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Ann Thorac Surg 2002;74:2026-2033
© 2002 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany
* Address reprint requests to Dr Kallenbach, Hannover Medical School, Department of Thoracic and Cardiovascular Surgery, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany.
e-mail: kallenbach{at}thg.mh-hannover.de
Presented at the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2002.
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Abstract |
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 Top Abstract IntroductionPatients and methodsResultsCommentDiscussionReferences |
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METHODS: From July 1993 to July 2001, 158 patients underwent replacement of the ascending aorta with native valve reimplantation. Mean age of patients was 52 ± 17 years (9 to 84 years), 103 were men (65%). Thirty-four patients (22%) suffered from Marfan’s syndrome. Aortic dissection Stanford type A was present in 29 patients (19%) (22 acute, 7 chronic), and concomitant partial or total arch replacement was necessary in 57 patients (36%). One or more additional procedures were performed in 28 patients (18%). Mean follow-up was 36 ± 25 months (0.4 to 96 months).
RESULTS: Thirty-day mortality was 3.8% (6 patients), but only 2.2% in elective patients. Mean bypass time was 169 ± 50 minutes (99 to 440 minutes), aortic cross-clamp time was 129 ± 31 minutes (79 to 205 minutes). In patients undergoing arch replacement, circulatory arrest was 26 ± 18 minutes (7 to 99 minutes). During follow-up, there were 5 (3.3%) cardiac-related late deaths. Grade of aortic insufficiency (AI) decreased from 2.3 ± 1.1 (0 to 4) preoperatively to 0.23 ± 0.44 (0 to 2) postoperatively (p < 0.0001). Six patients required aortic valve replacement, 4 of those due to progressive AI. Average grade of AI increased significantly to 0.42 ± 0.61 (0 to 3) at latest evaluation (p = 0.002). Two patients experienced a transient ischemic attack within the first postoperative week. No further thromboembolic complications were noticed. All patients presented with a favorable exercise tolerance.
CONCLUSIONS: The aortic valve reimplantation technique achieves excellent clinical outcome with few complications even in complex pathologies. Lack of anticoagulation and favorable durability encourage wider and earlier use of this technique.
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsCommentDiscussionReferences |
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Aortic root dilation is the most common cause of aortic insufficiency [8, 9]. Underlying pathologies are bicuspid valves, syndromes associated with weakness of the aortic wall (eg, Marfan’s syndrome) and idiopathic root dilation. In the latter, the aortic cusps are often morphologically intact. This might be true for the majority of aneurysms of the ascending aorta as well as for acute aortic dissection type A. Considering the underlying pathologies resulting in aortic insufficiency, new surgical techniques for valve preserving aortic root replacement have been reported in the early nineties. Yacoub and colleagues [10] developed a remodeling technique with reconstruction of the aortic sinuses, and David and Feindel [11] reported a reimplantation technique inserting the native valve with the commissures into a Dacron tube. At present, both techniques have gained wide acceptance. They are applied routinely in patients with aortic valve insufficiency or aortic ectasia presenting with normal aortic cusps.
At our institution, we have almost exclusively used the reimplantation technique as reported by David and Feindel [11]. We expanded the indication for the procedure from isolated aortic replacement due to ectasia to complex aortic operations necessary in patients with structurally impaired aortic wall tissue such as with Marfan’s syndrome, as well as for emergency situations in patients presenting with acute aortic dissection type A. The aim of this report is to summarize our experience in 158 consecutive patients to assess the durability and clinical outcome of valve-sparing aortic root reconstruction with the reimplantation technique.
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsCommentDiscussionReferences |
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Surgical technique
Standard median sternotomy and extracorporeal circulation as well as standard myocardial protection techniques were used in all patients.
The operative technique used for this procedure was recently described by our group [12]. After assessing the suitability of valve reconstruction, excision of the coronary ostia and resection of aortic sinuses up to a rim of 2 to 3 mm of aortic wall as well as extensive external dissection and mobilization of the aortic root followed. The diameter of the prosthesis was calculated from the diameter of the left ventricular outflow tract and the height of the aortic cusps. Practically, the annulus was sized with a Hegar dilator, diameter of the sinotubular junction with a valve sizer (St. Jude Medical, St. Paul, MN). The diameter of the sinotubular junction determined the diameter of the graft. Valve coaptation was considered ideal by intraoperative judgment if 30% to 50% of the cusp area was involved after correcting the diameter of the sinotubular junction.
Proximal anastomosis was performed with 12 threads of 3-0 coated polyester fiber (Ethibond, Ethicon Inc, Hamburg, Germany) used as a horizontal mattress suture placed circumferentially through the annulus underneath the valve. Sinuses were then reimplanted into the Dacron prosthesis using three 4-0 polypropylene sutures (Prolene, Ethicon Inc). Utmost care was taken to achieve correct cusp geometry and sufficient height of commissural resuspension within the prosthesis. Reimplantation of coronary ostia buttons completed the aortic root reconstruction. In cases with acute type A dissection of the aorta or large aneurysm involving the aortic arch, deep hypothermic circulatory arrest or, more recently, moderate hypothermic circulatory arrest with cold (15°C) antegrade cerebral perfusion was used.
Follow-up
One patient was lost to follow-up (99% completeness). Mean follow-up for all patients was 36 ± 25 months, with a minimum of 1 month and a maximum of 96 months. Patients undergoing root reconstruction received either acetylsalicylic acid or coumadin for 3 months postoperatively according to the surgeon’s preference. Thereafter, anticoagulation therapy was discontinued except in those patients who required antithrombotic prophylaxis for other reasons.
Intraoperative or immediate postoperative control of aortic valve function was determined by transesophageal echocardiography in all patients undergoing this operation. Before hospital discharge and at 1- to 2-year intervals thereafter, valve function was reevaluated using transthoracic color Doppler echocardiography either by our cardiologist or by the referring physician. Valve morphology as well as systolic and diastolic function were reported in accordance with published criteria [13, 14]. Aortic regurgitation was assessed semiquantitatively as follows: 0, none; I, minimal; II, mild; III, moderate; and IV, severe. Clinical follow-up was performed either by direct patient contact or by telephone interview with the patient and the referring physician. Valve performance, complications, and outcome analysis are reported as suggested by the guidelines of the American Association for Thoracic Surgery and the Society of Thoracic Surgeons [15].
Statistical analysis
Continuous variables are expressed as mean ± standard deviation. All data analyses were performed with SPSS 10.0.7 for Windows (SPSS Inc, Chicago, IL). Kaplan-Meier analysis was used for the evaluation of time-related variables. Statistical significance of differences in AI between preoperative and postoperative echocardiograms was tested using Wilcoxon’s signed rank test for not normally distributed data. A value of p less than 0.05 was considered significant.
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Results |
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TopAbstractIntroductionPatients and methodsResultsCommentDiscussionReferences |
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In the group of elective patients, 1 patient with chronic aortic dissection type B required complex additional operation with redo-coronary artery bypass grafting, mitral valve replacement, and aortic arch replacement with elephant trunk extension. She died from myocardial failure 3 days postoperatively. Another patient received additional arch replacement and elephant trunk extension without any intraoperative complication. He succumbed from sudden cardiac death in the referring hospital 17 days after the operation. A third patient received additional coronary artery bypass grafting due to diffuse coronary artery disease. After an initially uneventful operation, he died of an acute myocardial infarction on the first postoperative day.
In emergency cases, 1 patient with acute aortic dissection type A involving all supraaortic arteries and the abdominal aorta was diagnosed with a delay of 3 days. She developed pericardial tamponade and peripheral malperfusion before referral. During immediate transport to the operating room she was resuscitated before establishment of extracorporeal circulation. Aortic valve reimplantation, replacement of the aortic arch, reconstruction of the supraaortic branches with gelatin-resorcin-formalin glue, ligation of the left subclavian and left vertebral arteries, as well as implantation of a bifurcated Dacron prosthesis into the abdominal aorta were performed. She died from multiorgan failure shortly after transfer to the intensive care unit. Another patient with acute aortic dissection type A died 4 days after an uneventful operation and early postoperative course due to massive cerebral edema. A third patient with previous replacement of the aneurysmatic abdominal aorta suffered a type A aortic dissection reaching from the aortic valve annulus to the abdominal aortic graft. After aortic valve reconstruction and fenestration of the dissection membrane in the aortic arch, distal malperfusion required laparatomy showing severe ischemia of the bowel. Additional fenestration of the proximal abdominal aorta resulted in distal pulses. However, the patient died in the operating room due to diffuse bleeding and hemodynamic instability.
Intraoperative variables and additional procedures are listed in Table 2. Length of stay in the intensive care unit was 2.2 ± 2.6 days, with a range from 1 to 25 days. Average hospital stay was 15 ± 9 days (8 to 76 days). Within the first week, 2 patients experienced a transient ischemic attack with complete resolution. Seven patients (4.4%) required rethoracotomies because of bleeding.
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Cardiac-related mortality was 3.3% (5 patients), actuarial survival was 98.7% (±1%), 96.8% (±1.6%), and 96.8% (±1.6%) at 1, 3, and 5 years. Valve-related mortality was 2% (3 patients), actuarial survival was 99.3% (±1%), 98.3% (±1%), and 98.3% (±1%) at 1, 3, and 5 years in this group. Actuarial survival for both groups are shown in Figure 1.
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Neither thromboembolic events nor bleeding complications were noticed in any patient during follow-up.
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Comment |
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TopAbstractIntroductionPatients and methodsResultsCommentDiscussionReferences |
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Indications for this procedure have been all types of ascending aortic pathologies with and without aortic valve insufficiency. For such diseases, the surgical gold standard used to be aortic replacement with a valved conduit. Although excellent results have been achieved with this technique [16], the concept of valve preserving aortic root replacement gains increasing acceptance. Superior flow characteristic and the lack of lifelong anticoagulation in patients with reconstructed native aortic valves is potentially attractive.
Recently, we compared composite replacement and aortic valve reimplantation in a matched pair analysis. We found comparable survival rates, but significantly less thromboembolic and bleeding complications if the valve was preserved [17]. In this study, no thromboembolic- or anticoagulation-related complications were noticed during follow-up.
Potential recurrence of aortic insufficiency has been a proposed limitation of the reimplantation technique. We had to reoperate on 6 patients (4.0%) due to valve-related morbidity. According to the guidelines for reporting morbidity and mortality after cardiac valvular operations [15], we included 2 patients with competent aortic valves who developed acute endocarditis during follow-up. Operated on early in our series, 1 patient with inflammatory disease (morbus Wegener) had thickened and shrunken leaflets with histologic evidence of inflammatory reaction in the cusps. Since then, we exclude patients with inflammatory disease from valve-sparing operations. In 1 patient, the underlying pathology leading to aortic insufficiency grade III 2 weeks postoperatively remains unclear. One reason might be the use of a small prosthesis (24-mm in diameter) for reimplantation. The use of such a small prosthesis did not allow the building of artificial sinus of Valsalva by using a prosthesis 2 to 3 mm larger in diameter than needed, as described by David and colleagues [18]. In 2 patients, also operated on early in our experience, a technical reason might have caused progressive aortic valve insufficiency and finally reoperation. We reported the importance of high commissure implantation into the Dacron prosthesis, leading to cusp coaptation well above the inferior edge of the graft [12]. In both patients, coaptation underneath the inferior edge caused already early postoperatively cusp prolapse and mild aortic insufficiency. Modification of the surgical technique has almost eliminated this problem as a potential cause for reoperation. Early cusp degeneration as well as cusp contact with the prosthesis, as described by Leyh and associates [19], was observed neither immediately postoperatively nor at follow-up.
Freedom from reoperation was 96.8% (±2%) at 5 years. Interestingly, all reoperations were performed up to 14 months after the initial valve preserving operation. After 14 months postoperatively, no patient required reoperation for valvular reasons. This fact supports the observation that the preserved valve remains stable if reimplanted without significant aortic insufficiency at intraoperative echocardiography. Although we found a statistically significant increase of aortic insufficiency early postoperatively to last visit (mean 0.23 ± 0.44 to 0.42 ± 0.61), the relevance of this finding is questionable. Echocardiograms at the last visit were performed by different cardiologists. At the last follow-up, some cardiologist graded the degree of aortic regurgitation as grade I compared to grade 0 during the previous investigation. The discrepancy may depend on the individual judgment of absent or minimal aortic insufficiency by different investigators and has no clinical impact on the patient.
Valve-sparing operations in patients with aneurysms of the ascending aorta seem to be well designed for those with Marfan‘s syndrome. Because of their younger age, these patients specifically benefit from lack of anticoagulation. The risk of dissection in other aortic areas, with the need of a second or third operation, makes perioperative patient management more difficult under continuous anticoagulation. For this group, recent studies report of excellent outcome both in survival and valve stability regardless of the technique of valve preservation used [18, 20]. In contrast, it is unknown to what extent the structural fibrillin-1 defect may affect the stability and durability of valve reconstruction. Recently, published data confirm fibrillin fragmentation and deficiency in aortic cusps of patients with Marfan’s syndrome and significant valve deterioration in patients with advanced disease [21]. We must report on 3 of 34 patients (8.8%) with Marfan’s syndrome who required reoperation due to progressive aortic regurgitation. In addition, 2 patients died during follow-up for nonvalve-related reasons. Although the outcome in this group is less favorable than in the non-Marfan group, we attempt to apply the valve reimplantation technique in almost all patients with Marfan‘s syndrome at our institution. To avoid permanent damage to the aortic cusps, we tend to operate on patients with Marfan’s syndrome when the diameter of the aortic sinuses reaches 50 mm and echocardiography suggest normal cusps, as recommended by other investigators [18].
In our study, 22 patients with acute aortic dissection type A were operated on with the reimplantation method with an early mortality of 14%. One patient had to be reoperated due to endocarditis during follow-up. As a result, acceptable 30-day mortality rate and excellent midterm stability of the reconstructed valve is observed. These findings support the use of this surgical strategy as an alternative to established treatment forms, such as supracommissural or composite graft remodeling replacement. Major advantages of the reimplantation technique in these patients are the almost complete resection of diseased aortic tissue and excellent hemostasis. Although the mechanism of the development of secondary aneurysmatic dilatation of the aortic root after supracommissural replacement is multifactorial, these aneurysms are the main reason for reoperation due to development of moderate to severe aortic regurgitation with an incidence of 25% to 45% [22, 23]. Recently published studies have demonstrated the feasibility of valve-sparing aortic root operations in acute aortic dissection type A. Leyh and colleagues [24] compared 11 patients undergoing remodeling and 9 patients with reimplantation procedure. Neither significant increase of aortic insufficiency was noticed nor reoperation was required for a mean follow-up of 26 ± 18 months in acute type A dissection. David and associates [18] distinguished between 9 patients treated with reimplantation and 3 patients who underwent remodeling after acute aortic dissection and found no significant difference in 5-year survival to patients treated without a dissection. Yacoub and co-workers [20] reported on 49 patients operated for acute dissection with the remodeling technique. Early mortality was 18.4%. In their series of 158 patients treated with the remodeling technique, late survival in patients operated for acute dissection was significantly lower than in those operated for chronic aneurysm. It is not stated to what extend valve failure influenced survival.
Comparison of the two valve-sparing techniques seems to be difficult at this time. At follow-up after 5 years, David and colleagues [18] reported 99% freedom from aortic valve reoperation with the reimplantation technique. We could demonstrate 96% for the same time interval with this operation. In contrast, Yacoub and associates [20] published 89% freedom from reoperation at 5 years with the remodeling technique. Although these data imply a trend toward higher stability of reimplanted compared to remodeled aortic valves, further results will be required for final judgment regarding long-term durability of both procedures.
In conclusion, our results for valve-sparing aortic root operation using the reimplantation technique provide excellent clinical outcome with few complications even in complex pathologies. Low perioperative mortality and morbidity, lack of anticoagulation, and excellent hemodynamics encourage wider and earlier use of this technique. However, perfect valvular coaptation is essential for long-term durability; final judgment of this repair will require further studies.
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Discussion |
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TopAbstractIntroductionPatients and methodsResultsCommentDiscussionReferences |
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This study examines 158 patients followed for a mean of 36 months after operation. They applied the operation to a diverse set of aortic root pathology, excluding aortic dissection, both acute and chronic, Marfan’s syndrome, and ascending aortic aneurysm. They report excellent results, most noticeably, a 3.8% perioperative mortality rate and a 4.4% take-back rate for bleeding. These are excellent numbers. Their follow-up data reveal an actuarial survival of 92% at 6 years and 96% at 5 years.
The question of which operation cardiac surgeons should perform at the aortic root is difficult. The options are many and we really do not know which one is best. The options include: (1) the composite mechanical valve graft, which Dr Vincent Gott from Hopkins and others have shown to be very effective and very durable, (2) the "remodeling" valve-sparing technique developed by Dr Yacoub, which was not the technique used in this paper, (3) the "full root" homograft procedure, which is a biological alternative that has relatively long-term data at this point in adults, (4) the "reimplantation" valve-sparing technique advocated by Dr David and now by Dr Kallenbach and his group at Hannover, (5) and lastly, should we use the "full root" stentless valve as a biologic aortic root conduit? Our group at the University of Pennsylvania as well as Dr Neil Kon’s group in North Carolina are reporting near 100% 5-year freedom from structural valve deterioration with this conduit as an aortic root bioprosthesis. Of course, these are intermediate results, as are these results from Dr Kallenbach.
My questions for Dr Kallenbach are: (1) from my review of the manuscript, there were 5 Marfan’s patients with structural valve deterioration who required redo aortic valve replacement. This translates into a 14% rate of structural valve deterioration at a mean of 3 years’ follow-up. In light of this data, do you advocate valve repair for Marfan’s patients and what is your theory on this topic? (2) Do you have data on the fate of the valves that presented with +3 or +4 aortic insufficiency? Eighty-three of 158 patients, or just over half of the group, presented with +3 or +4 aortic insufficiency. The rest only had 0 to +2 aortic insufficiency and were presumably operated on for aortic disease only. I certainly advocate sparing the aortic valve in that subgroup. Could you tell us about the 83 patients with significant aortic insufficiency? Did they have worse structural valve deterioration rates? (3) There have been multiple reports commenting on aortic valve leaflet degeneration secondary to a poorly formed and anatomically abnormal sinus of Valsalva after this operation. In addition, there have been concerns regarding possible abnormal aortic valve opening and closing without a naturally curved sinus of Valsalva. Can you comment on whether this postoperative abnormal geometry affected your patients?
This is a wonderful paper. I learned a lot and enjoyed reviewing it. Again, congratulations, and this is the fine work we have come to expect from Professors Haverich and Harringer from Hannover, Germany. I hope your data will make it a bit easier for us to provide our patients with the best biological aortic root reconstruction.
I thank the Society for privilege of discussing this paper.
DR MICHAEL C. MAXWELL (Charlotte, NC): Did you use intraoperative transesophageal echocardiography to assess the valve function before coming out of the operating room, and if so, in the few patients who did require reoperation, did you see anything unusual about those flow dynamics?
Thank you.
DR KALLENBACH: Dr Bavaria, I thank you for discussion of the paper. First, I would like to answer the question about the Marfan’s and the reoperations. We had in total six reoperations: two due to endocarditis, one due to Wegener’s disease, and 3 patients who required reoperation actually due to technical problems at the very early beginning of the study. These 3 patients had Marfan’s syndrome. There was also 1 patient who received aortic arch replacement 5 years after the reimplantation, and because he showed the same problem as the others who needed to be reoperated, we implanted a mechanical valve, although there was aortic insufficiency grade I to II.
We believe that the technique we presented is very well suited for Marfan patients. I believe that this is more random than really a significant difference, and if you look at the data of Tirone David, and also of Dr Yacoub, who presented his technique, they even found in their series better results for Marfan patients. So I believe this technique is very well suited and should be applied to Marfan patients.
The second question was about the grade of aortic insufficiency and the influence of the reoperations. Our indication for this procedure has been an aneurysm of the aortic root or ascending aorta, regardless to the presence and grade of aortic insufficiency. We did not do a subanalysis, but we do not believe that the grade of aortic insufficiency before the operation has an impact on the reoperation rate, because we look closely at the valve before the operation with echocardiography and inspect it carefully during operation, and actually we only perform the operation if we do not see any valvular deconstruction. So I believe the grade of aortic insufficiency has no impact on the outcome.
And the last question about the opening and closing characteristics, it is true, when we look at the cusp motion, it is different from a normal cusp, but, however, we never see any valve degeneration during follow-up. Even in the patients where we have had to reoperate, the reason was not prolapse because of a technical mistake. We never observed any contact of the wall cusps with the Dacron tube that has been reported in the literature. There are changes in the closing behaviors, but it seemed not to be relevant for the stability of the valve cusps themselves.
In regard to Dr Maxwell’s question who asked for the transesophageal echocardiography, yes, we performed intraoperatively an echo at the end of the operation, and it is true in the cases of reoperation, at least in the 3 Marfan patients, we had already mild aortic insufficiency. And we learned from this experience after we went through and analyzed it that we really have to pull up the commissures as high as possible into the Dacron tube so that we get a cusp adaptation area of 30% to 50%, and the adaptation must lay into the Dacron tube. It should not lay beneath. Otherwise you will end up with aortic insufficiency and probably reoperation.
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R. G. Leyh, K. Kallenbach, M. Karck, C. Hagl, S. Fischer, and A. Haverich Impact of Preoperative Aortic Root Diameter on Long-Term Aortic Valve Function After Valve Sparing Aortic Root Reimplantation Circulation, September 9, 2003; 108(90101): II-285 - 290. [Abstract] [Full Text] [PDF]
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