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Ann Thorac Surg 2007;84:775-781
© 2007 The Society of Thoracic Surgeons
Department of Cardiovascular Surgery, University Hospital, Berne, Switzerland
Accepted for publication April 23, 2007.
* Address correspondence to Dr Stalder, Clinic for Cardiovascular Surgery, University Hospital Berne, Freiburgstrasse, Berne, 3010, Switzerland (Email: mario.stalder{at}insel.ch).
Presented at the Forty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 29–31, 2007.
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Abstract |
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Methods: Between June 2001 and December 2003, 244 patients underwent surgery for various diseases of the ascending aorta with or without involvement of the aortic valve or root. They were divided according to the operative procedure: 76 patients (31.2%) underwent isolated replacement of the ascending aorta, 42 patients (17.2%) received separate aortic valve replacement and supracoronary replacement of the ascending aorta, 86 patients (35.2%) received a mechanical composite graft, and 40 patients (16.4%) received a biologic composite graft. All in-hospital data were assessed, and a follow-up was performed in all survivors after 26.6 ± 8.8 months, focusing on outcome and quality of life (SF-36).
Results: Overall in-hospital mortality was 6.1%, and late mortality was 5.7%, with no significant difference between groups. Independent of the surgical technique and the extent of surgery, there was no difference in quality of life between the surgical collective and an age-matched and sex-matched standard population.
Conclusions: Operations of the ascending aorta and aortic valve are very safe, with low in-hospital mortality and favorable midterm outcome regarding late mortality and morbidity. Quality of life after operations of the ascending aorta and aortic valve is equal to a standard population and is not affected by the surgical procedure. Liberal use of aortic root replacement is therefore justified to radically treat the diseased aortic segment.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
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Besides clinical follow-up, evaluation of quality of life (QoL) after major surgery is of increasing interest. Some authors have already analyzed QoL after operations on the ascending aorta and aortic valve in relation to aortic disease, surgical technique, and duration of the procedure, for instance with or without deep hypothermic circulatory arrest (DHCA) [9–11]. They showed that QoL in these patients is significantly influenced by the duration of DHCA. As expected, patients who underwent operations with DHCA, especially without antegrade cerebral perfusion, enjoyed an impaired QoL compared with patients operated on without DHCA.
At the present time, the type of surgical procedure and its influence on QoL is of major interest in health care. Sometimes surgeons are afraid to use more complex operations in critical situations, and it remains unknown whether outcome and midterm QoL are affected by the extent of procedure in thoracic aortic surgery. In the present study we evaluated the impact of different surgical procedures at the level of the aortic valve, the aortic root, and the ascending aorta on midterm outcome and QoL.
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
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Mean age was 60.6 ± 14.6 years. One hundred eighty-three (75%) of 244 patients were male. One hundred fifty-one patients (61.9%) had true aortic aneurysm (>5 cm in diameter), 75 (30.7%) had acute type A aortic dissection, and 18 (7.4%) had various diseases (eg, severe aortic calcification). Twenty-nine patients (11.9%) had a reoperation on the aortic root with or without aortic valve replacement. One hundred forty-two patients (58.2%) underwent a procedure using DHCA, with a mean circulatory arrest time of 21.5 ± 10.3 minutes. Patient characteristics are summarized in Table 1.
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Complete in-hospital data were assessed, and mortality and morbidities were analyzed. Two hundred twenty-nine survivors received an SF-36 questionnaire supplemented with a disease-specific questionnaire for follow-up. The closing interval was 5 months (from December 2004 until May 2005). The disease-specific questionnaire focused on the following aspects: readmission, cerebrovascular insult, bleeding problems, and current medication. Patients who did not answer the questionnaire were contacted by phone to assess clinical follow-up. During the average follow-up of 26.6 ± 8.8 months, 13 patients (5.7%) died and 8 patients (3.5%) were lost of follow-up. From the remaining 208 patients (90.8%), 176 patients (76.9%) filled out the SF-36 questionnaire correctly. Clinical follow-up was 89.5%. As we used the German version of the SF-36 questionnaire, patients of another native language did not answer the QoL questionnaire, which was the main reason for incomplete follow-up. To yield a more complete clinical follow-up, patients were reached by phone. The study has been approved by the local ethics committee. It was the patient’s choice to answer the SF-36 questionnaire, and an answer by the patient was considered as informed consent.
Surgical Procedures
We divided the patients into four groups, according to the following surgical procedures: 76 patients (31.2%) underwent isolated replacement of the supracoronary ascending aorta (SC), 42 patients (17.2%) underwent separate replacement of the ascending aorta and the aortic valve (SC+AVR), 86 patients (35.2%) received a mechanical composite graft to replace the aortic root (MC), and finally 40 patients (16.4%) underwent replacement of the aortic root by a biologic composite graft (BC). Patients who received a selective sinus repair or an aortic root repair according to the Yacoub–David technique or a Ross operation were excluded. Three types of mechanical composite grafts were used: St. Jude Medical (St. Jude Medical, Inc, St. Paul, MN), ATS (ATS Medical, Inc, Minneapolis, MN), and Sorin Carbonart (Sorin Biomedica Cardio SpA, Saluggia, Italy), according to the surgeon’s preference. Biologic composite grafts were all from Shelhigh (Shelhigh Inc, Union, NJ). In all patients with acute type A aortic dissection at least a hemiarch procedure with DHCA was performed. In patients with aortic aneurysm, procedures on the aortic arch with DHCA were performed depending on the extension of the disease. At the beginning of the study not all of the patients who underwent DHCA received antegrade cerebral perfusion (ACP). This practice was changing during the time of the study, so that later on all patients with DHCA received ACP. Additional surgical interventions were done in several patients: 58 patients (23.8%) underwent concomitant coronary artery bypass grafting surgery and 8 patients (3.3%) had a mitral valve replacement, equally distributed among the four groups. Mean extracorporeal circulation time was 127.9 ± 52.2 minutes. Mean aortic cross-clamp time was 85.2 ± 33.1 minutes. Operative data for the total collective are summarized in Table 1.
Statistical Analysis
The SF-36 questionnaires were analyzed in accordance to the SF-36 manual, and missing values were replaced by using the described algorithm in the SF-36 manual [12]. Results were adjusted for sex and age to allow comparison with the normal population. Statistical analysis was done with the SPSS 13.0 statistical software package (SPSS Inc, Chicago, IL). The Mann-Whitney U test and Kruskal-Wallis test were used for comparison of statistical significance among the four groups. To analyze the impact of DHCA on QoL in comparison to operation type a linear regression was calculated for all eight items of the SF-36. A probability value less than 0.05 was considered as statistically significant. Survival was analyzed according to the Kaplan–Meier method. Data were assessed as mean value ± one standard deviation.
The authors had full access to the data and take responsibility for its integrity.
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Results |
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Patients who received a mechanical composite graft were significantly younger than those of the other groups (53.6 ± 15.2 versus 62.4 ± 11.7 years in the SC group, 63.8 ± 16.0 years in the SC+AVR group, and 69.2 ± 9.7 years in the BC group; p = 0.000). In the SC group, there were significantly more type A aortic dissections and fewer true aneurysms than in the other groups (56.7% versus 0% in SC+AVR group, 27.9% in MC group, and 20% in BC group; p = 0.000). In patients who required either a biologic or mechanical composite graft, the rate of redo surgery was higher (5.3% in SC group, 9.5% in SC+AVR versus 12.8% in MC group and 25% in BC group) but did not reach statistical significance (p = 0.065). Marfan syndrome was more frequent in patients of the mechanical composite group without a statistical significant difference from the other groups (9.3% versus 6.6% in SC group, 0% in SC+AVR group, and 2.5% in BC group; p = 0.143).
Patients of the SC+AVR group had fewer early neurologic events such as cerebrovascular insult than the patients of the other groups (2.4% versus 9.2% in SC group, 7% in MC group, and 15% in BC group) but there was no statistical significance (p = 0.189). Perioperative myocardial infarction was not statistically different among the four groups (p = 0.719). Postoperative data are summarized in Table 2.
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Specific Questions
A total of 192 patients (83.8%) answered the additional questionnaire about health state correctly. Sixty-eight patients (33.2%) were readmitted during follow-up; in 14 (6.8%) of them rehospitalization was related to the surgical procedure. There was a trend toward a higher incidence of readmission in the group of patients with the mechanical composite graft, but this did not reach statistical significance (p = 0.463). Thromboembolic events, especially cerebrovascular insults, were rather frequent, with 5.4% to 16.7% in the different groups during follow-up. Follow-up results are displayed in Table 3.
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
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Overall in-hospital mortality was low (6.1%) despite a relatively high percentage of patients with type A aortic dissection. These results are comparable to those of Sioris and colleagues [1], who showed an operative mortality of 4% in a composite graft group and 5% in aortic valve replacement combined with supracoronary replacement of the ascending aorta. Brandt and associates [2] showed a 30-day mortality of 5%.
Results of the follow-up were excellent. Late mortality was very low; 13 of 229 discharged patients (5.7%) died during an average follow-up of 26.6 ± 8.8 months. Similar results have been reported by Byrne and coworkers [3], who reported that late mortality rate was 8.3% after mechanical root replacement and 2.4% after biologic root replacement.
At our institution, mechanical composite replacement had the best outcome according to survival, with a late mortality rate of 2.4%, followed by biologic composite replacement (5.1%). Readmission rate was not significantly different among the four surgical procedures. Patients with Marfan syndrome had mostly mechanical composite grafts implanted. However, in the most recent period the David procedure using a new Valsalva graft is the procedure of choice for Marfan patients at our institution. Therefore, patients of the MC group probably had to be readmitted more frequently than the other operation groups because of the complexity of their disease.
Operations of the ascending aorta and the aortic valve in general are followed by an excellent QoL. Quality of life among the different operative procedures of the ascending aorta and the aortic valve was not significantly different and all groups scored within the normal range of an age-matched and sex-matched standard population.
It would reasonably be expected that DHCA affects QoL, especially when antegrade cerebral perfusion was not used during circulatory arrest. This hypothesis is confirmed by an impairment of QoL in all groups that underwent operations with DHCA. As previously reported, the drop in QoL is directly related to the duration of DHCA [9].
Lower scores from patients in the SC group may be related to the fact that there was a higher incidence of type A aortic dissection in this group (Table 1). The impairment in QoL was probably related to the use of DHCA, which tends to be longer in patients with acute type A aortic dissection than in those with aortic aneurysms undergoing elective repair [9, 10].
Improvement in QoL can be accomplished by the use of antegrade cerebral perfusion, which allows DHCA duration up to 30 minutes without impairment of the midterm QoL, as shown by our group previously [9].
A limiting factor in this study is the method by which patients were allocated to their groups. Because of the retrospective character of this study, patients were not allocated to the groups with preformed criteria. Allocation to the type of operation was based on the current clinical criteria for ascending aorta and aortic valve operation. It may be that in a few patients, indication to proceed with radical replacement of the aortic root was handled very liberally. However, the excellent outcome data might be proof that the allocation to any type of surgical procedure in our hospital is based on good clinical criteria and common sense. A second limitation exists as a result of the different languages in our country and the missing answers of patients from the French and Italian parts of Switzerland. However, there were no differences in patient characteristics and surgical procedures according to the language.
No patient undergoing composite graft replacement developed significant myocardial ischemia postoperatively: implantation of the coronary ostia in the modified Bentall button technique can be performed safely and does not add an additional perioperative risk.
Operations of the ascending aorta and aortic valve or root can be performed with low perioperative risk, with low in-hospital mortality, and low late mortality and morbidity. Quality of life after surgery of the ascending aorta, aortic valve, and aortic root is equal to a standard population and independent of the surgical procedure and the choice of mechanical or biologic valves or conduits.
Our results showed no difference among the different treatment groups; we conclude that replacement of the aortic root as the most radical treatment of the disease is justified and should be used liberally. We recommend pursuing an aggressive strategy in patients younger than 65 years of age with marginally enlarged aortic root. Aortic root replacement allows the minimal use of late redo operations and decreases the risk of secondary complications such as aortic dissection.
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Discussion |
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TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
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DR STALDER: That’s a good question. Thank you.
I think the thing is that you have to look in the future. And the goal is that you would like to probably prevent additional reoperations or redos. So we have heard in the previous paper that this can also be done with a low risk, but I think no one of us wants to do redos on the root if not necessary.
So in our opinion, if you can really replace the root first time when it’s necessary—we are not saying that you have to replace every root—then we think that you can avoid secondary complications such as secondary dilation or aortic dissection. This is not very frequent, but it can happen.
DR JESSEN: Your follow-up interval seemed to be about 36 months. Do you think you need a longer interval to really establish complication rates or longer-term outcomes to determine which of these procedures is better?
DR STALDER: I think it’s always good to have longer follow-up. For the moment, we can say at least midterm quality of life and midterm outcome is equal. It’s hard to predict, but it could be that there are differences.
DR EDWARD B. SAVAGE (St. Louis, MO): I think it’s important to elaborate on your answer to the previous question from the audience. You made the statement that long term it’s better to replace the root because you’re going to have fewer problems. I don’t think that there is any data in the literature to suggest that unless you have clear aneurysmal dilatation of the sinus segments of the aorta that a root replacement has any better long-term outcome than replacement of the valve and an ascending aortic graft replacement.
DR STALDER: Thank you for the question.
Well, what we think—actually, you’re right, there is no literature for that—but what we think is that if you can, obviously, radically treat the pathology of the patient, which means that you remove all the diseased parts of the enlarged aorta, which sometimes is only possible if you replace the root, then logically it should be that you can prevent.
DR SAVAGE: What you think is important, but what the evidence shows is also important. And that’s what the important take-home message here is. Because you don’t really have anything in here that says everyone should go out and just start doing root replacements for all patients.
DR JESSEN: Is there any particular size of the aortic sinuses that influences your decision as to which procedure to perform?
DR STALDER: Well, we stay to the measurements which were mentioned earlier, that we say when the ascending aorta is more than 5 cm in patients who were just undergoing this procedure, and 4.5 with Marfan’s patients and patients with bicuspid valves, if we see that, let’s say, one or two sinuses are enlarged, or even all of them, so we switch now to try anyway to keep the valve and then maybe do a partial sinus repair on one sinus and repair two sinuses, according to the procedure described by Yacoub.
DR FRANZ IMMER (Bern, Switzerland): There is important literature in acute type A aortic dissection that if you are too restrictive in replacement of the aortic root, you will have a high incidence of reoperation, due to secondary dilatation of the aortic root and aortic insufficiency. So the normal amount in the literature of composite grafts in type A dissection is around 30% to 40%. So if you are restraining from the surgery the patient needs, you will have reoperations. There are many publications on that.
DR STALDER: Thank you.
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References |
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TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
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