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Ann Thorac Surg 2000;70:1460-1465
© 2000 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiovascular Surgery, University Hospitals, Homburg/Saar, Germany
Address reprint requests to Dr Schäfers, Department of Thoracic and Cardiovascular Surgery, University Hospitals, 66421 Homburg/Saar, Germany
e-mail: chhjsc{at}med-rz.uni-sb.de
Presented at the Thirty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 31–Feb 2, 2000.
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Abstract |
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Methods. From October 1995 to December 1999, 52 patients (35 men, 17 women) underwent repair of AADA. Patient ages ranged from 30 to 83 years. Composite replacement was chosen for degenerated aortic valves or prior valve replacement (group A; n = 8). With normal root diameter, supracommissural replacement of the ascending aorta was performed (group B; n = 22). For preexisting root dilatation the aortic root was either remodeled (root diameter 30 to 50 mm, group C; n = 17) or the valve reimplanted within a vascular graft (root diameter more than 50 mm, group D; n = 5).
Results. All patients underwent either proximal (n = 46) or total (n = 6) arch replacement under circulatory arrest. Eight patients (15.4%) died (group A: n = 3; group B: n = 3; group C: n = 2). Freedom from aortic regurgitation of grade 2 or more at 2 years was 100% in groups A and D, 90.9% in group C, and 75% following supracommissural replacement. At 2 years freedom from proximal reoperation was 100% in groups A, C, and D and 84.5% in group B.
Conclusions. In AADA valve-preserving root replacement leads to improved stability of aortic valve function without an increased operative risk. Midterm results are promising and may show further superiority over supracommissural aortic replacement in the future.
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Introduction |
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Reconstitution of the aortic wall layers and interposition of a Teflon graft in the ascending aorta for acute type A dissection was described by Daily and colleagues [1] and has been used with modifications by many surgeons since Guilmet and coworkers [2] suggested reconstruction of the aortic root using gelatin-resorcin-formalin (GRF) adhesive (Colle Chirurgicale Cardial, Trigon MTS, Mönchengladbach, Germany). This approach has been used by many others and currently is the standard operation in European countries. Using either technique, good early results have been published by experienced groups with early mortality generally ranging from 10% to 20% [3–6]. Apart from avoiding hemorrhage in conjunction with reimplantation of dissected coronary ostia, this approach preserves the native aortic valve and avoids thrombembolism and anticoagulation-related complications related to prosthetic heart valves.
Preservation of the native root, however, may have the potential of long-term changes of both aortic valve and root. In a number of series, a variable proportion of patients developed secondary aortic regurgitation with or without progressive root dilatation [3, 7]. These changes with the resulting need for reoperation have been particularly apparent in the face of anuloaortic ectasia and connective tissue disorders, such as Marfan syndrome [3, 8, 9]. For these patients, primary composite replacement of valve and root has been suggested by a number of groups [10, 11]. To completely eliminate the need for proximal reoperation, some groups favor a more aggressive approach, that is, complete resection of the dissected root and primary composite replacement of valve and root in all patients [12, 13].
To achieve the same goal and avoid prosthetic heart valves, David and Feindel [14] proposed a valve-preserving type of operation for acute dissection. Sarsam and Yacoub [15] have used and propagated remodeling of the root for the same purpose. Both variants appear reasonable within the context of acute dissection; follow-up information of these approaches, however, is limited.
We have similarly applied the principles of valve-preserving proximal aortic replacement to acute aortic dissection. We hypothesized that increased wall tension would be the most important risk factor for secondary aortic regurgitation and root dilatation, requiring valve-preserving root replacement whenever preexistent root dilatation was found at the time of acute dissection. Depending on the individual root pathology, either a remodeling approach or aggressive replacement with reimplantation of the native valve within a vascular graft was carried out [16]. The early results are described here.
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Material and methods |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Relevant cardiac tamponade with signs of hypotension or cardiogenic shock was found in 21 patients (Table 1). The interval between the first symptom and the operation was less than 24 hours in 38 patients, between 24 and 48 hours in 5 patients, and longer than 48 hours in 9 patients. In the reimplantation group 1 patient exhibited the typical signs of Marfan syndrome.
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Procedures
One femoral artery was dissected for cannulation and the chest opened by a median sternotomy. Before opening of the pericardium, heparine was administered and the femoral artery cannulated. The pericardium was opened and, following cannulation of the right atrium, the patient was placed on extracorporeal circulation and cooled to a nasopharyngeal temperature of 18°C to 21°C. A vent catheter was placed into the left atrium through the right superior pulmonary vein, the ascending aorta cross-clamped and incised in standard fashion. Crystalloid cardioplegia (St. Thomas solution, Köhler Pharma, Alsbach, Germany) was administered directly into the coronary ostia.
The root was transected above the level of the commissures and inspected carefully. Diameters of sinutubular and aortoventricular junction were measured within the true lumen. Reconstitution of the aortic wall layers in the arch, the coronary buttons, and the aortic root (remodeling group, reimplantation group, and supracommissural group) was performed in all instances, using GRF adhesive. The individual operative strategy was then based depending on the preexisting pathology of the aortic root.
If the aortic valve had been replaced previously or showed significant degenerative changes, composite replacement of aortic valve and root was carried out. Patients were allocated to the different root procedures depending on the diameter of the sinutubular and aortoventricular diameter. If the aortic valve was structurally normal and the diameter at the level of the sinutubular junction did not exceed 30 mm, supracommissural ascending aortic replacement was performed in standard fashion (Fig 1A). In patients with moderate dilatation of the aortic root (sinutubular diameter less than 50 mm, aortoventricular diameter less than 30 mm) the aortic sinuses were excised, leaving a 5-mm rim of sinus wall adjacent to the aortic valve. A Dacron graft was then chosen with a diameter corresponding to that of the aortoventricular junction. One end of the graft was configured so that the edges conformed to the insertion lines of the aortic valve leaflets. This graft was sutured to the aortic root with the suture line closely following the insertion of the leaflets, thus remodeling the aortic root (Fig 1B).
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Once a nasopharyngeal temperature of 18°C to 21°C was reached, extracorporeal circulation was interrupted, the aortic clamp removed, and the arch inspected carefully for additional entries. Proximal arch lesions were resected in typical fashion and the aortic wall layers in the arch reconstituted using GRF adhesive. Partial arch replacement was then carried out using a second Dacron graft.
In the presence of complex distal arch entries total replacement of the arch was performed with direct implantation of the supraaortic branches. In these instances an elephant trunk-type extension [17] into the proximal descending aorta was used. Retrograde cerebral perfusion was maintained for further cooling in these instances.
Following rewarming and discontinuation of extracorporeal circulation, aortic valve function was assessed by intraoperative transoesophageal echocardiography. All patients were followed postoperatively using computed tomography and transthoracic echocardiography. The patients were seen at 3, 6, 9, and 12 months and every 6 months thereafter.
For semiquantitive measurement of aortic valve insufficiency the diameter of the regurgitation jet in relation to the left ventricular outflow tract was used as well as the intensity and decrease of the regurgitation signal in the continuous wave Doppler [18, 19]. Regurgitation was quantified into five grades: 0 = none, I = minimal (regurgitation jet/leftventricular outflow tract less than 5%), II = mild (5% to 10%), III = moderate (10% to 40%), and IV = severe insufficiency (more than 40%).
For statistical analysis, mean values and standard deviation were calculated. Further analysis included one-way analysis of variance if the data were distributed normally. If normal distribution was not present, the Kruskal–Wallis one-way analysis on ranks was applied. A p value of less than 0.05 was considered significant.
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Results |
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The aortic root diameters were considered normal (sinutubular junction less than 30 mm) in 26 patients. In 21 cases, moderate dilatation of the root was seen with a mean sinutubular diameter of 42 mm (range 32 to 48 mm). Five patients had the typical appearance of anuloaortic ectasia, that is, a sinutubular diameter of more than 50 mm in conjunction with an aortoventricular junction of 31 to 33 mm. Of the native aortic valves (n = 49), 46 were tricuspid and 3 had the typical appearance of a bicuspid valve. The leaflet morphology appeared preserved in 41 tricuspid and 3 bicuspid aortic valves.
Supracommissural aortic replacement was carried out in 22 patients, including 1 patient with a bicuspid valve. Eight patients underwent composite replacement of valve and root for degenerative valve changes (n = 3), following previous valve replacement (n = 3) and for apparent friability of the dissected root (n = 2). In 17 instances root remodeling was carried out, and radical replacement of the proximal aorta with reimplantation of the aortic valve was used in 5 patients.
Partial arch replacement following reconstitution of the wall layers in the arch was performed in 46 patients. In 6 patients complex distal arch tears were treated by total arch replacement utilizing the elephant trunk technique.
Aortic cross-clamp time was shortest in supracommissural replacement (67 ± 16 minutes); however, only the difference to valve reimplantation was statistically significant (p < 0.05; Table 2). There were no significant differences between the different root procedures with respect to circulatory arrest and cardiopulmonary bypass times.
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Echocardiography documented early postoperatively that all reconstructed valves functioned properly with aortic insufficiency grade I or less. Following remodeling 1 patient developed aortic insufficiency grade I–II after 10 months but remained asymptomatic. Following supracommissural replacement 4 of 22 patients (18.2%) developed secondary aortic regurgitation larger than grade 2 within 12 months, 3 of whom had to undergo reoperation. All 3 patients had a sinutubular diameter of 30 to 32 mm at the time of dissection repair. At reoperation recurrent or persisting dissection was found in 2, and 1 patient apparently had developed aortic valve insufficiency due to progressive dilatation of the root.
Freedom from aortic regurgitation grade II or greater at 2 years was 100% for reimplantation, 90.9% for remodeling, and 75% for supracommissural replacement (Fig 2). After 2 years actuarial freedom from reoperation was 100% for remodeling, reimplantation, and composite replacement. Freedom from reoperation after supracommissural replacement was 84.5% (Fig 3).
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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With increasing experience, however, the potential for proximal reoperation has become apparent in those patients whose native aortic valves had been preserved in conjunction with supracommissural replacement of the proximal aorta. Secondary aneurysmal dilatation of the aortic root and aortic regurgitation have been the main indications for reoperations [3, 4, 7, 20]. This problem has been particularly apparent in patients with Marfan syndrome and in those who had acute dissection with preexisting anuloaortic ectasia; for these patients composite replacement of valve and root has been recommended [3, 8, 9]. Patients who did not exhibit the features of anuloaortic ectasia have been at a much smaller, but still present, risk of proximal reoperation.
A number of mechanisms may be responsible for the secondary development of root dilatation. In those operations in which GRF adhesive had been used, an element of tissue necrosis has been hypothesized despite absence of histologic proof [21]. Persistence of proximal dissection and incomplete healing of the dissected root following incomplete reconstruction can be expected to predispose these patients to root dilatation. Finally, wall tension is increased in a moderately dilated root, which may impair healing of dissected tissue and increase the likelihood of secondary dilatation. All three factors may either individually or in combination contribute to this secondary pathologic process.
From published data it is impossible to judge whether the risk of secondary aortic regurgitation exists in all patients following supracommissural replacement. Possibly a subgroup of patients may exist with preexistent moderate root dilatation that was not considered pathologic at the time of dissection repair, but these patients may still carry an increased risk of secondary regurgitation. Anecdotal evidence points out that this possibility exists [3, 21]. Also in our current, limited experience secondary aortic regurgitation was observed in those cases, in which a 28- or 30-mm graft had been inserted to reduce the size of a somewhat larger sinutubular diameter.
To achieve a stable long-term repair it thus appears logical to correct any preexisting aortic pathology in addition to the elimination of dissection. This result can be achieved by composite replacement of valve and root with good results [10, 11]. It infers, however, the disadvantages of a mechanical heart valve including anticoagulation-related morbidity [22]. Avoidance of anticoagulation plays an even more important role in the patient with persistent dissection and potential risk of rupture or need for distal reoperation.
Valve-preserving aortic root replacement has been shown to be a realistic alternative with excellent midterm results using either the remodeling technique [15] or reimplantation of the aortic valve within a graft [14] or modifications. Reproducible results have been obtained in the stable, nondissected aortic root [14–16, 23]. Although we have chosen the individualized approach according to the preexisting degree of root dilatation rather than applying both in a randomized fashion, both techniques appear similarly applicable to type A dissection. Our current experience indicates no major difference with respect to stability of the aortic valve. In fact, the stability of aortic valve function has been remarkable given the fact that these patients had to be considered at an increased risk of secondary regurgitation compared with individuals with a normal-sized root. The remodeling approach has been less complex, as reflected by shorter cross-clamp times. Compared with valve reimplantation, however, surgical hemostasis has been somewhat more difficult to achieve. We plan to continue these two variants in a randomized fashion to assess the relative advantages under more objective circumstances. Thus, valve-preserving root replacement definitely appears as a reasonable option for those patients who develop dissection because of preexistent root pathology. However, for many patients supracommissural ascending aortic replacement still remains a relatively simple and reproducible therapeutic approach.
We thus conclude that the two valve-preserving approaches, remodeling and reimplantation, can be used in the setting of acute dissection with good results. These operative variants appear particularly suitable in patients with preexistent dilatation of the aortic root, allowing for elimination of dissection and restoration of aortic valve and root configuration. Long-term observations will be necessary to assess whether these valve-preserving operations will minimize the need for proximal reoperation comparable to that seen in composite replacement.
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