Ann Thorac Surg 2008;86:1510-1517. doi:10.1016/j.athoracsur.2008.07.051
© 2008 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Composite Valve Graft Replacement of the Aortic Root: Twenty-Seven Years of Experience at One Japanese Center
Tomohiro Tsunekawa, MDb,
Hitoshi Ogino, MDa,*,
Hitoshi Matsuda, MDa,
Kenji Minatoya, MDa,
Hiroaki Sasaki, MDa,
Junjiro Kobayashi, MDa,
Toshikatsu Yagihara, MDa,
Soichiro Kitamura, MDa
a Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan
b Department of Cardiothoracic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
Accepted for publication July 14, 2008.
* Address correspondence to Dr Ogino, Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka, 565-8565, Japan (Email: hogino{at}hsp.ncvc.go.jp).
 |
Abstract
|
|---|
Background: The aim of this study was to evaluate the early and long-term results of a composite valve graft root replacement for various aortic root diseases.
Methods: Between 1978 and 2005, 273 patients with various disorders of the aortic root underwent a composite valve graft root replacement. The mean age of the patients was 47.5 ± 13.2 years. There were 93 patients with Marfan syndrome, 56 aortitis, and 63 type A aortic dissections. Thirty-nine emergency operations and 55 redo operations were included. For the proximal anastomosis, a skirted technique was used in 157 patients. For the coronary reconstruction, Bentall's original inclusion technique was utilized in 36 patients, a direct button technique in 159, and a graft interposition technique in 63. The mean follow-up was 106 months.
Results: The in-hospital mortality was 9.5%. An emergency operation emerged as a significant predictor of early death. The actuarial survival rate was 87.0% and 72.9% at 5 and 15 years, respectively. The age at the operation, aortitis, Marfan syndrome, and use of a standard proximal anastomosis emerged as independent determinants of late death. The actuarial reoperation free rate was 96.3% and 89.7% at 5 and 15 years, respectively. In the patients who underwent the skirted technique the incidence of late graft detachment was less frequent than that of the standard technique.
Conclusions: A composite valve graft root replacement is a safe and reliable procedure for various aortic root diseases with stable early- and long-term results. The skirted technique seems to be attractive to avoid late graft detachment even in cases with a fragile inflammatory pathology.
|
Introduction
|
|---|
A composite valve graft root replacement (CGR), first reported by Bentall and DeBono in 1968 [1], has been applied to a variety of aortic root diseases. During the last two decades, CGR, with various technical modifications [2–5], has become a standard procedure for aortic root disorders. This report reviews the experience of CGR over the past 27 years in this center to overview the broad profiles of this procedure, including risk factor analyses and an evaluation of the long-term results.
|
Patients and Methods
|
|---|
This study included 273 patients who underwent a CGR at the National Cardiovascular Center, Osaka, Japan, between October 1978 and October 2005. Patients who required preoperative cardiopulmonary resuscitation were excluded. Patients who underwent an aortic root replacement using an aortic homograft, pulmonary autograft, or a stentless bioprosthesis were also excluded. All of the surgeries were identified from the Registry of Cardiovascular Surgery in the National Cardiovascular Center. The data in the registry were approved for use by the Institutional Ethical Committee. Follow-up data were obtained using a postal questionnaire or telephone interview with patients and their physicians. The preoperative patients' characteristics are summarized in Table 1. There were 93 patients with Marfan syndrome, 56 with aortitis, and 63 with an acute or chronic type A aortic dissection. Thirty-nine emergency operations and 55 redo operations were included. The patients in this study had various aortic root diseases. The indications that prompted the CGR are listed in Table 2. The majority of the patients in this series had an annuloaortic ectasia as the primary pathologic lesion (200 of 273; 73.3%). Thirty-nine patients with annuloaortic ectasia were accompanied by an acute or a chronic type A aortic dissection. The second most frequent indication was an acute type A aortic dissection (25 of 273; 9.2%), which was defined as an aortic dissection which showed apparent symptoms and was treated surgically within seven days after the onset of the symptoms. Of the 16 patients with a prosthetic valve dysfunction, 12 had aortitis, one had Marfan syndrome, and one had a chronic type A aortic dissection.
Surgical Technique
Through a median sternotomy, a cardiopulmonary bypass was established by ascending aortic and bicaval cannulation, which was performed in a routine manner. If the ascending aortic cannulation was considered difficult, such as in an aortic dissection, axillar or femoral arterial cannulations were utilized. Myocardial protection was maintained with antegrade and retrograde cardioplegia. When replacing the aortic arch simultaneously, either profound or moderate hypothermic circulatory arrest between 18°C and 28°C and selective or retrograde cerebral perfusion were utilized according to surgeons' preferences. The details of surgical procedures are summarized in Table 3. For the coronary reconstruction and proximal aortic root anastomosis, various different surgical techniques were utilized. The method of coronary reconstruction was Bentall and De Bono's original inclusion technique in the initial 36 patients, a direct button technique in 159, a graft interposition technique of the bilateral (45) or unilateral (18) coronary arteries in 63 [4], the technique of Cabrol and colleagues [5] in 9, coronary artery bypass grafting in 5, and unknown in 1. Bentall and De Bono's original inclusion technique, in conjunction with wrapping the aortic aneurysm wall around the composite graft, was utilized until 1987. This technique was abandoned after a report in 1986 by Kouchoukos and colleagues [6] of late complications associated with this technique. The technique of Cabrol and colleagues was utilized between 1984 and 1989. This technique was discontinued because one early coronary graft obstruction and two perioperative coronary-related deaths were observed. A direct button technique has been utilized since 1985, which has been adopted as the first line technique for the coronary reconstruction. A graft interposition technique has also been utilized since 1985 and is still one of the choices when the button technique is considered difficult to perform without tension on the suture line, especially in redo cases.
For the proximal anastomosis, two different techniques were utilized. In 116 patients (42.5%), the composite valve graft was made by attaching a prosthetic valve to the edge of the graft with a continuous 3-0 polyester suture. The sewing ring of the prosthetic valve was attached to the aortic annulus with 2-0 polyester interrupted everting mattress sutures ("standard technique"). In the other 157 patients (57.5%), a prosthetic valve was anastomosed to the graft at 5 to 10 mm above the edge of the graft with continuous 3-0 polyester sutures. The segment of the proximal end of the vascular graft was referred to as the "vascular skirt." Only this soft skirt was attached to the aortic annulus with everting mattress sutures using 2-0 polyester sutures ("skirted technique"). The primary purpose of the modification of the proximal anastomosis with skirted technique was to secure the intraoperative hemostasis at the proximal anastomosis and to reduce the incidence of late graft detachment.
Bioprosthetic valves were utilized in 33 patients; the Ionescu-Shiley valve (Shiley Laboratory, Irvine, CA) was implanted in 19 patients until 1984 and the Carpentier-Edwards bovine pericardial valve (Edwards Lifescience, Irvine, CA) in 14 since 1987. A mechanical valve was implanted in 240 patients, the St Jude Medical bileaflet prosthesis (St. Jude Medical, St. Paul, MN) in 149 patients, the CarboMedics bileaflet prosthesis (CarboMedics Inc., Austin, TX) in 54, the Björk-Shiley tilting disc prosthesis (Shiley Laboratory) in 22, and the ATS Medical bileaflet prosthesis (ATS Medical Inc., Minneapolis, MN) in 15.
Statistical Analysis
Data analyses were performed using SPSS 15.0 for Windows (SPSS, Chicago, IL). Data are expressed as the mean ± standard deviation, with the statistical significance determined at the 95% confidence level. The variables associated with an increased risk of early death were assessed using univariate and multivariate logistic regression analyses. Long-term survival and event-free rates were calculated using the Kaplan-Meier method. The endpoints were late death, reoperation, prosthesis dysfunction, thromboembolism, bleeding requiring in-hospital treatment or blood transfusion, coronary complications, graft infection, and graft detachment. Only the first occurrence of any specified complications was considered in the analyses. The variables associated with increased risk of late death and reoperation were assessed by the univariate and multivariate Cox proportional regression analyses.
|
Results
|
|---|
Early Mortality
Overall, the in-hospital mortality rate, defined as death prior to discharge or within 30 days of the operation in discharged patients, was 9.5% (26 patients). Eighteen of those patients died from postoperative heart failure. The other causes were refractory ventricular fibrillation in 3 patients, pulmonary hemorrhage in 2, prosthetic valve endocarditis in 2 and ischemic colitis in 1. A multivariate analysis showed that an emergency operation, the presence of preoperative cerebrovascular disease, and no use of a direct button technique were statistically significant predictors for in-hospital death (Tables 4 and 5).
Long-Term Survival
The mean follow-up duration was 106.1 ± 80.4 (2 to 306) months. The follow-up data were lost in 17 patients during the study period and the complete follow-up data were collected in 93.8%. A total of 45 late deaths (18.2%) were observed. Fourteen of those deaths were related to the composite valve prosthesis; graft infection in 7, cerebral hemorrhage under anticoagulation therapy in 4, gastrointestinal ischemia in 2, and acute myocardial infarction in one. Seven patients died from the rupture of a residual aortic aneurysm or aortic dissection. The cause of the late death was unknown in 5 patients. The actuarial survival rate was 87.0%, 79.9%, and 72.9% at 5, 10, and 15 years respectively (Fig 1). A multivariate analysis showed that the age at operation, Marfan syndrome, aortitis, the presence of preoperative renal failure, the use of a standard proximal anastomosis and a redo operation were all significant independent predictors of late death (Tables 4; 5).
View larger version (9K):
[in this window]
[in a new window]
|
Fig 1. Overall survival curve and the influence of Marfan syndrome and aortitis on the actuarial survival.
|
|
Reoperation
Twenty-four patients (9.5%) presented for reoperation of the ascending aorta and the aortic root. Some of the 24 patients had multiple indications for the reoperation. Of these patients, a prosthetic valve dysfunction was observed in 11 patients, graft detachment in 10 patients, and graft infection in 5 patients. Of the 11 patients with a prosthetic valve dysfunction, 9 of them underwent a secondary aortic valve replacement. The other 2 patients had a redo CGR for a coexisting graft detachment or a coronary ostial true aneurysm. Four patients with a graft detachment underwent a direct repair of the detachment with or without coronary reconstruction, and the other 6 patients with a graft detachment received a redo CGR. All the patients who were treated for a graft infection underwent a redo CGR. An aortic homograft was utilized in 2 patients. One patient underwent an aortic homograft root replacement due to methicillin-resistant staphylococcal prosthetic endocarditis 10 months after the initial CGR and concomitant total aortic arch replacement. He required a re-total arch replacement to treat the residual infection and a graft detachment 4 months later and died from an uncontrollable infection. Another patient who required an aortic homograft root replacement had giant-cell aortitis and repeated graft detachment. An aortic homograft was utilized for his third root replacement. He died 9 years after the aortic homograft root replacement. The procedures for reoperation are summarized in Table 6. Three patients (12.5%) died after the reoperation for graft infection. The reoperation free rates of the total patient population were 96.3%, 92.2%, and 89.7% at 5, 10, and 15 years, respectively (Fig 2). The multivariate analysis showed that the use of a bioprosthesis was the only significant independent predictor for reoperation (Tables 4; 5). In the patients who underwent a CGR with a mechanical valve, no prosthetic valve dysfunction was observed and the reoperation free rates were 96.5%, 96.5% and 95.0% at 5, 10, and 15 years, respectively (Fig 2). Univariate and multivariate analyses did not identify any variables as a significant predictor for reoperation in the patients who utilized mechanical valves.
View larger version (11K):
[in this window]
[in a new window]
|
Fig 2. Actuarial freedom from reoperation of the ascending aorta and the aortic root in overall patients, patients with mechanical prosthesis, and patients with bioprosthesis.
|
|
Graft Infection
Ten patients (4.0%) developed a graft infection. Three of them experienced an accompanied graft detachment. Five patients underwent reoperation; a redo CGR in four patients and an aortic homograft root replacement in one. Three of them (60%) died after the reoperation. Five patients were observed without reoperation, and four of them (80%) eventually died. The actuarial probability of remaining free of a graft infection was 95.5% at 15 years.
Detachment of the Graft Anastomosis
Fourteen graft detachments were observed in 12 patients (4.8%) including 6 patients with Marfan syndrome and 5 with aortitis. Seven detachments occurred at the proximal anastomosis. Of the 7 patients who developed a proximal graft detachment, the standard proximal anastomosis technique was utilized in 5 patients (5 of 105; 4.8%) and the skirted proximal anastomotic technique in 2 patients (2 of 147; 1.4%). The other 6 detachments developed at the coronary anastomosis. Of these 6 patients, Bentall and De Bono's original inclusion technique [1] was utilized in 2 patients, the graft interposition technique in 3, and the direct button technique in 1. One patient presented with multiple detachments at both the proximal and coronary anastomoses due to a graft infection. Ten of 12 patients with graft detachment underwent reoperation. One patient with a detachment of the proximal anastomosis accompanied by coronary true aneurysms has been followed up medically, and another patient with a detachment of the coronary anastomosis died from chronic renal failure before a reoperation was considered. The actuarial probability of remaining free of detachment of the graft anastomosis was 96.9% at 10 years and 95.5% at 15 years.
Thromboembolisms
Thromboembolic events occurred in 8 patients (3.2%); cerebral infarction in 7 and thromboembolism of the superior mesenteric artery in one. Seven patients had received anticoagulation therapy for the use of a mechanical valve. The actuarial probability of remaining free of thromboembolic events was 96.5% at 15 years.
Anticoagulant-Related Complications
Fourteen patients (5.6%) had complications related to anticoagulant therapy which required blood transfusion or in-hospital treatment; an intracranial hemorrhage in 7 patients, gastrointestinal bleeding in 5, and genital bleeding in 2. Four of the intracranial hemorrhages were fatal. In all, the actuarial probability of remaining free of these complications was 93.6% at 15 years.
Coronary Artery Complications
Coronary ostial aneurysms developed at 6 coronary anastomoses in 4 Marfan patients (1.6%). Of the 6 coronary ostial aneurysms, Bentall and De Bono's original inclusion technique was utilized in 3 of the anastomoses and the graft interposition technique was utilized in 3 anastomoses. A coronary obstruction was observed in 3 patients. Of the 3 patients, the Cabrol technique was utilized in 1 and the direct button technique in 2. Two of the 3 patients with a coronary obstruction had aortitis.
Event-Free Survival Rate
The actuarial probability of being alive and free from a prosthesis-related complication was 79.4%, 67.8%, and 60.7% at 5, 10, and 15 years, respectively. The incidence of prosthesis-related complication was significantly high in aortitis patients (Fig 3).
|
Comment
|
|---|
Several large studies have demonstrated excellent outcomes associated with a CGR with low 30-day mortality rates ranging from 4.3 to 9.0% [2, 3, 7]. The current study documented a comparable result of 9.5% of the in-hospital mortality, even including that of the emergency surgeries. The mortality of elective surgery was 4.3%. Since 1995, no in-hospital death has occurred in 95 elective patients. The increased experience, as well as other factors, such as the development of a refined pump oxygenator system and the myocardial protection technique, the availability of "zero porosity" vascular grafts, and improved perioperative management, has contributed to the improvement of the outcome.
The actuarial survival rate was also comparable with the range of 62% to 93% at 10 years, which were previously published [7–9]. The present results suggest that one of the significant independent risk factors of late death is aortitis, which is predominant in Asian countries. The prevalence of aortitis leading to surgery is high in the current series. Takayasu arteritis was dominant among the 56 patients with the pathology of aortitis. The main pathologic findings associated with Takayasu arteritis are severe destruction of the medial elastic fibers and thickening of intima, media, and adventitia. The pathologic fragility causes frequent detachment of the prosthesis after an aortic valve replacement or CGR [10, 11]. Indeed, in the current study, late graft detachment was observed in 5 of 56 aortitis patients (8.9%). Although the appropriate approach to the aortic valve diseases associated with aortitis is unclear, we prefer a CGR, especially in the active stage, because the graft detachment was less frequent when treated with a CGR than with an isolated aortic valve replacement [10]. Ishikawa and colleagues [12] reported the long-term mortality of the patients having Takayasu arteritis with major complications who require surgical treatment was considerably poor, with only 43% at 15 years [12]. In the present study, the 10-year and 15-year survival rates of aortitis patients were 69% and 58%, respectively. In addition, the incidence of prosthesis-related complications was significantly high in aortitis patients; 5 graft infections (8.9%), 4 cerebral infarctions (7.1%), and 2 coronary arterial obstructions (3.4%). Not only the poor natural history of this subset, but also the frequent need for a reoperation for graft detachment, the life-long steroid therapy, and the high incidence of graft infection can thus influence the poor long-term survival.
Although controversy remains in regard to whether Marfan syndrome decreases the late survival rate [2, 7, 13, 14], the current results suggested that Marfan syndrome was one of the significant predictors of late deaths. The high incidence of an aortic dissection and an aneurysm of the residual aorta, or subsequent operations can potentially increase the late mortality in Marfan patients. In fact, in the current series, the incidence of a reoperation on the residual aorta was significantly higher in Marfan patients (27 patients; 29%) than in non-Marfan patients (5%). In addition, 16 of 27 Marfan patients who required an operation on the residual aorta required a third or fourth operation. The incidence of graft detachment and coronary ostial true aneurysm were significantly high in Marfan patients. To reduce these complications, a direct button technique can be the most favorable technique, especially in Marfan patients. The size of the side hole made in the graft must be reduced to fit the diameter of the coronary artery, and a suture should be placed inside the origin of the coronary artery so that a residual aortic wall can be eliminated [15].
A composite valve graft root is one of the best treatment strategies for an acute type A aortic dissection and aortic regurgitation [16, 17]. In the current study only 25 patients had acute type A aortic dissection. The low prevalence of acute aortic dissection in this study can be explained by the fact that most of patients with acute type A aortic dissection and aortic regurgitation were effectively treated by an aortic valve resuspension and ascending aortic replacement, unless aortic root was pathologically dilated or destroyed by the dissection process. In addition, recently, an aortic valve-sparing operation has been used as an alternative strategy for this condition.
Although recent studies report an excellent early survival rate for a proximal reoperation after a CGR, ranging between 70% and 86% [15, 18, 19], a redo CGR remains a challenging procedure with a high morbidity and mortality, especially in the setting of graft infection. Graft detachment is one of the predominant indications for late reoperation [3, 8, 15, 20–23]. In the present study, graft detachment occurred in 11 patients with Marfan syndrome or aortitis. Extreme caution is necessary for the anastomosis in these patient subsets. The direct button technique is widely utilized and has reduced the rate of reoperation on the ascending aorta or aortic valve after a CGR (0% to 19% at 3 to 10 years) [2, 3, 8, 9, 14, 20]. Since 1985, we have utilized the direct button technique for coronary artery reconstruction and that technique has contributed to reducing the incidence of graft detachment and coronary complications. At present, the direct button technique is our first-line technique. However, if there is anatomic difficulty or dense adhesion precluding the direct button anastomosis, especially in a redo root surgery, the alternative is a short-length graft interposition technique [4]. The current data support the efficacy of the graft interposition technique with nearly the same long-term reliability as the direct button technique. With regard to the proximal anastomosis, the skirted technique has been the current preference. The concept of translocating the prosthetic valve, initially described by Cabrol and colleagues in 1981 [5], was adopted in 1989 to secure the anastomosis without bleeding and to reduce the risk of late graft detachment. In the skirted technique, the prosthetic valve does not apply direct stress on the aortic annulus by separating the suture-line of the prosthetic valve from that of the aortic annulus [24]. Although the current study was not designed to compare the two proximal anastomosis techniques and it was not assumed that the skirted technique would completely surpass the standard technique, the current results demonstrate some advantages of the skirted technique by improving the frequency of late proximal graft detachment and the long-term survival. The results encourage the continued utilization of the skirted technique, especially in patients with a fragile aortic annulus, such as those with aortitis and Marfan syndrome. However, 2 patients experienced proximal graft detachment after a CGR using the skirted technique. One patient had giant cell aortitis and another had Behçet disease. The former underwent a second skirted CGR and repeated graft detachment of the right coronary ostium and was eventually treated with an aortic homograft root replacement. The latter underwent 3 CGR procedures for repeated graft detachment. In patients with a fragile inflammatory aortic pathology, further refinement of the anastomotic technique, such as buttress sutures from the lateral side of the aortic wall for reinforcement of the prosthesis at the aortic annulus, placement of thick belt-like Teflon felt on the lateral side of the aortic wall, is required to reduce late graft detachment [24].
The use of a bioprosthesis is an independent risk factor for a late reoperation. It is obvious that the prosthetic valve dysfunction is an inherent late complication of a bioprosthesis. However, all of the valve failures occurred in use of the Ionescu-Shiley (Shiley Laboratory) bioprosthesis implanted early in the study period. Since 1987, the Carpentier-Edwards bovine pericardial prosthesis has been used and there have been no valve failures. The durability of the manufactured bioprosthesis, especially the pericardial valve, is well-documented [25]. Galla and colleagues [26] also reported excellent long-term performance of bioprosthetic CGR with no instances of valve failure during a 5-year follow-up. A CGR using a bioprosthesis is a useful option for some subsets such as elderly patients, or those who are contraindicated for anticoagulation therapy. Currently, a "Valsalva graft" has been used with a bioprosthetic aortic valve for the long-term valve durability.
The current study has inherent biases. The series of patients examined were derived from a retrospective review covering a long time interval and the patients included in this study had various different surgical indications and were treated by different surgeons.
This report presented the 27-year experience in performing a CGR and concluded that a CGR is a safe and reliable procedure for various aortic root diseases, thus resulting in sufficient early and long-term results. Aortitis is the significant predictor of late death after CGR, with a high incidence of late graft detachment and other complications. The skirted proximal anastomotic technique can help surgeons to avoid late proximal graft detachment and the need to perform a reoperation.
|
Acknowledgments
|
|---|
We greatly thank Dr Akiko Kada for her valuable biostatistical expertise.
|
References
|
|---|
- Bentall H, De Bono A. A technique for complete replacement of the ascending aorta Thorax 1968;23:338-339.[Abstract/Free Full Text]
- Kouchoukos NT, Wareing TH, Murphy SF, Perrillo JB. Sixteen-year experience with aortic root replacement Ann Surg 1991;214:308-320.[Medline]
- Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Composite valve graft replacement of the proximal aorta: comparison of techniques in 348 patients Ann Thorac Surg 1992;54:427-439.[Abstract/Free Full Text]
- Piehler JM, Pluth JR. Replacement of the ascending aorta and aortic valve with a composite graft in patients with nondisplaced coronary ostia Ann Thorac Surg 1982;33:406-409.[Abstract/Free Full Text]
- Cabrol C, Pavie A, Gandjbakhch I, et al. Complete replacement of the ascending aorta with reimplantation of the coronary arteries. New surgical approach. J Thorac Cardiovasc Surg 1981;81:309-315.[Abstract]
- Kouchoukos NT, Marshall Jr WG, Wedige-Stecher TA. Eleven-year experience with composite graft replacement of the ascending aorta and aortic valve J Thorac Cardiovasc Surg 1986;92:691-705.[Abstract]
- Gott VL, Gillinov AM, Pyeritz RE, et al. Aortic root replacement: risk factor analysis of a seventeen-year experience with 270 patients J Thorac Cardiovasc Surg 1995;109:536-545.[Abstract/Free Full Text]
- Dossche KM, Schepens MA, Morshuis WJ, de la Rivière AB, Knaepen PJ, Vermeulen FE. A 23-year experience with composite valve graft replacement of the aortic root Ann Thorac Surg 1999;67:1070-1077.[Abstract/Free Full Text]
- Hagl C, Strauch JT, Spielvogel D, et al. Is the Bentall procedure for ascending aorta or aortic valve replacement the best approach for long-term event-free survival? Ann Thorac Surg 2003;76:698-703.[Abstract/Free Full Text]
- Matsuura K, Ogino H, Kobayashi J, et al. Surgical treatment of aortic regurgitation due to Takayasu arteritis: long-term morbidity and mortality Circulation 2005;112:3707-3712.[Abstract/Free Full Text]
- Miyata T, Sato O, Deguchi J, et al. Anastomotic aneurysm after surgical treatment of Takayasu's arteritis: a 40-year experience J Vasc Surg 1998;27:438-445.[Medline]
- Ishikawa K. Natural history and classification of occlusive thromboaortopathy (Takayasu's disease) Circulation 1978;57:27-35.[Abstract/Free Full Text]
- Gott VL, Greene PS, Alejo DE, et al. Replacement of the aortic root in patients with Marfan's syndrome N Engl J Med 1999;340:1307-1313.[Medline]
- Alexiou C, Langley SM, Charlesworth P, Haw MP, Livesey SA, Monro JL. Aortic root replacement in patients with Marfan's syndrome: the Southampton experience Ann Thorac Surg 2001;72:1502-1508.[Abstract/Free Full Text]
- Kazui T, Yamashita K, Terada H, et al. Late reoperation for proximal aortic and arch complications after previous composite graft replacement in Marfan patients Ann Thorac Surg 2003;76:1203-1208.[Abstract/Free Full Text]
- Lai DT, Miller DC, Mitchell RS, et al. Acute type A aortic dissection complicated by aortic regurgitation: Composite valve graft versus separate valve graft versus conservative valve repair J Thorac Cardiovasc Surg 2003;126:1978-1986.[Abstract/Free Full Text]
- Halstead JC, Spielvogel D, Meier DM, et al. Composite aortic root replacement in acute type A dissection: time to rethink the indications? Eur J Cardiothorac Surg 2005;27:626-632.[Abstract/Free Full Text]
- Lemaire SA, DiBardino DJ, Köksoy C, Coselli JS. Proximal aortic reoperations in patients with composite valve grafts Ann Thorac Surg 2002;74:S1777-S1780.[Abstract/Free Full Text]
- Lepore V, Larsson S, Bugge M, Mantovani V, Karlsson T. Replacement of the ascending aorta with composite valve grafts: long term results J Heart Valve Dis 1996;5:240-246.[Medline]
- Panos A, Amahzoune B, Robin J, Champsaur G, Ninet J. Influence of technique of coronary artery implantation on long-term results in composite aortic root replacement Ann Thorac Surg 2001;72:1497-1501.[Abstract/Free Full Text]
- Dougenis D, Daily BB, Kouchoukos NT. Reoperation on the aortic root and ascending aorta Ann Thorac Surg 1997;64:986-992.[Abstract/Free Full Text]
- Hahn C, Tam SKC, Vlahakis GJ, Hilgenberg AD, Akins CW, Buckley MJ. Repeat aortic root replacement Ann Thorac Surg 1998;66:88-91.[Abstract/Free Full Text]
- Luciani GB, Casali G, Faggian G, Mazzucco A. Predicting outcome after reoperative procedures on the aortic root and ascending aorta Eur J Cardiothorac Surg 2000;17:602-607.[Abstract/Free Full Text]
- Ando M, Kosakai Y, Okita Y, Nakano K, Kitamura S. Surgical treatment of Behçet's disease involving aortic regurgitation Ann Thorac Surg 1999;68:2136-2140.[Abstract/Free Full Text]
- Plume SK, Sanders J. The Carpentier-Edwards stented supra-annular pericardial aortic prosthesis: clinical durability and hemodynamic performance Curr Opin Cardiol 2002;12:183-187.
- Galla JD, Lansman SL, Spielvogel D, et al. Bioprosthetic valved conduit aortic root reconstruction: the Mount Sinai experience Ann Thorac Surg 2002;74:S1769-S1772.[Abstract/Free Full Text]
Top
Abstract
Introduction
