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Ann Thorac Surg 2001;71:1460-1463
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Redo aortic root replacement: experience with 31 patients

^a Division of Cardiovascular Surgery, Toronto General Hospital, and University of Toronto, Toronto, Ontario, Canada

Accepted for publication December 14, 2000.

Address reprint requests to Dr David, 200 Elizabeth St, 13EN-219, Toronto, Ontario M5G 2C4, Canada
e-mail: tirone.david{at}uhn.on.ca

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Aortic root re-replacement is being performed with increased frequency. Limited information is available regarding the surgical approaches and clinical outcomes of this reoperation.

Methods. Between May 1980 and May 1999, 31 patients (mean age, 45 ± 15 years) underwent redo composite replacement of the aortic valve and ascending aorta. Indications for reoperation were prosthetic valve endocarditis in 12 patients (39%), failed biological valve in 17 (55%), and false aneurysm in 2 (6%). At reoperation, mechanical valves were implanted in 24 patients and biologic valves in 7. All patients with endocarditis had annular abscess and required reconstruction of the left ventricular outflow tract before implantation of a new valved conduit. Mechanical valves were used in 24 patients, aortic homograft in 4, and bioprosthetic valves in 3. The coronary button technique was used to reimplant the coronary arteries whenever possible. Extension of one or both coronary arteries with a short segment of saphenous vein or a synthetic graft was used in 16 patients (52%). The aortic arch was replaced in 7 patients (23%).

Results. There was one operative death (3%) because of rupture of an abdominal aortic aneurysm. The mean follow-up was 47 ± 46 months and was 100% complete. There were five late deaths (16%), three of which were cardiac related. The actuarial survival was 71% ± 12% at 5 years. Three patients experienced recurrent prosthetic valve endocarditis 4 months to 8 years after operation. The 8-year freedom from endocarditis for patients operated on for endocarditis was 82% ± 11% compared with 100% for those operated on for other reasons (p = 0.1). At the last follow-up, 21 of 25 survivors (84%) were in New York Heart Association functional classes I or II, and 4 were in class III.

Conclusions. Redo aortic root replacement can be performed with good early and late results. Patients operated on for prosthetic root endocarditis may have an increased risk of recurrent late endocarditis.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
In 1968 Bentall and De Bono [1] described an operation to treat patients with aortic root aneurysm in which a tubular graft containing a prosthetic valve was used for replacement of the aortic valve and ascending aorta, and the coronary arteries were reimplanted in a side-to-side fashion. During the past two decades, surgical modifications have improved the short-term and long-term outcomes of this procedure [2, 3]. In addition, the increased use of biologic conduits such as homograft, pulmonary autograft, and stentless xenograft roots have substantially increased the number of aortic root replacements. Consequently, a growing number of patients will require redo aortic root replacement with reattachment of the coronary arteries to a new conduit, and frequently, reconstruction of the aortic annulus and parts of the left ventricular outflow tract is necessary, such as in patients with aortic root abscess. Limited information is available regarding the surgical approaches and clinical outcomes of these complicated reoperations [4–7].

In this study we reviewed our experience and clinical outcome in this high-risk group of patients who underwent redo aortic root replacement.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Between May 1980 and May 1999, 143 patients underwent aortic root replacement as a reoperation in our hospital. Thirty-one of these patients had replacement of the aortic root. The records of these 31 patients were reviewed. The mean age at reoperation was 44.7 ± 15 years (range, 18 to 73 years), and 29 (94%) were men. Twenty-one patients (68%) were in New York Heart Association (NYHA) functional class III or IV, and 3 patients were in cardiogenic shock preoperatively because of acute aortic insufficiency. One third of the patients had moderate to severe left ventricular dysfunction. Previous aortic root replacement had been performed with a composite graft containing a mechanical valve in 8 patients, a bioprosthetic valve in 10, an aortic homograft in 11, and a pulmonary autograft in 2 patients. The mean interval between the primary procedure and the reoperation was 61 ± 41 months (range, 1 to 144 months). The indications for reoperations were failed biologic valve in 17 patients (55%), active prosthetic valve endocarditis in 12 (39%), and false aneurysm in 2 (6%). All patients with active endocarditis had an aortic root abscess. Concomitant procedures and operative data are presented in Table 1.

All previous graft material was excised, leaving coronary ostial buttons, and the proximal part of the coronary arteries was mobilized. The surgical principle in prosthetic valve endocarditis was one of aggressive debridement of all suspiciously infected tissues and reconstruction of the heart with fresh autologous pericardium or glutaraldehyde-fixed bovine pericardium [9–11]. To accomplish that, it was often necessary to resect a portion of or the whole aortoventricular junction and sometimes the surrounding structures, such as the roof of the left atrium, the interventricular septum, the right ventricular or atrial wall, and the mitral valve. The most commonly performed procedure for patients with aortic root abscess was resection of the infected part of the left ventricular outflow tract and circumferential reconstruction of the left ventricular outflow tract with glutaraldehyde-treated bovine pericardium. A strip of bovine pericardium measuring approximately 2 x 10 cm was sutured to the base of the anterior leaflet of the mitral valve, the fibrous trigones, and the interventricular septum using a continuous 2-0 or 3-0 polypropylene suture. A valved conduit was then secured to this pericardial patch with another continuous polypropylene suture. Since 1990, aortic valve homografts were used whenever available in patients with aortic root abscess.

Mechanical valves were used in 24 patients, aortic homografts in 4, and bioprosthetic valves in 3.

If one or both coronary arteries did not reach the new aortic root without tension or if the proximal part of the artery was involved by the abscess, a short segment (approximately 1 to 2 cm long) of saphenous vein or a synthetic graft was used to increase their length before reimplantation. Sixteen patients required extension of one or both coronary arteries.

The mitral valve was replaced in 4 patients through the aortic annulus and dome of the left atrium. In cases of endocarditis, the bovine pericardial patch used to reconstruct the left ventricular outflow tract was sutured directly to the sewing ring of the mitral valve prosthesis and a separate patch was used to close the roof of the left atrium.

The aortic arch was replaced in 7 patients (23%). The mean duration of circulatory arrest was 20 minutes (range, 11 to 46 minutes). The mean aortic cross-clamp time was 123 ± 41 minutes (range, 58 to 228 minutes), and the mean cardiopulmonary bypass time was 163 ± 56 minutes (range, 73 to 305 minutes).

Follow-up and data analysis
Follow-up information was obtained between March and June 1999 by personal interview or by a questionnaire completed by the patient or the personal physician. Follow-up was 100% for all hospital survivors. Mean follow-up was 47 months (range, 1 to 225 months). Data were analyzed using SAS 6.12 statistical software (SAS Institute, Cary, NC). Descriptive statistics include the mean ± standard deviation (standard error in figures) for continuous variables and frequency tables for categorical variables. Long-term survival and freedom from adverse events were evaluated univariately by Kaplan-Meier curves.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
There was one operative death in a patient who underwent re-replacement of the aortic root and transverse arch using the elephant trunk technique and mitral valve replacement. She died a few hours postoperatively. Autopsy showed an acute rupture of the thoracoabdominal aneurysm. She had a chronic type A aortic dissection. Two patients (6%) required reexploration of the mediastinum for bleeding. Two patients (6%) had a stroke, with complete recovery in 1. Six patients (18%) required implantation of a permanent pacemaker. No patient had a perioperative myocardial infarction.

There were five late deaths, 1 to 18.7 years postoperatively. Three deaths were cardiac related: one fatal stroke, one recurrent prosthetic valve endocarditis, and one cerebral hemorrhage. The three deaths occurred in patients with mechanical valves who were taking oral anticoagulant. The actuarial survival at 1 and 5 years was 93% ± 5% and 71% ± 12%, respectively (Fig 1). The 1- and 5-year survival rates for patients receiving a coronary extension were 93% ± 6% and 65% ± 14%, respectively, compared with 93% ± 6% and 93% ± 6% (p = 0.08) for the patients who did not require a coronary extension. There was no significant difference in survival rates between patients operated on for endocarditis and patients operated on for other indications.

View larger version (11K): [in this window] [in a new window]   Fig 1. Actuarial survival.

Three patients suffered recurrent prosthetic endocarditis 4 months to 8 years postoperatively. One underwent successful reoperation, 1 was treated medically and did well, and 1 died. The 8-year freedom from endocarditis for patients operated on for prosthetic valve endocarditis was 82% ± 11% compared with 100% for those operated on for other reasons (p = 0.1).

At the latest follow-up, 84% (21 of 25) of the patients were in NYHA class I or II and 16% (4 of 25) are in NYHA class III.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
This study describes the outcomes in patients who underwent re-replacement of the aortic root, which was conducted to address specific problems related to replacing the entire prosthetic or biologic aortic root, such as re-reattachment of the coronary arteries and extensive reconstruction of the left ventricular outflow tract in cases of infected conduits. Hospital mortality in this series was 3.3% (1 of 31). Considering the complexity of the cases, such as repair of prosthetic root abscess, false aneurysms, and aortic arch replacement, these results are very encouraging. We attribute our low mortality to several factors. First, as with any redo cardiac surgical procedure, a safe reentry into the chest is indispensable. This is accomplished by reviewing the patient’s lateral chest roentgenogram, and, if the right ventricle or ascending aorta graft is close to the sternum, a computed tomography scan is obtained. Cardiopulmonary bypass through the femoral vessels was used when concern was raised about the safety of the resternotomy. Second, because those operations include a relatively long aortic cross-clamp time, careful myocardial protection is a key element. We routinely use antegrade cold blood, delivered in a continuous fashion through self-inflated soft coronary artery cannula at volumes of 150 to 250 mL/min depending on the size of the heart. This technique also prevents debris from entering the coronary circulation. The third factor is aggressive debridement of all suspiciously infected tissues, and reconstruction of the heart with pericardium in patients with aortic root abscess [10]. We believe this strategy is more important to eradicate infection and enhance survival than the type of valve implanted [10]. However, we do not dispute that aortic valve homograft may be more resistant to reinfection than prosthetic valves [12].

It is difficult to compare the outcomes of this series to other reports. There is a wide spectrum of reinterventions on the aortic root and disease [4–7]. Operative mortality rates for reoperations on the ascending aorta in previously reported large series ranged from 6% to 19% [4–7].

Fifty percent of our patients (16 of 31) required extension of one or both coronary arteries to reach the new conduit. This method enables safe re-reattachment of the coronary arteries without tension. We do, however, have concerns related to long-term patency of such grafts. The long-term survival of patients with coronary extension was worse than those without. However, the causes of late death were not related to the coronary arteries as no patient died suddenly or because of myocardial infarction. Thus, this increase in mortality in this subgroup of patients could have been entirely caused by chance because of the small sample size.

Patients with prosthetic valve endocarditis are more likely to have another episode of endocarditis. Indeed, in this series 3 of 12 patients operated on for prosthetic valve endocarditis suffered another bout of infection 4 months to 8 years later. Although it is possible that the first patient had persistent infection, it is unlikely that the two others had this. Aortic valve homografts are believed to be more resistant to reinfection than prosthetic valves [12]. Only 4 of 12 patients in our series had aortic homografts, but this series covers a 20-year experience and includes patients operated on before we began to use aortic homograft in our unit in the late 1980s.

Aortic root re-replacement is a complex operation but it can be performed with low operative mortality and very good long-term results even in moribund patients with infected valved conduits.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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