HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Marc A.A.M. Schepens Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Schepens, M. A.A.M. Articles by Morshuis, W. J. Search for Related Content PubMed PubMed Citation Articles by Schepens, M. A.A.M. Articles by Morshuis, W. J.

Ann Thorac Surg 1999;68:1676-1680
© 1999 The Society of Thoracic Surgeons

---

Original Articles

Reoperations on the ascending aorta and aortic root: pitfalls and results in 134 patients

^a Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands

Address reprints requests to Dr Schepens, Department of Cardiothoracic Surgery, St Antonius Hospital, Koekoekslaan 1, CM Nieuwegein, The Netherlands
e-mail: marc.schepens{at}worldonline.nl

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. This analysis was performed to evaluate the results of reoperations on the ascending aorta and aortic root.

Methods. All reoperations (n = 134) on the aortic root and ascending aorta performed between February 1981 and April 1998 were retrospectively analyzed. Indications for reintervention were a true or false aneurysm (35%), acute dissection (3.0%), aortic valve stenosis and/or insufficiency (23.1%), prosthetic valve endocarditis (32.8%), and combinations (4.5%). The principal reoperations performed were aortic root replacement (composite graft, freestyle, aortic allograft, or pulmonary autograft) in 116 patients, ascending aortic replacement in 10 patients, and closure of a false aneurysm in 5 patients. Results were analyzed using univariate statistical methods.

Results. Hospital mortality was 6.6% (8 patients). Univariate predictors of hospital death were preoperative functional class III or IV (p = 0.02), an interval of less than 6 months between the primary and actual operation (p = 0.02), preoperative creatinine level of more than 200 µmol/L (p = 0.001), acute aortic dissection (p = 0.001), intraoperative technical problems (p = 0.001), and postoperative dialysis (p = 0.001). Freedom from repetitive reoperation was 99% at 1 year and 98% at 5 and 10 years.

Conclusions. Reoperations on the aortic root and ascending aorta can be performed with an early mortality which is very acceptable.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Various techniques have been described for aortic root replacement since the first successful replacement of the ascending aorta and aortic valve was performed in 1964 by Wheat [1]. Four years later, Bentall and De Bono [2] described a technique for total aortic root replacement with a composite graft containing a prosthetic valve with side-to-end reimplantation of the coronary artery ostia. In 1981, Cabrol and associates [3] modified the aortic root operation introducing a second tube graft connecting both coronary ostia and the main ascending aortic graft. This was inspired by the many complications of the original Bentall procedure. Later, in 1991, Kouchoukos and coworkers [4] showed that his modification, the "open or button technique," for the reimplantation of the coronary arteries was safer in terms of a lower incidence of late false aneurysms. Meanwhile, the use of aortic allografts [5] and pulmonary autografts [6] has become an attractive alternative for specific indications. Degeneration of aortic valve substitutes, prosthetic valve endocarditis, formation of true or false aneurysms, all form indications for repeat aortic root surgery. Therefore, it is not surprising that the number of procedures reperformed on these aortic segments is increasing. In this report, we present our experience with reoperations on the aortic root and ascending aorta during a 17-year interval.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patient population
Between February 1981 and April 1998, 134 patients were reoperated on the aortic root or ascending aorta. The records of all patients were examined retrospectively. Ninety-three (93) of the 134 patients were initially operated by us. Patients who required reoperation only on the aortic valve (eg, for exclusively degeneration of their bioprosthetic aortic valve) were excluded. However if the extent of the actual intervention included more than only the degenerated aortic valve (eg, complete root replacement), patients were included. The mean age of patients at reoperation was 50.7 years (range 35 to 79 years), and 98 (73.1%) were male. The clinical stigmata of Marfan’s syndrome were present in 17 patients. The mean interval between the last previous repair and the actual intervention was 8.2 years (range 0.1 to 32 years). Patient characteristics are shown in Table 1, previous operations in Table 2 and indications for reoperation in Table 3. Aneurysms were limited to the ascending aorta in most cases but in 6 patients with degenerative aneurysm and in 9 with a postdissection aneurysm the pathology extended into the aortic arch and/or descending thoracic aorta. False aneurysms originated from the proximal suture line in 7 patients, the distal suture line in 4 patients, the coronary reimplantation sites in 4 patients and from the hockey stick incision after aortic valve replacement in 1 patient. At reoperation, replacement of the aortic root with an aortic allograft or a composite graft was the principal operation performed (Table 4). Concomitant operative procedures performed are listed in Table 5. Technical problems as mentioned in Table 6 are defined as the need for a repeated cardioplegic arrest in order to redo an anastomosis due to uncontrollable bleeding.

Statistical analysis
Group statistics were expressed as the mean ± one standard deviation. We looked at 13 perioperative risk factors using univariate analysis (standard Student’s t test, ², or Fisher’s exact test, when appropriate) to determine whether any single variable influenced hospital mortality. These variables were sex, presence of Marfan syndrome, the number of previous interventions, NYHA class, the presence of aortic valve insufficiency, the preoperative serum creatinine level, the indication for surgery (false or true aneurysm, acute dissection, prosthetic valve dysfunction, prosthetic valve endocarditis), type of the procedure (composite graft, pulmonary autograft, aortic allograft), concomitant procedure, technical problems, age, postoperative dialysis, early reintervention. Each variable with a p value of less then 0.05 was entered in a multiple logistic regression analysis model to study its independent predictability in influencing hospital mortality. Hospital mortality was defined as death from any cause during or after operation within 30 days if the patient was discharged or within any interval if the patient was not discharged. Survival rates and freedom from reoperation were calculated using the actuarial method [10]. SAS (SAS Institute, release 6.03, Cary, NC) and BMDP (release 1990, Los Angeles, CA) statistical software packages were used.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Hospital mortality
Eight patients (6.6%) died in the hospital. Three of them died intraoperatively due to low cardiac output. The other causes of hospital death were cardiac in 1 patient, neurologic in 1 patient, multiple organ failure in 2 patients and unknown in 1 patient. After univariate analysis, New York Heart Association class III/IV, a preoperative serum creatinine of more than 200 µmol/L, operation for acute dissection, an interval less than 6 months between the previous and actual intervention, technical problems necessitating repeated cardioplegic arrest and postoperative dialysis were independent risk factors for hospital death (Table 6). The mean hospital stay was 23 days ± 6. After logistic regression analysis no single factor retained significance.

Morbidity
Early reoperation for excessive bleeding (in 7 patients) and/or signs of cardiac tamponade (in 15 patients), the removal of compress gauzes purposefully left behind (in 8 patients), a cardiac arrest (in 1 patient), and miscellaneous (in 3 patients) was necessary in 32 patients (24.5%). One patient required an intraaortic balloon pump (0.8%), 1 patient sustained a perioperative myocardial infarction (0.8%), 13 patients needed a permanent pacemaker for complete heart block (9.8%), 6 patients needed tracheostomy (4.5%), 3 patients sustained a central neurologic deficit (2.3%), and 10 patients (7.7%) had to be dialyzed after surgery. Univariate analysis (including all appropriate pre and intraoperative variables) showed that only a preoperative serum creatinine level of more than 200 µmol/L was a predictive risk factor for dialysis. Hospital mortality was 30% in this group and the mean duration of hospitalization was 56 days ± 12.

Survival
All patients were followed up at regular intervals at the outpatient clinic of our department or the referring center. The follow-up was 100% complete. The 1-year, 5-year, and 10-year survival rates (including hospital deaths) were 89%, 83%, and 62% respectively (Fig 1). Freedom from reoperation on the ascending aorta or aortic root (excluding early in-hospital reinterventions for excessive bleeding) was 99% at 1 year and 98% at 5 and 10 years (Fig 2). There was no difference in reoperation rate between the patients with and without the Marfan syndrome (p = 0.7).

View larger version (13K): [in this window] [in a new window]   Fig 1. Actuarial survival after reoperation.

View larger version (11K): [in this window] [in a new window]   Fig 2. Freedom from future aortic root reintervention after reoperation.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

One of the key elements to successful reoperation on the ascending aorta and aortic root is a safe re-entry into the chest. This is again illustrated by the fact that 2 out of 3 patients in which problems with sternal re-entry were encountered, died in the hospital. In these cases a planned short period of deep hypothermic circulatory arrest before reopening might have been a better alternative. A proper preparation and assessment of the risk at each step will decrease the incidence of severe problems. We think that a preoperative CT scan is mandatory in every patient since this will allow the accurate delineation of the relation between the aorta, aneurysm or conduit and the bony structures of the chest wall. Besides a CT scan we recommend studying the lateral chest x-ray films to establish the presence of a retrosternal space. In 20 patients of our series, femorofemoral partial cardiopulmonary bypass with moderate cooling was started before reopening because of doubts about the safety of re-entry. Mostly, even in case of laceration of major structures and major blood loss, the pump suckers can return the blood to the oxygenator, preventing severe hypotension. If bleeding cannot be controlled in a short time thereafter, deep hypothermic circulatory arrest should be used.

The risk factors for hospital mortality that emerged after univariate analysis are not surprising to us. A high preoperative serum creatinine and the necessity of postoperative dialysis accentuate the major impact of renal dysfunction on outcome after cardiovascular surgery. A short period of less than 6 months between the first and subsequent intervention illustrates that the timing of the second repair is crucial. Adhesions cannot be avoided after the original operation. Although sternal re-entry is usually easy during the first 10 days after the original intervention, subsequently highly vascularized adhesions and granulations will originate and the decision for reoperation should be carefully planned in order to avoid the relative critical period from 2 weeks to 6 months after the primary repair. Catastrophes such as entrance of the aneurysm or conduit at re-entry will have serious consequences for the intervention and post-operative period.

The choice of the conduit used at reoperation will depend on the extent and nature of the underlying pathology. In case of prosthetic valve endocarditis, aortic allograft root replacement is our technique of choice [8].

The incidence of early reintervention for excessive bleeding was high: almost 25%. In most patients, no active bleeding could be found and the blood loss was attributed to coagulation disorders. All our patients were preoperatively on oral anticoagulation and none of them received aprotinin during surgery. We think it is better to perform an early rethoracotomy than to wait for dramatic circumstances due to acute tamponade; this liberal attitude might have influenced the high incidence of early reintervention. A blood loss of more than 1500 mL 12 hours postoperatively, together with hemodynamic parameters, was considered as an indication for early rethoracotomy.

The need for continued long-term cardiovascular surveillance is accentuated by the fact that 2 of our patients needed their reintervention only 31 years after the primary one. The mean interval of 8.2 years between the two interventions illustrates that patients remain at risk for later development of complications that require new repair, even if the first repair was a radical one. This warrants annual examination by the cardiologist and/or cardiovascular surgeon with echocardiography, CT scan, or MRI.

Long-term survival after redo surgery on the ascending aorta is good: 83% at 5 years and 62% at 10 years. Actuarial freedom from further reoperation on the ascending aorta is 98% at 10 years (excluding the early postoperative in-hospital reinterventions for excessive bleeding), which is excellent.

Charles Hufnagel [14] in 1962 already pointed out that the goal of surgical procedures in the treatment of cardiovascular disease is the complete restoration of physiologic and mechanical normality. This important concept, although impossible to reach, was underscored by another great pioneer in cardiovascular surgery, namely E.S. Crawford [15], advocating complete removal of the entire diseased aortic segment at the first operation. At the end of the 20th century, more aortic and valved conduits are at our disposal, making the choice at the primary repair, eg, in a young patient, not easy. Furthermore, less-invasive to minimally invasive procedures are being proposed now. These techniques often offer only a partial solution to the problem and long-term follow-up is actually unclear. To reduce the need for further reoperations, only an aggressive management of aortic and valvular disease and the use of proper prostheses at the first operation can reduce the need for further reinterventions. Despite our low operative risk and satisfactory long-term results, this attitude is underscored by the experience of others [16].

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Wheat M.W., Jr, Wilson J.R., Bartley T.D. Successful replacement of the entire ascending aorta and aortic valve. JAMA 1964;188:717-719.
2. Bentall H., De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338-339.[Abstract/Free Full Text]
3. Cabrol C., Pavie A., Gandjbakhch I., et al. Complete replacement of the ascending aorta with reimplantation of the coronary arteries. New surgical approach. J Thorac Cardiovasc Surg 1981;81:309-315.[Abstract]
4. Kouchoukos N.T., Wareing T.H., Murphy S.F., Perrillo J.B. Sixteen-year experience with aortic root replacement. Results of 172 operations. Ann Surg 1991;214:308-320.[Medline]
5. Lau J.K., Robles A., Cherian A., Ross D.N. Surgical treatment of prosthetic endocarditis. Aortic root replacement using a homograft. J Thorac Cardiovasc Surg 1984;87:712-716.[Abstract]
6. Ross D.N. Replacement of the aortic valve with a pulmonary autograft. Ann Thorac Surg 1991;52:1346-1350.[Abstract/Free Full Text]
7. Dossche K.M., Schepens M.A., Morshuis W., Knaepen P., Brutel de la Rivière A. A 23-year experience with composite valve graft replacement of the aortic root. Ann Thorac Surg 1999;67:1070-1077.[Abstract/Free Full Text]
8. Dossche K.M., Defauw J.J., Ernst S.M., Craenen T.W., De Jongh B.M., Brutel de la Rivière A. Allograft aortic root replacement in prosthetic aortic valve endocarditis. Ann Thorac Surg 1997;63:1644-1649.[Abstract/Free Full Text]
9. Dossche K.M., Brutel de la Rivière A., Morshuis W., Schepens M.A., Ernst S.M. Aortic root replacement with human tissue valves in aortic valve endocarditis. Eur J Cardiothorac Surg 1997;12:47-55.[Abstract/Free Full Text]
10. Cutler S.J., Ederer F. Maximum utilization of the life-table method in analyzing survival. J Chron Dis 1958;8:699-712.[Medline]
11. Crawford E.S., Crawford J.L., Safi H.J., Coselli J.S. Redo operations for recurrent aneurysmal disease of the ascending aorta and transverse aortic arch. Ann Thorac Surg 1985;40:439-455.[Abstract/Free Full Text]
12. Carrel T., Pasic M., Jenni R., Tkebuchava T., Turina M.I. Reoperations after operation on the thoracic aorta. Ann Thorac Surg 1993;56:259-269.[Abstract/Free Full Text]
13. Bachet J.E., Termignon J.L., Dreyfus G., et al. Aortic dissection. Prevalence, cause, and results of late reoperations. J Thorac Cardiovasc Surg 1994;108:199-205.[Abstract/Free Full Text]
14. Hufnagel C.A., Conrad P.W. Dissecting aneurysms of the ascending aorta. Surgery 1962;51:84-89.
15. Crawford E.S., Coselli J.S., Safi H.J. Reoperations for thoracic and thoracoabdominal aneurysms. In: Stark J., Pacifico A.D., eds. Reoperations in cardiac surgery. Berlin: Springer-Verlag, 1989:361-381.
16. Dougenis D., Daily B.B., Kouchoukos N.T. Reoperations on the aortic root and ascending aorta. Ann Thorac Surg 1997;64:986-992.[Abstract/Free Full Text]

This article has been cited by other articles:

				M. Di Eusanio, P. Berretta, L. Bissoni, F. D. Petridis, L. Di Marco, and R. Di Bartolomeo Re-operations on the proximal thoracic aorta: results and predictors of short- and long-term mortality in a series of 174 patients Eur J Cardiothorac Surg, November 1, 2011; 40(5): 1072 - 1076. [Abstract] [Full Text] [PDF]

				J. A. Bekkers, L. M. A. Klieverik, G. B. Raap, J. J. M. Takkenberg, and A. J. J. C. Bogers Re-operations for aortic allograft root failure: experience from a 21-year single-center prospective follow-up study Eur J Cardiothorac Surg, July 1, 2011; 40(1): 35 - 42. [Abstract] [Full Text] [PDF]

				B. El Oumeiri, Y. Louagie, and M. Buche Reoperation for ascending aorta false aneurysm using deep hypothermia and circulatory arrest Interact CardioVasc Thorac Surg, April 1, 2011; 12(4): 605 - 608. [Abstract] [Full Text] [PDF]

				P. G. Malvindi, B. P. van Putte, R. H. Heijmen, M. A. A. M. Schepens, and W. J. Morshuis Reoperations for Aortic False Aneurysms After Cardiac Surgery Ann. Thorac. Surg., November 1, 2010; 90(5): 1437 - 1443. [Abstract] [Full Text] [PDF]

				J. Silva, L. C. Maroto, M. Carnero, I. Vilacosta, J. Cobiella, E. Villagran, and J. E. Rodriguez Ascending Aorta and Aortic Root Reoperations: Are Outcomes Worse Than First Time Surgery? Ann. Thorac. Surg., August 1, 2010; 90(2): 555 - 560. [Abstract] [Full Text] [PDF]

				N. Luciani, A. Anselmi, R. de Geest, F. Glieca, and G. Possati Facilitated aortic root substitution after aortic valve replacement: Technique and results of the prosthesis-sparing operation J. Thorac. Cardiovasc. Surg., March 1, 2010; 139(3): 785 - 787. [Full Text] [PDF]

				P. G. Malvindi, B. P. van Putte, R. H. Heijmen, M. A.A.M. Schepens, and W. J. Morshuis Reoperations on the Aortic Root: Experience in 46 Patients Ann. Thorac. Surg., January 1, 2010; 89(1): 81 - 86. [Abstract] [Full Text] [PDF]

				C. D. Etz, K. A. Plestis, T. M. Homann, C. A. Bodian, G. Di Luozzo, D. Spielvogel, and R. B. Griepp Reoperative aortic root and transverse arch procedures: A comparison with contemporaneous primary operations J. Thorac. Cardiovasc. Surg., October 1, 2008; 136(4): 860 - 867. [Abstract] [Full Text] [PDF]

				G. Krasopoulos, T. E. David, and S. Armstrong Custom-tailored valved conduit for complex aortic root disease J. Thorac. Cardiovasc. Surg., January 1, 2008; 135(1): 3 - 7. [Abstract] [Full Text] [PDF]

				W. Y. Szeto, J. E. Bavaria, F. W. Bowen, A. Geirsson, K. Cornelius, W. C. Hargrove, and A. Pochettino Reoperative Aortic Root Replacement in Patients With Previous Aortic Surgery Ann. Thorac. Surg., November 1, 2007; 84(5): 1592 - 1599. [Abstract] [Full Text] [PDF]

				A. Albertini, A. Dell'Amore, C. Zussa, and M. Lamarra Modified Bentall operation: the double sewing ring technique Eur J Cardiothorac Surg, November 1, 2007; 32(5): 804 - 804. [Abstract] [Full Text] [PDF]

				C. Olsson, N. Eriksson, E. Stahle, and S. Thelin Surgical and long-term mortality in 2634 consecutive patients operated on the proximal thoracic aorta Eur J Cardiothorac Surg, June 1, 2007; 31(6): 963 - 969. [Abstract] [Full Text] [PDF]

				J. Bachet, M. Pirotte, F. Laborde, and D. Guilmet Reoperation for Giant False Aneurysm of the Thoracic Aorta: How to Reenter the Chest? Ann. Thorac. Surg., May 1, 2007; 83(5): 1610 - 1614. [Abstract] [Full Text] [PDF]

				L. N. Girardi, K. H. Krieger, C. A. Mack, L. Y. Lee, A. J. Tortolani, and O. W. Isom Reoperations on the ascending aorta and aortic root in patients with previous cardiac surgery. Ann. Thorac. Surg., October 1, 2006; 82(4): 1407 - 1412. [Abstract] [Full Text] [PDF]

				Aortic root replacement after previous surgical intervention on the aortic valve, aortic root, or ascending aorta. J. Thorac. Cardiovasc. Surg., March 1, 2006; 131(3): 601 - 608.

				F. Dagenais, P. Voisine, and P. Mathieu Giant pseudoaneurysm after proximal aortic surgery treated by means of redo axillary artery cannulation and use of an Endoclamp device J. Thorac. Cardiovasc. Surg., July 1, 2005; 130(1): 208 - 209. [Full Text] [PDF]

				A. L. Estrera, C. C. Miller III, E. Porat, S. Mohamed, R. Kincade, T. T. Huynh, and H. J. Safi Determinants of early and late outcome for reoperations of the proximal aorta Ann. Thorac. Surg., September 1, 2004; 78(3): 837 - 845. [Abstract] [Full Text] [PDF]

				T. Carrel, L. Beyeler, A. Schnyder, P. Zurmuhle, P. Berdat, J. Schmidli, and F. S. Eckstein Reoperations and late adverse outcome in Marfan patients following cardiovascular surgery Eur J Cardiothorac Surg, May 1, 2004; 25(5): 671 - 675. [Abstract] [Full Text] [PDF]

				K. Kurisu, Y. Ochiai, T. Kajiwara, H. Kumeda, and R. Tominaga A modified valve-on-valve approach for aortic root replacement Ann. Thorac. Surg., December 1, 2003; 76(6): 2099 - 2101. [Abstract] [Full Text] [PDF]

				M. B. Mitchell, D. N. Campbell, D. A. Bishop, T. Mackenzie, and D. R. Clarke Surgical options and results of repeated aortic root replacement for failed aortic allografts placed in childhood J. Thorac. Cardiovasc. Surg., September 1, 2002; 124(3): 459 - 470. [Abstract] [Full Text] [PDF]

				E. Raanani, T. E. David, G. Dellgren, S. Armstrong, J. Ivanov, and C. M. Feindel Redo aortic root replacement: experience with 31 patients Ann. Thorac. Surg., May 1, 2001; 71(5): 1460 - 1463. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Marc A.A.M. Schepens Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Schepens, M. A.A.M. Articles by Morshuis, W. J. Search for Related Content PubMed PubMed Citation Articles by Schepens, M. A.A.M. Articles by Morshuis, W. J.