm, with preservation of the native aortic valve and use of biologic glue. J Thorac Cardiovasc Surg 1992;103:369-374.[Abstract]
4. Von Segesser L.K., Lorenzetti E., Lachat M., et al. Aortic valve preservation in acute type A dissection: is it sound?. J Thorac Cardiovasc Surg 1996;111:381-391.[Abstract/Free Full Text]
5. Ergin M.A., McCullough J., Galla J.D., et al. Radical replacement of the aortic root in acute type A dissection: indications and outcome. Eur J Cardiothorac Surg 1996;10:840-845.[Abstract]
6. Jex R.K., Schaff H.V., Piehler J.M., et al. Repair of ascending aortic dissection. Influence of associated aortic valve insufficiency on early and late results. J Thorac Cardiovasc Surg 1987;93:375-384.[Abstract]
7. Massimo C.G., Presenti L.F., Marranci P., et al. Extended and total aortic resection in the surgical treatment of acute type A aortic dissection: experience with 54 patients. Ann Thorac Surg 1988;46:420-424.[Abstract]
8. Mazzucotelli J.P., Deleuze P.H., Baufreton C., et al. Preservation of the aortic valve in acute aortic dissection: long-term echocardiographic assessment and clinical outcome. Ann Thorac Surg 1993;55:1513-1517.[Abstract]
9. Fann J.I., Glower D.D., Miller D.C., et al. Preservation of the aortic valve in type A aortic dissection complicated by aortic regurgitation. J Thorac Cardiovasc Surg 1991;102:62-75.[Abstract]
10. Seguin J.R., Picard E., Frapier J.M., Chaptal P.A. Aortic valve repair with fibrin glue for type A acute aortic dissection. Ann Thorac Surg 1994;58:304-307.[Abstract]
11. Westaby S., Katsumata T., Freitas E. Aortic valve conservation in acute type A dissection. Ann Thorac Surg 1997;64:1108-1112.[Abstract/Free Full Text]
12. David T.E. Aortic root aneurysms: remodeling or composite replacement?. Ann Thorac Surg 1997;64:1564-1568.[Abstract/Free Full Text]
13. Pugliese P., Pessotto R., Santini F., et al. Risk of late reoperations in patients with acute type A aortic dissection: impact of a more radical surgical approach. Eur J Cardiothorac Surg 1998;13:576-580.[Abstract/Free Full Text]

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