ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Ann Thorac Surg 2009;87:109-115. doi:10.1016/j.athoracsur.2008.10.008
© 2009 The Society of Thoracic Surgeons
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Atsushi Nakahira
Toshihiko Shibata
Koji Hattori
Shigefumi Suehiro
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Nakahira, A.
Right arrow Articles by Suehiro, S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Nakahira, A.
Right arrow Articles by Suehiro, S.
Related Collections
Right arrow Great vessels
Right arrowRelated Article

Original Articles: Adult Cardiac

Outcome After the Modified Bentall Technique With a Long Interposed Graft to the Left Coronary Artery

Atsushi Nakahira, MDa,*, Toshihiko Shibata, MD, PhDa, Yasuyuki Sasaki, MD, PhDa, Hidekazu Hirai, MD, PhDa, Koji Hattori, MD, PhDa, Mitsuharu Hosono, MD, PhDa, Shoichi Ehara, MD, PhDb, Shigefumi Suehiro, MD, PhDa

a Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
b Department of Internal Medicine and Cardiology, Osaka City University Graduate School of Medicine, Osaka, Japan

Accepted for publication October 8, 2008.

* Address correspondence to Dr Nakahira, Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, 1-4-3, Asahimachi, Abenoku, Osaka City, Osaka, 545-8585, Japan (Email: osushi123{at}med.osaka-cu.ac.jp).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Background: The modified Bentall technique, which was reported by Svensson in 1992, is an aortic root composite valve graft replacement involving reimplantation of the left coronary ostium with a long interposed graft wrapping behind the composite graft. The technique is technically advantageous, particularly for complicated or redo aortic roots. To justify the technique, the midterm outcome needs to be evaluated.

Methods: Since 1992, 40 patients (4 with Marfan syndrome) underwent the modified Bentall technique (Svensson's modification). The mean age was 54.7 ± 13.6 years, and 32 patients (80.0%) were male. All hospital survivors have been consecutively followed with annual echocardiographic evaluations. Furthermore, in 2007, multislice computed tomography was performed at 4.7 ± 3.5 years (maximum, 14.9 years) postoperatively in 30 patients who had preserved renal function.

Results: No patients have experienced any complications regarding the technique at the follow-up of 5.7 ± 4.0 years (maximum, 14.9 years), although there were 2 hospital deaths of emergency cases and 5 late deaths owing to noncardiac causes. In 35 patients (92.1% of hospital survivors), no structural complications were detected by multislice computed tomographies of the 30 patients or coronary angiograms of the remaining 5 patients. The consecutive echocardiographic follow-ups showed well-preserved left ventricular function with the most recent ejection fraction being 0.581 ± 0.078.

Conclusions: This Svensson's modification technique was associated with favorable midterm outcomes by multislice computed tomography and consecutive echocardiographic evaluations, indicating long-lasting advantages as well as technical benefits. Thus, the technique can be considered as a helpful and justifiable alternative method.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Aortic root composite valve graft replacement, which was originally described by Bentall and De Bono in 1968 [1], has been used for a large spectrum of pathologic conditions involving the aortic valve and ascending aorta [2]. The original Bentall technique [1] with an inclusion technique for coronary ostial reimplantation and aortic wall wrapping is associated with a high incidence of postoperative complications, particularly pseudoaneurysm formation, caused by tension on the coronary ostial suture line [3, 4]. Therefore, various modified techniques have been developed, especially with regard to the coronary ostial reimplantation technique, in an effort to achieve better outcomes [5–8]. Nowadays, the most preferred method seems to be coronary ostial reimplantation as an aortic button, referred to as the "aortic button technique," which has shown favorable midterm outcomes [9–11]. However, the aortic button technique is not always feasible, particularly when the coronary ostia are quite dislocated or tightly bound to the aortic annulus and when coronary artery mobilization is not possible or adequate as in cases of complicated or redo aortic roots [12–14]. To avoid mobilization of the coronary ostia, Piehler and Pluth [6] developed a modified technique using a separate short interposed graft for each coronary ostial reconstruction, whereas Cabrol and colleagues [5] reported another technique using a common long interposed graft for both left and right coronary ostial reconstructions. However, both of these techniques have associated disadvantages, such as operative difficulty in orienting the interposed graft, and kinking or thrombosis of the graft with subsequent myocardial ischemic events [3].

Compared with these modifications, Svensson [8] developed a modification of the Bentall technique which combined the advantages of the aortic button technique for the right coronary artery and the Cabrol technique for the left coronary artery with an individual long interposed graft, referred to as "Svensson's modification" (Fig 1). Svensson's modification brings various operative benefits, which become more advantageous in complicated or redo aortic roots. The representative advantages are technical ease in reattaching the left coronary ostium, minimal tension on the ostial anastomosis, and clear visualization of all the anastomoses. On the other hand, as surgeons, we must be concerned about various complications regarding the long interposed graft, such as kinking of the graft or ostium, pseudoaneurysm formation, and thrombosis inside the graft causing subsequent distal coronary embolisms. To justify the Svensson's modification, we evaluated the midterm outcomes using the highly reliable noninvasive imaging technique of multislice computed tomography (MSCT) [15–17] and consecutive echocardiographic evaluations.


Figure 1
View larger version (22K):
[in this window]
[in a new window]

  		Fig 1. Operative schemas of the modified Bentall technique (Svensson's modification). (A) In a representative ascending and aortic root aneurysm, cardiopulmonary bypass is established by cannulation of the distal ascending aorta. (B) After opening the ascending aorta and excising the aortic valve cusps, the beveled end of the long interposed graft is first anastomosed in the left coronary orifice. Infusion of cardioplegic solution into the long interposed graft (arrow) is effective for confirmation of hemostasis. (C) After completion of the proximal to distal anastomoses of the composite graft, temporary release of the aortic cross-clamp and pressurized infusion of cardioplegic solution into the long interposed graft make both grafts distended, similar to their natural alignments, such that appropriate anastomotic sites for the right coronary ostial button and the proximal long interposed graft on the left are easily determined. (D) In the completely replaced aortic root, all the anastomoses can be observed for hemostasis, even after removing the aortic clamp. The loose arrangement of the interposed graft is supposed to prevent additional tension in the left coronary ostial anastomosis.

 

   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Acknowledgments
 References
 
Patient Selection
Between December 1992 and November 2006, 40 consecutive patients underwent aortic root composite valve graft replacement according to Svensson's modification [8] (Fig 1) at Osaka City University Hospital (Osaka, Japan). The patients' profiles and abnormalities of the aortic roots necessitating surgical treatment are shown in Table 1. The ethics committee in our institution approved the study and waved the need for patient consent for the retrospective review part. Informed consent for the MSCT examination was obtained from all patients who underwent an examination.


View this table:
[in this window]
[in a new window]

  		Table 1 Patient Characteristics
 
Operative Techniques
Through a median sternotomy, cardiopulmonary bypass was established by cannulation of the distal ascending aorta, aortic arch, right subclavian artery or femoral artery (depending on the extension of the aneurysm and the presence of dissection), and right atrium or superior and inferior venae cavae (Fig 1A). The left ventricle was vented by cannulation through the right upper pulmonary vein.

Aortic root composite valve graft replacement was performed according to Svensson's report [8]. After cooling the patient to 29°C, the distal ascending aorta was cross-clamped and the aorta was opened. Antegrade cold blood cardioplegic solution was administered into the coronary ostia to obtain cardiac standstill. Thereafter, cardioplegic solution was administered in an antegrade and retrograde fashion during aortic clamping. Moderate systemic hypothermia (25°C) with selective cerebral perfusion was applied in 5 patients requiring concomitant arch replacement. The distal ascending aorta was circumferentially dissected. A generous aortic button (approximately 1.5 cm in diameter) containing the right coronary ostium was excised. The aortic valve cusps were excised, leaving a 1- to 2-mm rim of the annulus, and the size of the annulus was checked. Next, an 8- or 10-mm knitted polyethylene terephthalate fiber (Dacron; DuPont, Wilmington, DE) interposed graft was beveled at one end and sutured end-to-end to the left coronary ostium with a running 4-0 polypropylene suture (Fig 1B). In 2 patients with acute aortic dissection extending to the sinus of Valsalva, we generously excised the left coronary ostium, reinforced the edge around the aortic button with a pledget, and sutured a long interposed graft. Hemostasis of this ostial anastomosis was checked under pressure by infusing cardioplegic solution to the interposed graft. Pledgeted 2-0 polyester sutures were placed around the annulus, and a simultaneously prepared composite valve graft was seated after the annular sutures were passed through the rim of the suturing ring.

The distal aortic anastomosis was performed in an end-to-end fashion with a 3-0 polypropylene suture (4-0 polypropylene for acute aortic dissection or patients with Marfan syndrome). Next, the aortic cross-clamp was temporarily released, allowing blood to fill the composite graft. In the distended aortic root composite graft and the pressurized interposed graft, appropriate reimplantation sites of the proximal end of the long interposed graft as well as the right coronary button were easily determined by infusing cardioplegic solution (Fig 1C). The proximal end of the interposed graft was divided and beveled to approximately 1.0 to 1.5 cm longer than the measured length, thereby allowing the graft to loosely wrap around the composite graft and avoiding any additional tension in the anastomoses.

After clamping the composite graft again, an oval hole was created at the marked site of the composite graft, and the proximal anastomosis of the interposed graft was made with a running 4-0 polypropylene suture. Next, reimplantation of the right coronary button was carried out. In 6 patients, we did not use the button technique for the right coronary artery reconstruction. In 2 of these patients, interposition grafts with a saphenous vein graft or prosthetic graft were used because of concern about some residual tension. In the other 4 patients, coronary artery bypass grafting with a saphenous vein graft to the right coronary artery was performed after coronary ostial closure because of extension of aortic dissection to the orifice, porcelain aorta, and injuries to the coronary ostium. Even after removing the clamps, all anastomoses were visible to the surgeons (Fig 1D). The operative data are shown in Table 2.


View this table:
[in this window]
[in a new window]

  		Table 2 Operative Data
 
Follow-Up by Consecutive Echocardiography and Anticoagulation
The mean follow-up period was 5.7 ± 4.0 years (range, 1.0 to 14.9 years), and the follow-up data were consecutively available for all hospital survivors for our direct examination. The patients were followed up by echocardiography at least once or twice a year. The data for the last examinations were obtained in 2007. Regarding postoperative anticoagulation, we administered aspirin alone for patients with a bioprosthetic valve and added warfarin for patients with a mechanical valve to control the international normalized ratio of prothrombin time at approximately 2.0. Postoperative complications were analyzed according to the "Guidelines for reporting morbidity and mortality after cardiac valvular operations" [18].

Multislice Computed Tomography Image Acquisition and Reconstruction, and Coronary Angiography
The patients were scanned during a single breath-hold in the caudocranial direction using a 64-slice computed tomography scanner (SOMATOM Sensation 64; Siemens Medical Solutions, Erlangen, Germany). Regarding the methods for displaying the data, we applied volume rendering, curved multiplanar reformation, and an angiographic view.

All 30 patients who had preserved renal function underwent MSCT in 2007, at 4.7 ± 3.5 years (maximum, 14.9 years) postoperatively. In the other 5 patients, we evaluated their postoperative coronary angiograms, which were performed at 2.6 ± 4.0 years postoperatively. Altogether, we were able to examine postoperative contrast image of MSCT or coronary angiograms in 35 patients (92.1% of hospital survivors) at 4.5 ± 3.6 years (maximum, 14.9 years) postoperatively.

Statistical Analysis
The results are presented as the mean ± standard deviation. Statistical significance for the evaluation of each echocardiographic variable was determined by means of a paired Student's t test with Bonferroni's adjustment, and probability values less than 0.05 were considered significant. All statistical analyses were performed using the StatView 5.0 software package (SAS Institute, Cary, NC).


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Acknowledgments
 References
 
Mortality
The overall early mortality rate (defined as death within 30 days or during initial hospitalization) was 5.0% (2 patients), as shown in Table 3. Both of these patients were emergency cases with preoperative shock owing to acute aortic dissection, and their causes of death were multiple organ failure with systemic shower embolisms or low cardiac output syndrome. There were 5 late deaths, and the causes of death were 4 noncardiac malignancies and 1 cerebral infarction.


View this table:
[in this window]
[in a new window]

  		Table 3 Mortality and Morbidity
 
Morbidity
The postoperative complications encountered are also shown in Table 3. Although not shown in Table 3, no patients required a second aortic cross-clamp for hemostasis. The cause of the rethoracotomy was bleeding from the distal aortic anastomosis with a composite graft in a hemiarch replacement. During the follow-up period of up to 14.9 years, there were no myocardial ischemic events or any complications related to the technique. Unfortunately, redo operations for aortic roots were required in 3 patients because of prosthetic aortic valve infections. In their reoperations, we could perform the Svensson's modification again, preserving the long interposed graft, and all of them have been followed up without any recurrence of infection.

Multislice Computed Tomography and Coronary Angiography
Volume rendering images (Figs 2A, 2B) revealed that there were no structural problems, such as kinking or compression of the interposed graft, thrombosis inside the graft, ostial narrowing, or pseudoaneurysm formation in any anastomotic sites in the replaced roots. Curved multiplanar reformation images (Fig 2C) and angiographic views (Fig 2D) more precisely showed the intraluminal information along the long interposed graft and coronary artery system, and also confirmed a lack of any associated problems. The coronary angiographies in the other 5 patients revealed patent long interposed grafts without any problems. Taking all the postoperative images of the 35 patients (92.1% of hospital survivors) together, we were able to confirm that there were no structural complications in the replaced aortic roots. Consistent with these results, none of the 38 hospital survivors required any postoperative interventions regarding the long interposed grafts.


Figure 2
View larger version (125K):
[in this window]
[in a new window]

  		Fig 2. Representative postoperative images obtained by multislice computed tomography. (A, B) Volume rendering images of the right-anterior (A) and cranial (B) views showing the general alignment of the reconstructed aortic root. (C) A curved multiplanar intensity reformation image, providing precise intraluminal information. (D) An angiographic view, showing independent images of the overall coronary structures, including the long interposed graft. (LAD = left anterior descending coronary artery; RCA = right coronary artery.)

 
Echocardiography
All consecutive echocardiographic data for the hospital survivors revealed significant decreases (p < 0.01) in the end-diastolic and end-systolic dimensions of the left ventricle, even at 1 year postoperatively, compared with the corresponding preoperative data (Fig 3A). Accordingly, the percentage of fractional shortening had recovered significantly (p < 0.01) at 5 years postoperatively compared with the preoperative data (Fig 3A). Consistent with these results, the consecutive left ventricular ejection fraction data showed well-preserved left ventricular function (Fig 3B), with the most recent ejection fraction value being 0.581 ± 0.078.


Figure 3
View larger version (33K):
[in this window]
[in a new window]

  		Fig 3. Perioperative consecutive echocardiographic data. (A) The diastolic and systolic dimensions of the left ventricle (LVDd and LVDs, respectively) have become shorter and, accordingly, the percentage of fractional shortening (%FS) has improved during follow-up. (B) The left ventricular ejection fraction (EF) has also improved postoperatively and been well preserved. **p < 0.01 and *p < 0.05 versus the corresponding preoperative data (Pre).

 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Acknowledgments
 References
 
The present study has demonstrated that the modified Bentall technique (Svensson's modification) [8] is associated with favorable midterm outcomes without any complications. The midterm MSCT evaluations revealed no structural problems in the replaced aortic roots, and the consecutive echocardiographic follow-up data showed dimensional recovery and well-preserved function of the left ventricle. This well-preserved left ventricular function can exclude embolic myocardial ischemia from thromboses inside the long interposed graft. Although use of a long interposed graft may cause some concern, the Svensson's modification can be considered as a helpful and justifiable alternative method, particularly for complicated or redo aortic roots.

In aortic root composite valve graft replacement, the procedures for reconstructing the coronary ostia are very important for influencing the long-term outcome as well as the early operative results. Aortic root composite valve graft replacement has been a standard technique with favorable outcomes, which seem to be no worse than those of aortic valve replacement with or without ascending aortic replacement [11, 19–21]. As life expectancy after cardiac operations has become longer, redo operations of aortic roots have been performed with increasing frequency as a result of various undesirable complications [12–14, 21–23]. Although the outcomes of aortic root reoperations are acceptable according to some reports [22, 23], redo procedures require more complexity in their operative strategies and techniques, and are associated with high postoperative mortality [12–14]. In a complicated or redo aortic root operation, technical problems associated with coronary ostial reimplantation seem to be critical issues and contribute heavily to worse outcomes [13]. During weaning from cardiopulmonary bypass or achieving hemostasis, kinking of the reconstructed coronary arteries or bleeding from the coronary ostial anastomosis can cause an intraoperative hemodynamic problem to be fatal. During long-term follow-up, complications associated with deterioration such as kinking of the graft with impaired coronary perfusion or coronary ostial pseudoaneurysm formation can develop [24, 25]. Therefore, surgeons should be ready to choose an appropriate coronary reconstruction technique to avoid fatal complications and improve the outcome [26].

The procedure for left coronary ostial reconstruction is sometimes technically demanding, particularly in complicated aortic roots, because the left coronary ostium is located behind the aortic root. In most patients, the aortic button technique can be applied with mobilization and displacement of the left coronary ostium [9–11]. However, if there is a wide gap between the aneurysmal wall and the composite graft or if the coronary ostia are tightly bound to the surrounding tissue, mobilization of the coronary ostia is difficult or can damage the surrounding structures [23]. Furthermore, bleeding from the inaccessible left coronary ostial anastomosis behind the seated composite graft is difficult to control. To obviate these problems, the Cabrol technique [5] and Piehler technique [6] were developed as modified Bentall techniques to enable coronary ostial anastomosis in situ. The Cabrol technique was used in complicated aortic roots, when mobilization and approximation of the coronary ostia are difficult [9, 23, 27]. However, the original Cabrol technique has currently been replaced by other techniques owing to potential technical difficulties in the arrangement of the common interposed graft and subsequent graft-related complications [3]. In both techniques, the left coronary ostial anastomosis is finally hidden behind the seated composite graft and the possible bleeding is difficult to control without a second cardiac arrest.

In contrast, the Svensson's modification simplifies the composite graft insertion with coronary ostial reconstructions and can be applied to various kinds of diseased aortic roots. Compared with other techniques, the Svensson's modification enables individual proximal reimplantation of the left and right coronary arteries after insertion of the composite graft as shown in Figure 1C, and accordingly brings about many operative advantages as follows. First, any meticulous, time-consuming, and risky dissection around the left main coronary artery is avoided. Second, soon after finishing the left coronary ostial anastomosis with the long interposed graft, hemostasis can be confirmed under the pressurized interposed graft by infusing cardioplegic solution. Third, an appropriate arrangement of the long interposed graft can easily be carried out by temporary release of the aortic cross-clamp and cardioplegic infusion into the interposed graft (Fig 1C). Fourth, because all the anastomoses are visible to the surgeon even after removal of aortic clamps, hemostasis can be ensured and attained without any requirement for a second cardiac arrest (Fig 1D). Fifth, because the interposed graft is slightly longer than the measured length behind the composite graft, additional tension in the left coronary ostial anastomosis after aortic declamping can be minimized. Owing to these operative advantages, no patients required a second cardiac arrest or rethoracotomy for hemostasis in the aortic root in our series.

Pseudoaneurysm formation after aortic root replacement is a life-threatening complication. Even in patients operated on using the aortic button technique, coronary ostial pseudoaneurysm formation has been reported [25]. Dougenis and colleagues [21] reported that pseudoaneurysm formation was the reason for aortic root reoperations in 16 of 81 patients and that 2 of these patients died, resulting in an early mortality rate of 12.5%. LeMaire and associates [14] reported a series of 14 pseudoaneurysms after aortic root composite valve graft replacement and reported that the origin of the pseudoaneurysm formation was the coronary artery attachment site in 4 patients. The suture line tension in the coronary ostial anastomosis and friability of the aortic wall are suggested to be responsible for pseudoaneurysm formation. In the present study, the MSCT evaluations of our consecutive patients clearly demonstrated that no pseudoaneurysms occurred. This finding probably arises because the long interposed graft decreases the suture line tension.

Our current observations have shown that MSCT represents a preferable and suitable evaluation tool for aortic root replacement. The incidence of pseudoaneurysm formation after aortic root replacement is unknown and may be higher than expected because not all patients are evaluated by diagnostic imaging studies. Milano and colleagues [26] precisely evaluated the fates of coronary ostial anastomoses after variously modified aortic root replacement using several imaging techniques and concluded that more extensive use of new imaging techniques was desirable to assess the true incidence of complications after aortic root replacements.

Finally, we should mention some limitations of our current investigation. First, this is a retrospective study involving a small number of patients. Second, we did not compare the results with those of other techniques or choose only complicated or redo aortic roots. Third, we cannot reach any conclusion regarding anticoagulation for long interposed grafts from the current study because we applied warfarin depending on the type of implanted prosthetic valve and have only been able to perform follow-up of 4 patients with a bioprosthetic valve without using warfarin.

In conclusion, midterm evaluations of the Svensson's modification revealed no myocardial ischemic events, no structural complications by MSCT, and no deterioration of left ventricular function by consecutive echocardiography. Therefore, the operative advantages of this procedure can be reemphasized by these favorable outcomes, and surgeons can become more confident about using this technique. Although the aortic button technique is applicable in most aortic root composite valve graft replacements, the Svensson's modification can be considered as a helpful and justifiable alternative method, particularly for complicated or redo aortic roots.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
References
 
We gratefully acknowledge the excellent technical assistance of Mitsuru Fukui, PhD, (Laboratory of Statistics, Osaka City University, Osaka, Japan) in the statistical analyses.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Bentall H, De Bono A. A technique for complete replacement of the ascending aorta Thorax 1968;23:338-339.[Abstract/Free Full Text]
  2. Crawford ES, Svensson LG, Coselli JS, Safi HJ, Hess KR. Surgical treatment of aneurysm and/or dissection of the ascending aorta, transverse aortic arch, and ascending aorta and transverse aortic arch. Factors influencing survival in 717 patients. J Thorac Cardiovasc Surg 1989;98:659-674.[Abstract]
  3. Pacini D, Ranocchi F, Angeli E, et al. Aortic root replacement with composite valve graft Ann Thorac Surg 2003;76:90-98.[Abstract/Free Full Text]
  4. Kouchoukos NT, Wareing TH, Murphy SF, Perrillo JB. Sixteen-year experience with aortic root replacement. Results of 172 operations. Ann Surg 1991;214:308-320.[Medline]
  5. 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]
  6. 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]
  7. 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]
  8. Svensson LG. Approach for insertion of aortic composite valve grafts Ann Thorac Surg 1992;54:376-378.[Abstract/Free Full Text]
  9. 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]
  10. Svensson LG. Progress in ascending and aortic arch surgery: minimally invasive surgery, blood conservation, and neurological deficit prevention Ann Thorac Surg 2002;74:1786-1788.
  11. 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]
  12. Roselli EE, Pettersson GB, Blackstone EH, et al. Adverse events during reoperative cardiac surgery: frequency, characterization, and rescue J Thorac Cardiovasc Surg 2008;135:316-323.[Abstract/Free Full Text]
  13. Kirsch EW, Radu NC, Mekontso-Dessap A, Hillion ML, Loisance D. Aortic root replacement after previous surgical intervention on the aortic valve, aortic root, or ascending aorta J Thorac Cardiovasc Surg 2006;131:601-608.[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;74:1777-1780.
  15. Kamdar AR, Meadows TA, Roselli EE, et al. Multidetector computed tomographic angiography in planning of reoperative cardiothoracic surgery Ann Thorac Surg 2008;85:1239-1245.[Abstract/Free Full Text]
  16. Schlosser T, Konorza T, Hunold P, Kuhl H, Schmermund A, Barkhausen J. Noninvasive visualization of coronary artery bypass grafts using 16-detector row computed tomography J Am Coll Cardiol 2004;44:1224-1229.[Abstract/Free Full Text]
  17. Ropers D, Moshage W, Daniel WG, Jessl J, Gottwik M, Achenbach S. Visualization of coronary artery anomalies and their anatomic course by contrast-enhanced electron beam tomography and three-dimensional reconstruction Am J Cardiol 2001;87:193-197.[Medline]
  18. Edmunds Jr LH, Clark RE, Cohn LH, Grunkemeier GL, Miller DC, Weisel RD. Guidelines for reporting morbidity and mortality after cardiac valvular operations. Ad Hoc Liaison Committee for Standardizing Definitions of Prosthetic Heart Valve Morbidity of The American Association for Thoracic Surgery and The Society of Thoracic Surgeons. J Thorac Cardiovasc Surg 1996;112:708-711.[Free Full Text]
  19. Stalder M, Staffelbach S, Immer FF, et al. Aortic root replacement does not affect outcome and quality of life Ann Thorac Surg 2007;84:775-781.[Abstract/Free Full Text]
  20. 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]
  21. 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]
  22. Szeto WY, Bavaria JE, Bowen FW, et al. Reoperative aortic root replacement in patients with previous aortic surgery Ann Thorac Surg 2007;84:1592-1599.[Abstract/Free Full Text]
  23. Girardi LN, Krieger KH, Mack CA, Lee LY, Tortolani AJ, Isom OW. Reoperations on the ascending aorta and aortic root in patients with previous cardiac surgery Ann Thorac Surg 2006;82:1407-1412.[Abstract/Free Full Text]
  24. Dossche KM, de la Riviere AB, Morshuis WJ, Schepens MA, Bal ET, Ernst SM. Treatment of impaired coronary blood flow after aortic root replacement with human tissue valves J Thorac Cardiovasc Surg 1999;117:1034-1035.[Free Full Text]
  25. Erkut B, Ceviz M, Becit N, Gundogdu F, Unlu Y, Kantarci M. Pseudoaneurysm of the left coronary ostial anastomoses as a complication of the modified Bentall procedure diagnosed by echocardiography and multislice computed tomography Heart Surg Forum 2007;10:191-192.
  26. Milano AD, Pratali S, Mecozzi G, et al. Fate of coronary ostial anastomoses after the modified Bentall procedure Ann Thorac Surg 2003;75:1797-1802.[Abstract/Free Full Text]
  27. Bachet J, Termignon JL, Goudot B, et al. Aortic root replacement with a composite graft. Factors influencing immediate and long-term results. Eur J Cardiothorac Surg 1996;10:207-213.[Abstract/Free Full Text]

Related Article

Invited Commentary
Leonard N. Girardi
Ann. Thorac. Surg. 2009 87: 115-116. [Extract] [Full Text] [PDF]



This article has been cited by other articles:


Home page
 J. Thorac. Cardiovasc. Surg.Home page
S. C. Stamou, M. C. Murphy, and N. T. Kouchoukos
Left ventricular outflow tract reconstruction and translocation of the aortic valve for annular erosion: Early and midterm outcomes
J. Thorac. Cardiovasc. Surg., August 1, 2011; 142(2): 292 - 297.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
L. N. Girardi
Invited Commentary
Ann. Thorac. Surg., January 1, 2009; 87(1): 115 - 116.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Atsushi Nakahira
Toshihiko Shibata
Koji Hattori
Shigefumi Suehiro
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Nakahira, A.
Right arrow Articles by Suehiro, S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Nakahira, A.
Right arrow Articles by Suehiro, S.
Related Collections
Right arrow Great vessels
Right arrowRelated Article

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS