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Ann Thorac Surg 2006;82:1407-1412
© 2006 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Reoperations on the Ascending Aorta and Aortic Root in Patients With Previous Cardiac Surgery

Leonard N. Girardi, MD*, Karl H. Krieger, MD, Charles A. Mack, MD, Leonard Y. Lee, MD, Anthony J. Tortolani, MD, O. Wayne Isom, MD

Department of Cardiothoracic Surgery, Weill Medical College of Cornell University, New York, New York

Accepted for publication April 3, 2006.

* Address correspondence to Dr Girardi, Department of Cardiothoracic Surgery, Weill Medical College of Cornell University, 525 East 68th Street, M-424, New York, NY 10021 (Email: lngirard{at}med.cornell.edu).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
BACKGROUND: First time operations on the ascending aorta are performed with low mortality, few complications, and excellent long-term results. Reoperations for aortic pathology in patients with previous cardiac surgery carry significantly more risk. Technical issues during the procedure, as well as age, preoperative New York Heart Association class, and perioperative renal dysfunction, have been shown to contribute heavily to worse outcomes. We analyzed our results with aortic reoperations with the intent of further reducing surgical risk through alterations in surgical technique or patient selection.

METHODS: From July 1997 until October 2005, 147 patients having previous cardiac surgery presented with aneurysm or dissection of the ascending aorta or root. Perioperative data were retrospectively analyzed. Morbidity, mortality, and risk factors for these events were calculated.

RESULTS: Eight patients expired (5.4%) after their reoperation. Significant (p < 0.05) univariate risk factors for mortality included age greater than 75 years (< 0.001), previous coronary artery bypass grafting (CABG) (< 0.008), cardiopulmonary bypass greater than 240 minutes (< 0.01), need for intraaortic balloon pump support (< 0.001), need for new CABG (< 0.007), postoperative cerebrovascular accident (< 0.032), and tracheostomy (< 0.003). Age 75 years or older (p < 0.025) was the only significant variable for death by multivariate analysis. A majority of patients (n = 87, 60%) required circulatory arrest to complete their procedure. However, neither arch involvement nor type of aortic root procedure was predictive of perioperative mortality.

CONCLUSIONS: Surgery on the ascending aorta and root in patients who have had previous cardiac surgery can be performed with low mortality. Advanced age and significant coronary disease may negatively influence surgical results.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Elective reconstruction of the ascending aorta and aortic root can be performed with low operative risk. The expected mortality from complex procedures such as composite valve-graft replacement or valve-sparing root reconstruction is predictably less than 5% in experienced hands, with few life-threatening perioperative complications [1–4]. Such reproducible success, however, has been much more difficult to attain when the same operations are performed on patients who have had previous cardiac surgery. While reoperations such as coronary artery bypass grafting (CABG) and valve replacement are performed with little increase in risk above a first time operation [5, 6], reoperative aortic surgery continues to challenge cardiac surgeons with an expected mortality at least 5 times that of primary aortic procedures.

One of the earliest reports on this high-risk cohort of patients examined 59 patients undergoing 67 reoperative aortic procedures [7]. The mortality was 17% with all deaths being attributed to myocardial failure, cerebrovascular accident, or hemorrhage. Since that time modifications in myocardial and cerebral protection have dramatically reduced the incidence of stroke and ventricular failure after these lengthy procedures. In addition, advances in surgical technique, graft technology, and adjuncts for hemostasis continue to make life-threatening hemorrhage a much less frequent cause of operative failure [1, 8–10]. Surgical groups with a particular interest in aortic disease have utilized these advancements to improve significantly the outcomes of these complex reoperations while providing excellent long-term survival with little need for more aortic reconstruction [11–15]. We wished to analyze our results with these operations in order to determine whether further improvements in surgical technique and patient selection would allow for a further reduction in surgical risk.


   Material and Methods
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 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
This study was approved by the Institutional Review Board of the Weill Medical College of Cornell University (protocol 0511008281). The need for individual consent was not necessary as per the vice-chairman of the IRB.

From July 1997 until October 2005, 737 consecutive patients underwent reconstruction of the ascending aorta or aortic root for aortic aneurysms or dissections. One hundred forty-seven of these patients had undergone previous cardiac surgery through a mediansternotomy. A retrospective analysis of perioperative data on this cohort of patients is the focus of this study. Patients with either native or prosthetic aortic valve endocarditis were excluded from this analysis. The patients ranged in age from 24 to 85 years and had a mean age of 61 years. The male to female ratio was 117 to 30. Aneurysms and dissections ranged in diameter from 3.5 to 12.5 centimeters and had a mean diameter of 6.5 centimeters. Ten patients (7%) had aneurysms larger than 10 centimeters. The comorbid conditions of the patients are listed in Table 1. Chronic obstructive pulmonary disease was defined by a history of emphysema, a forced expiratory volume in 1 second of less than 60% of predicted, or the need for steroids to maintain adequate respiratory function. Renal insufficiency was defined as having a baseline creatinine of 1.5 mg/dL or greater or the need for hemodialysis.


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  		Table 1. Preoperative Comorbid Conditions for 147 Patients Undergoing Reoperative Surgery of the Ascending Aorta and Aortic Root
 
The cardiac surgical procedures that these 147 patients previously had undergone are listed in Table 2. Thirty-three percent of patients had a previous CABG either as an isolated procedure (n = 39) or combined with aortic valve replacement (n = 9). Fifty percent of patients had previous aortic valve replacement (AVR) either as an isolated procedure (n = 42), composite valve graft (CVG) (n = 17), Ross procedure (n = 6), or combined with CABG (n = 9). Thirteen percent had previous repair of an acute type A dissection (n = 19). Isolated procedures such as previous pericardiectomy, ventricular septal defect repair, and cardiac stab wound were also included.


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  		Table 2. Previous Cardiac Surgery Procedures for 147 Patients Undergoing Reoperative Surgery of the Ascending Aorta and Aortic Root
 
The extent of aneurysmal disease, the presence of an aortic dissection, and the proximity of the aorta to the sternum was assessed in all patients preoperatively with a computed tomographic (CT) scan of the chest and abdomen. Right and left heart catheterization was also performed in all hemodynamically stable patients to delineate their native coronary anatomy and the status of any bypass grafts. Transthoracic echocardiography was performed if left ventricular function could not be assessed at the time of catheterization.

Operative Techniques
After induction of general anesthesia, right heart catheterization and transesophageal echocardiography (TEE) were performed. External pacing and defibrillation pads (Zoll Medical Corp, Chelmsford, MA) and cerebral oxymetry monitors (Somanetic Corp, Troy, MI) are positioned, and tubing from the cardiopulmonary bypass circuit is brought onto the field after sterile preparations are completed. Six million units of aprotonin (Bayer AG, Leverkusen, Germany) was given to all patients. After making a skin incision and removing the sternal wires, the sternum is reopened in one of three ways. If the preoperative CT demonstrates a space of at least 1 centimeter between the posterior sternal table and the mediastinal contents, an oscillating saw is used to divide the bone. If there is space of less than 1 cm between the posterior sternum and the heart or aorta, the mediastinal contents are dissected away from the posterior sternal table under direct vision and the sternum is divided sequentially with a reciprocating saw, similar to the technique described by Estrera and colleagues [15]. If there is no obvious space between the sternum and the aorta, femoral or axillary artery cannulation is performed, cardiopulmonary bypass is initiated, and systemic cooling to 18 degrees Celsius is performed. The sternum is then opened under profound hypothermic circulatory arrest (PHCA). In these cases, if there is significant aortic insufficiency, a small anterior thoracotomy is made over the ventricular apex for placement of a vent.

In cases where PHCA is not required prior to resternotomy, dissection of the cardiac anatomy and identification of all bypass grafts, including a patent internal mammary artery, is completed before heparin is given. Meticulous attention to hemostasis is mandatory before initiating bypass. If the patient has a pseudoaneurysm or aneurysm without a dissection, the ascending aorta or aortic arch is the preferred site for cannulation. In the presence of arch involvement from a chronic or acute type A dissection, the femoral artery is the preferred second site for arterial cannulation. If the descending aorta is severely diseased by CT scan or TEE, or if there is significant iliofemoral disease, the axillary artery is then cannulated through an 8 millimeter sidebranch graft (Hemashield; Meadox, Oakland, NJ). Cannulation in this cohort of 147 patients was distributed in the following fashion: aortic, n = 101, femoral, n = 45, axillary, n = 1. Once on bypass, a right superior pulmonary vein vent is placed, mean arterial pressure is maintained between 70 and 80 mm Hg and, if possible, the ascending aorta is cross-clamped. A padded bulldog clamp is used to occlude any patent internal mammary artery grafts. Antegrade and retrograde cold blood potassium cardioplegia are administered maintaining ventricular septal temperatures between 10 to 15 degrees Celsius. If PHCA is required, systemic cooling to a bladder temperature of 18 degrees Celsius is performed. Retrograde cerebral perfusion (RCP) is utilized as an adjunct for cerebral protection as previously described [10].

After completion of the procedure, blood products are administered as needed to reverse any coagulopathy. Inotropes, pressors, and intraaortic balloon pump (IABP) support are given as necessary to maintain adequate hemodynamics. All postoperative complications were recorded and mortality was defined as any patient death in the hospital or within 30 days of the procedure.

Statistical Analysis
A retrospective, comparative statistical analysis of perioperative variables was performed using SPSS statistical package (SPSS, Chicago, IL). Univariate analyses were performed with {chi}2 analysis to determine relationships between mortality and perioperative risk factors. The influences of these significant factors on patient's mortality were then examined using multiple logistic regression. Parameters with a p value less than 0.05 were included in the model.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
The indications for surgery are listed in Table 3. Patients having previous cardiac surgery presented for reoperation of the aorta in one of three ways. Eighty-six developed an aneurysm or pseudoaneurysm of the ascending aorta or aortic root while 23 presented with an acute type A dissection and 38 presented with a chronic type A dissection. A majority of patients (20 of 29) having a previous CVG or ascending aortic tube graft required reoperation because of dehiscence of coronary button attachments or the proximal or distal suture line after having their previous operation performed utilizing an inclusion wrap technique. All 6 patients having a previous Ross procedure had bicuspid aortic valves at the time of their autograft procedure. The autograft dilated to over 6 centimeters in all 6 patients a mean of 6.5 years postoperatively.


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  		Table 3. Indications for Surgery in 147 Patients With Previous Cardiac Surgery Requiring Reoperative Repair of the Ascending Aorta and Aortic Root
 
Of the 147 patients in this cohort, 91 required reconstruction of the ascending aorta at the sinotubular junction with a tube graft. The remaining 56 had reconstruction of the aortic root. Forty-five had composite replacement of the aortic root utilizing the exclusion technique [8] while 11 required a modification of the Cabrol procedure [16]. Early in our experience 4 patients who were poor candidates for anticoagulation had root reconstruction with a cadaveric aortic homograft (Cryolife Corp, Kennesaw, GA). These 4 patients would have their root rebuilt with a bovine pericardial-based CVG in the present era. Eighty-seven (60%) required aortic arch reconstruction under PHCA with RCP. The mean time under PHCA was 28 minutes (range, 14 to 67 minutes).

The aortic valve required repair or replacement in 97 of 147 (66%) of cases. Fifty-six patients had aortic valve replacement as a CVG or homograft root replacement. Twenty-three required isolated AVR along with tube graft reconstruction of the ascending aorta, sparing the sinuses of Valsalva. Eighteen had either aortic valve resuspension or repair and tube graft replacement of the ascending aorta, again sparing the sinuses of Valsalva. Additional valve procedures included three mitral valve replacements, one mitral valve repair, and one tricuspid valve repair.

Of the 48 patients with previous CABG surgery, 35 (73%) had patent saphenous vein grafts requiring reimplantation at the time of aortic reconstruction. Thirty-one had direct reattachment of their grafts on small buttons of aortic tissue while 4 required reattachment of their SVGs by a short Dacron interposition graft. Interposition saphenous vein grafts were not utilized in this series. Twenty-three patients (16%) required new bypass grafts into the native coronary circulation.

The mean time on cardiopulmonary bypass (CPB) was 172 minutes (range, 65 to 352; median time, 168 minutes) and the mean myocardial ischemic time was 104 minutes (range, 22 to 208; median time 107 minutes). Thirteen patients were on CPB for 240 minutes or longer. For 21 patients, the duration of myocardial ischemia exceeded 150 minutes.

Blood product usage was also recorded for these procedures. The mean number of units of packed red blood cells (PRBC) and fresh frozen plasma (FFP) needed was 1.7 units per patient (PRBC range, 0 to 13U; FFP range, 0 to 9U). Approximately 4.9 units of platelets were needed for each patient (range, 0 to 24U) and a mean of 1.3 units of cryoprecipitate also were utilized (range, 0 to 20U).

Postoperative complications are listed in Table 4. Ten patients (6.8%) required reexploration for postoperative hemorrhage. In all cases a coagulopathy was noted and there were no surgical sources of bleeding. However, a return to the operating room for postoperative hemorrhage did not significantly increase the in-hospital mortality (p = 0.5). Three patients experienced a cerebrovascular accident. Two had improvement in their neurologic deficit prior to discharge. One patient had a prolonged period of hypotension secondary to catastrophic bleeding upon sternal reentry. The patient remained comatose after surgery and support was withdrawn. Three patients required cardiac support with an IABP. Two recovered left ventricular function while one remained in a persistently low cardiac output state and expired. Six patients required a tracheostomy for respiratory failure and two patients developed renal failure requiring hemodialysis. Six patients required permanent pacemaker placement for complete heart block after surgery. Two patients had major abdominal complications. One developed acalculous cholecystitis and underwent successful cholecystectomy while an additional patient developed gangrenous bowel and expired. There were no deep sternal wound infections.


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  		Table 4. Postoperative Complications in 147 Patients Undergoing Reoperations on the Ascending Aorta and Aortic Root
 
Eight patients expired after reoperative aortic surgery. The causes of death, previous cardiac operation, current aortic operation, CPB times, cross-clamp times (XCT), and age are listed in Table 5. Five of 8 patients who were 75 years of age or greater expired after surgery (p < 0.001). Five of 13 patients who were on CPB for longer than 4 hours also expired (p < 0.01). Those having previous CABG surgery (6 of 48, p < 0.007) and those requiring new bypass grafts (4 of 23, p < 0.006) were also at risk for postoperative mortality. Other significant univariate risk factors for perioperative mortality are also listed in Table 6. Type of current procedure, need for arch reconstruction or circulatory arrest, need for emergent surgery, Marfan syndrome, sex, postoperative gastrointestinal complications, and postoperative hemodialysis were not significantly associated with increased perioperative mortality. Age greater than 75 years was the only risk factor (p < 0.025, risk ratio [RR] = 12.38) to remain significant under multivariate analysis.


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  		Table 5. In-Hospital and 30-Day Mortality for 147 Patients Requiring Reoperations on the Ascending Aorta and Aortic Root
 

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  		Table 6. Univariate Analysis of Perioperative Risk Factors for Death After Reoperations on the Ascending Aorta and Aortic Root
 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Patients who have had previous cardiac surgery may require reoperation for aneurysms or dissections that subsequently develop in the ascending aorta. First time operations on the ascending aorta or aortic root are now routinely performed with a very low operative risk [1–4]. Even in the setting of an acute type A dissection, the mortality has continued to decline with improvements in myocardial and cerebral protection, surgical technique, and postoperative care [17, 18]. Patients undergoing aortic reoperations still have a higher operative risk than those undergoing first time procedures. Previous reports have demonstrated an operative mortality ranging from 6% to 19% [11–15]. Aftersuccessful reoperation, patients can expect excellent long-term results with 5-year and 10-year survivals of 80% and 60%, respectively [12, 13]. In addition, when an aggressive surgical approach is utilized during the reoperation, few will require additional procedures for aortic-related problems in the future [7]. Statistical analysis of previously published reports with this type of surgery has identified a number of risk factors that contribute to poor outcome in these high-risk procedures. Advanced New York Heart Association functional class, preoperative renal dysfunction and postoperative hemodialysis, age, duration of CPB, and intraoperative "technical problems" have all been shown to increase the mortality. We have identified additional risk factors that may improve surgical outcome through modifications in surgical technique and patient selection.

Technical complications during aortic reoperations continue to contribute heavily to perioperative mortality and safe sternal reentry is the first step in a successful outcome. Preoperative imaging of the chest is mandatory to delineate the proximity of the great vessels or heart to the posterior sternal table. We believe chest CT scanning provides the most accurate assessment of the anatomy in this region. If there is evidence that the aorta is either adherent to the sternum, PHCA before opening the sternum avoids the unmanageable hypotension and cerebral anoxia associated with catastrophic aortic entry during opening. Patients with significant aortic insufficiency may develop significant ventricular distention with this maneuver. However, a small anterior thoracotomy over the point of maximal impulse allows for safe placement of a vent into the left ventricular apex. In the series by Schepens and colleagues [12], 2 of 3 patients having reentry issues expired. Our single experience with this complication produced equally dismal results and we do not hesitate to apply preentry PHCA when there is potential for this fatal event.

Patients requiring aortic reoperations with a history of previous bypass grafting present unique technical challenges that can translate into prolonged cross-clamp and cardiopulmonary bypass times with a significant increase in operative mortality. In addition to the extended time needed for vein graft reimplantation or new bypass grafting, marginal myocardial protection, especially with a patent internal mammary artery (IMA) graft, may lead to a greater incidence of ventricular failure, with a concomitant increase in the need for IABP support. Liberal use of retrograde cardioplegia in this setting is encouraged, along with obtaining control of patient IMA grafts. However, one must be cognizant of the potential for insufficient right heart protection during procedures with extended periods of myocardial ischemia. For the elective patient with the constellation of complex aortic disease and extensive native vessel coronary artery disease, percutaneous coronary intervention may be a reasonable consideration prior to surgery. For those with more urgent need for aortic repair, a higher operative mortality can be expected when significant coronary disease is encountered.

Elderly patients requiring reoperations for aortic pathology are particularly challenging. David and colleagues [11] found that 5 year increments in age were independently predictive of poor long-term survival after these procedures. We found an even more dramatic and immediate relationship between advanced age and perioperative mortality. Five of 8 patients aged 75 or greater were unable to survive to discharge. Eighty percent of this elderly subgroup required PHCA for their aortic reconstruction and a similar percentage had significant coronary artery disease requiring reimplantation of existing vein grafts or construction of new bypasses. The cerebral protection provided by PHCA and retrograde cerebral perfusion is evident in that no patient in this age group experienced a stroke. However, 3 of the 5 mortalities were after prolonged hospitalizations with the patients requiring long periods of ventilatory support. While the natural history of significant aneurysmal disease is clearly dismal, perhaps patients of advanced age would be better served with aggressive medical therapy rather than being exposed to surgery with little hope of meaningful survival.

An increasing percentage of patients undergoing aortic valve procedures for bicuspid disease are returning for reoperations on the aorta. Borger and colleagues [19] demonstrated that when the aorta is 4.5 cm or greater at the time of the initial procedure, 60% of patients will develop an aortic event, either rupture, dissection, or the need for reoperation, over the ensuing decade. Many have undergone isolated aortic valve replacement or repair but an increasing number in our practice are returning with aneurysms after having undergone a Ross procedure. De Sa and colleagues [20], identified a number of histologic abnormalities of the ascending aorta and pulmonary trunk in patients with bicuspid valve disease, lending support to the supposition that bicuspid valve disease is within the spectrum of connective tissue disorders. We believe an aggressive approach, either composite valve-graft replacement or separate valve and tube graft repair, during the first operation may eliminate the unacceptably high rate of late aortic catastrophes in these patients. Additionally, patients undergoing bypass surgery with ascending aortic diameter approaching 5.0 centimeters may be best served with prophylactic aortic replacement because of the unacceptably high mortality associated with reoperation for aortic disease in patients with previous CABG surgery.

Patients with ascending aneurysms or dissections in the setting of previous cardiac surgery can undergo repair with a high likelihood of success. A well thought out surgical plan is crucial to minimize the incidence of "technical errors" that usually result in death. Elderly patients with complex aortic pathology and significant coronary artery disease are a particularly high-risk cohort and should be evaluated on a case by case basis prior to proceeding with surgery.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Girardi LN, Coselli JS. Aortic root replacement: contemporary results utilizing the St. Jude Medical/Hemashield composite valved conduit Ann Thorac Surg 1997;64:1032-1035.[Abstract/Free Full Text]
  2. Zehr KJ, Orszulak TA, Mullany CJ, et al. Surgery for aneurysms of the aortic rootA 30 year experience. Circulation 2004;110:1364-1371.[Abstract/Free Full Text]
  3. Sioris T, David TE, Ivanov J, Armstrong S, Feindel CM. Clinical outcomes after separate and composite replacement of the aortic valve and ascending aorta J Thorac Cardiovasc Surg 2004;128:260-265.[Abstract/Free Full Text]
  4. Pethig K, Milz A, Hagl C, Harringer W, Haverich A. Aortic valve reimplantation in ascending aortic aneurysm: risk factors for early failure Ann Thorac Surg 2002;73:29-33.[Abstract/Free Full Text]
  5. Potter DD, Sundt 3rd TM, Zehr KJ, et al. Operative risk of reoperative aortic valve replacement J Thorac Cardiovasc Surg 2005;129:94-103.[Abstract/Free Full Text]
  6. Sabik III JF, Blackstone EH, Houghtaling PL, Walts PA, Lytle BW. Is reoperation still a risk factor in coronary artery bypass surgery? Ann Thorac Surg 2005;80:1719-1727.[Abstract/Free Full Text]
  7. Crawford ES, Crawford JL, Safi HJ, Coselli JS. Redo operations for recurrent aneurysmal disease of the ascending aorta and transverse aortic arch Ann Thorac Surg 1985;40:439-455.[Abstract]
  8. Kouchoukos NT, Marshall Jr WG, Wedige STA. Eleven-year experience with composite graft replacement of the ascending aorta and aortic valve J Thorac Cardiovasc Surg 1986;92:691-705.[Abstract]
  9. Goldstein DJ, DeRosa CM, Mongero LB, et al. Safety and efficacy of aprotinin under conditions of deep hypothermia and circulatory arrest J Thorac Cardiovasc Surg 1995;10:1615-1622.
  10. Coselli JS. Retrograde cerebral perfusion via a superior vena caval cannula for aortic arch aneurysm operations Ann Thorac Surg 1994;57:1668-1669.[Abstract]
  11. David TE, Feindel CM, Ivanov J, Armstrong S. Aortic root replacement in patients with previous heart surgery J Card Surg 2004;19:325-328.[Medline]
  12. Schepens MA, Dossche KM, Morshuis WJ. Reoperations on the ascending aorta and aortic root: pitfalls and results in 134 patients Ann Thorac Surg 1999;68:1676-1680.[Abstract/Free Full Text]
  13. Dougenis D, Daily BB, Kouchoukos NT. Reoperations on the aortic root and ascending aorta Ann Thorac Surg 1997;64:986-992.[Abstract/Free Full Text]
  14. LeMaire SA, DiBardino DJ, Koksoy C, Coselli JS. Proximal aortic reoperations in patients with composite valve grafts Ann Thorac Surg 2002;74:S1777-S1780.[Abstract/Free Full Text]
  15. Estrera AL, Miller CC, Porat E, et al. Determinants of early and late outcome for reoperations of the proximal aorta Ann Thorac Surg 2004;78:837-845.[Abstract/Free Full Text]
  16. Svensson LG. Approach to the insertion of composite valve graft Ann Thorac Surg 1992;54:376-378.[Abstract]
  17. Girardi LN, Krieger KH, Lee LY, Mack CA, Tortolani AJ, Isom OW. Management strategies for type A dissection complicated by peripheral vascular malperfusion Ann Thorac Surg 2004;77:1309-1314.[Abstract/Free Full Text]
  18. Bavaria JE, Pochettino A, Brinster DR, et al. New paradigms and improved results for the surgical treatment of acute type A dissection Ann Surg 2001;234:336-343.[Medline]
  19. Borger MA, Preston M, Ivanov J, et al. Should the ascending aorta be replaced more frequently in patients with bicuspid aortic valve disease? J Thorac Cardiovasc Surg 2004;128:677-683.[Abstract/Free Full Text]
  20. de Sa M, Moshkovitz Y, Butany J, David TE. Histologic abnormalities of the ascending aorta and pulmonary trunk in patients with bicuspid aortic valve disease: clinical relevance to the Ross procedure J Thorac Cardiovasc Surg 1999;118:588-594.[Abstract/Free Full Text]



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