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Ann Thorac Surg 2002;74:S1777-S1780
© 2002 The Society of Thoracic Surgeons
a Cardiothoracic Surgery, Baylor College of Medicine, and the Methodist DeBakey Heart Center, Houston, Texas, USA
* Address reprint requests to Dr LeMaire, 6560 Fannin St, Suite 1100, Houston, TX77030, USA
e-mail: slemaire{at}bcm.tmc.edu
Presented at the Aortic Surgery Symposium VIII, May 2–3, 2002, New York, NY.
Abstract
BACKGROUND: The purpose of this study was to examine our experience with proximal aortic reoperations in patients with composite valve grafts (CVGs) and assess postoperative survival and morbidity.
METHODS: Since 1991, 33 patients with CVGs underwent reoperation for one or more of the following indications: aneurysms distal to the CVG (n = 20, 61%), false aneurysms (n = 13, 39%) and graft infection (n = 7, 21%). Operations included false aneurysm repair (n = 13, 39%), graft replacement of distal ascending aortic or transverse aortic arch aneurysm (n = 20, 61%) and aortic root re-replacement with a new CVG (n = 6, 18%) or homograft (n = 4, 12%).
RESULTS: Operative mortality was 15% (n = 5), including 2 of the 7 patients who had infected CVGs (29%). All 4 patients who had infected CVGs replaced with aortic root homografts survived. Complications included vocal cord paralysis (n = 4, 12%), bleeding requiring reoperation (n = 3, 9%) and stroke (n = 2, 6%). Actuarial 3-year survival was 74.4% ± 7.9%.
CONCLUSIONS: Reoperations in patients with CVGs remain challenging procedures with high associated morbidity and mortality, especially in the setting of graft infection. The results of homograft aortic root re-replacement for infected CVGs are encouraging.
Data from several centers have established that primary aortic root replacement can be performed with low morbidity and mortality [1–6]. In the wake of these excellent results an increasing number of these patients are returning with a variety of indications for reoperation [7–9]. Patients requiring reoperation on the proximal aorta after previous composite valve graft (CVG) placement represent a challenging subset [10]. The purpose of this retrospective review was to examine our experience with proximal aortic reoperations in patients who have undergone previous CVG placement.
Patients and methods
Since 1991, 33 patients with previously placed CVGs presented for reoperation. During the same period, the senior author (J.S.C.) performed aortic root replacement with CVGs in 124 patients, only 1 of whom returned for reoperation; the remaining 32 patients had their original CVG placed elsewhere. The average age at reoperation was 46 ± 14 years. Twenty-seven patients (82%) were men and 6 (18%) were women. Seventeen patients (52%) had Marfan’s syndrome. The average time interval between the initial operation and presentation was 81 ± 71 months (range, 3 to 252). In many cases there were multiple simultaneous indications for reoperation.
Twenty patients (61%) presented with a recurrent aneurysm distal to the previously placed CVG; this was the most common indication for reoperation. One of these patients underwent an emergency operation for rupture. Two patients had acute dissection and 12 had chronic dissection. In 19 patients the graft repair extended into the transverse aortic arch. Graft extension was performed as the sole operation in 13 patients and combined with other procedures in 7 patients; 5 of these underwent concomitant pseudoaneurysm repair and 2 underwent placement of a new CVG for perivalvular pseudoaneurysm or bioprosthetic aortic valve insufficiency.
Seven patients (21%) presented with infected CVGs, proven by either preoperative blood culture (n = 6) or intraoperative mediastinal fluid culture (n = 1). One patient underwent only pseudoaneurysm repair and omental coverage of the infected graft. Two patients underwent CVG resection and replacement with a new CVG; a pedicled omental flap was placed around the new graft in 1. Since mid-1994 we have used homografts for all patients with infected CVGs. Four patients underwent CVG resection and replacement with a homograft aortic root; omentum was placed around the homograft in 1 patient. One of these patients had also undergone beveled polyester graft replacement of the proximal transverse aortic arch during the initial operation; his reoperation included resection of all prosthetic material and replacement with homograft aortic root and arch.
Pseudoaneurysms were present in 13 patients (39%, Table 1) and were usually associated with other pathology. Only 1 pseudoaneurysm (perivalvular) was related to graft infection. One patient with a perivalvular pseudoaneurysm and prosthetic aortic valve insufficiency underwent placement of a new CVG. One patient had a perivalvular pseudoaneurysm-to-right atrial fistula that was closed at the time of pseudoaneurysm repair. Pseudoaneurysms were the sole indication for reoperation in only 4 patients (12%); 3 underwent repair alone and 1 underwent placement of a new CVG.
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Results
There were no intraoperative deaths. There were 5 operative deaths (15%). All deaths occurred during the initial hospitalization and 3 occurred within 30 days. The indications for operation in these 5 patients were CVG infection (n = 2), recurrent aneurysm of the ascending aorta and aortic arch (2, including 1 rupture) and false aneurysm (n = 1). Both patients who had an infected CVG removed and replaced with a new CVG died. Causes of death included multiple organ failure (n = 2), stroke (n = 1), heart failure (n = 1), and pulmonary embolism (n = 1).
There were no postoperative complications in 42% of patients (n = 14). Two patients had strokes (6%), one of which was fatal. Both strokes occurred in patients who required hypothermic circulatory arrest. Nine patients (27%) required more than 48 hours of ventilatory support. Two patients required a tracheostomy; both were successfully weaned from the ventilator and discharged home. Left vocal cord paralysis occurred in 4 patients (12%). Three of these patients had undergone graft replacement of the transverse aortic arch during reoperation and 1 had an infected CVG with a perivalvular pseudoaneurysm. Three patients (9%) required reoperation for postoperative bleeding. Wound infection occurred in 3 patients (9%) and required a subsequent operation for wound debridement in 2 cases; only 1 of these patients had initially presented with an infected CVG. One patient developed atrioventricular block, but did not require pacemaker placement.
Of 28 patients surviving to discharge, long-term follow-up was available for 24 patients (86%) and included data up to 9 years postoperatively (mean follow-up, 4.7 ± 2.5 years). There were 5 late deaths yielding a 79% survival rate among these 24 patients. Actuarial 3-year survival was 74.4% ± 7.9% (Fig 1). The patient who underwent a pedicled omental wrap of the existing infected CVG was discharged on oral antibiotics and remains active and healthy 8 years after discharge. Three patients who received homografts were discharged with intravenous antibiotics and tunneled central venous lines. Three of the 4 patients with homografts remain alive and well with no further complications an average of 6 years after discharge. The patient who presented with an infected CVG and beveled hemiarch graft died of a myocardial infarction 5 months after discharge. Two of the 13 patients who underwent pseudoaneurysm repair developed new pseudoaneurysms. One patient had undergone repair of a left main coronary pseudoaneurysm and presented 4 years later with a new pseudoaneurysm involving the distal aortic anastomosis; this was repaired elsewhere by graft extension into the proximal hemiarch. The other patient had undergone repair of a pseudoaneurysm at the distal aortic anastomosis by graft extension into the proximal hemiarch and concomitant coronary artery bypass; 5 years later he developed a pseudoaneurysm involving the vein grafts but was lost to follow-up before treatment.
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The most common indication for reoperation in this series was aneurysm recurrence just distal to the previously placed graft [11]. Although more judicious inspection and aggressive resection of the proximal aorta at the original operation may reduce the incidence of recurrence, we recognize that limiting the initial repair (especially under emergency circumstances) is often prudent. When feasible, brief periods of hypothermic circulatory arrest allow assessment of the aortic arch and may alter the extent of reconstruction. Cooley and Livesay [12] have referred to this as the open distal anastomosis technique and have long recommended its use to more clearly identify the need for extended resection in patients with aortic dissection.
The open button technique of coronary artery reattachment during CVG insertion has decreased the incidence of coronary artery pseudoaneurysm [3]. Similarly, using interrupted sutures rather than a continuous suture line at the annular anastomosis may reduce the risk of perivalvular pseudoaneurysm [13]. The variety of the 14 pseudoaneurysms in this series, however, serves as a reminder that patients with CVGs are at risk for the development of pseudoaneurysms regardless of the technique used. Lifelong surveillance with echocardiography and computed tomography scanning is required to assess the integrity of the valve mechanism, the development of pseudoaneurysms, and dilatation of the distal aorta.
As we have reported previously [14], CVG infection remains a catastrophic complication. Prosthetic endocarditis is the most common complication after CVG placement and carries a mortality that exceeds 50% [2]. Although simply wrapping the infected graft with a pedicled omental flap and administering long-term intravenous antibiotics was successful in 1 patient, replacement of the infected CVG with a homograft aortic root provided encouraging early and midterm results. After homograft placement, we recommend a 6-week course of intravenous antibiotics through a tunneled central venous catheter. Importantly, the risk of CVG infection continues long after the initial operation. In our series 4 of the 7 patients (57%) with graft infection presented more than 3 years after CVG placement. We believe that this justifies an aggressive approach to antibiotic prophylaxis whenever patients with CVGs require invasive procedures that produce bacteremia such as bronchoscopy, colonoscopy, and dental procedures; regardless of the length of time since CVG placement, we recommend periprocedural administration of intravenous broad-spectrum antibiotics.
References
This article has been cited by other articles:
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  R. Almeida, T. Pinho, N. P. Oliveira, J. Almeida, F. Macedo, A. R. Sousa, and M. J. Maciel A case of acute heart failure due to giant aortic pseudoaneurysm with fistulization to the right ventricle after a modified Bentall operation Eur J Echocardiogr, September 1, 2008; 9(5): 716 - 719. [Abstract] [Full Text] [PDF]
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 S. A. LeMaire and J. S. Coselli Options for managing infected ascending aortic grafts. J. Thorac. Cardiovasc. Surg., October 1, 2007; 134(4): 839 - 843. [Full Text] [PDF]
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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]
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