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Original Articles: Adult Cardiac

Long-Term Results of Aortic Root Replacement: 15 Years' Experience

Ilker Mataraci, MD^a,_*, Adil Polat, MD^b, Burak Kran, MD^c, Ahmet Calkan, MD^a, Altug Tuncer, MD^a, Vedat Erentug, MD^d, Kaan Kirali, MD^a, Omer Isik, MD^e, Cevat Yakut, MD^a

^a Kartal Kosuyolu Heart and Research Hospital, Cardiovascular Surgery Clinic, Istanbul, Turkey
^d Bagcilar Research and Training Hospital, Istanbul, Turkey
^e JFK Hospital, Istanbul, Turkey
^b Military Hospital, Elazig, Turkey
^c Elazig Research and Training Hospital, Elazig, Turkey

Accepted for publication March 17, 2009.

^_* Address correspondence to Dr Mataraci, Kartal Kosuyolu Heart and Research Hospital, Cardiovascular Surgery Clinic, Istanbul, Turkey (Email: adilpol{at}yahoo.com).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
Background: Long-term results of aortic root replacements and the factors affecting long-term mortality were analyzed.

Methods: We operated on 254 patients from June 1993 to November 2008 for aortic root replacement with Bentall de Bono procedure. Two hundred five patients were male (80.7%) and 49 patients (19.3%) were female. The mean age was 48.3 ± 14.7 years (range, 14 to 78 years). We performed 72 concomitant procedures in 69 patients, and the most commonly performed procedure was coronary artery bypass grafting in 37 patients (14.6%). The most common indication for aortic root replacement was aneurysm in 235 patients (92.5%). Thirty-four patients (13.4%) had Marfan syndrome. Hypothermic circulatory arrest was used in 52 patients (20.5%). After removing the clamp, we had to reclamp the aorta in 26 patients (10.2%) undergoing operation.

Results: Postoperatively 30 patients (11.8%) had in-hospital mortality. The late mortality was 2.8% (7 patients). The most common reason for hospital mortality was low cardiac output (18 in 30 patients; 51.4%). Neurologic complications were seen in 16 patients (6.3%). The mean duration of hospital stay was 16.6 ± 11.3 days (range, 5 to 77 days). Postoperative follow-up was 6.3 ± 4.5 years (range, 0 to 15.5 years) on average. Late mortality was significantly affected by Marfan syndrome (p = 0.025) and reclamping the aorta (p = 0.036). Actuarial survival for the overall 254 patients is 88.4% ± 2.1%, 87.4% ± 2.2%, and 84.5% ± 2.56% at 1, 3, and 10 years, respectively.

Conclusions: The late-term results of aortic root replacement with the modified Bentall de Bono procedure are satisfactory. Survival is decreased in patients with Marfan syndrome and in the patients who had reclamping intraoperatively.

	Introduction

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Aortic root reconstruction techniques have evolved since the first introduction of the composite graft replacement of the aortic root in 1968 [1]. Subsequent modifications helped surgeons avoid tension on the button coronary anastomosis, preventing excessive bleeding and kinking of the coronary arteries and decreasing operation times. We have introduced a flanged modification before [2] that also enables root enlargement and repair of iatrogenic subvalvular defects occurring during aortic root operations. Together with the operations done with Kouchoukos modification (inclusion method), we have operated on 254 patients since June 1993. After 1996 we started to operate on patients with the flanged modification of the Bentall de Bono procedure. We have analyzed the early and late-term results of all the aortic root procedures retrospectively.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
Patient Selection and Study Protocol
The study was done with the approval of the institutional ethics committee. Between June 1993 and December 2008, 254 patients underwent aortic root replacement at Kartal Kosuyolu Heart and Research Hospital (which was known as Kosuyolu Heart and Research Hospital until June 2005). Data were collected with regard to patient age, sex, indication for procedure, preoperative risk factors (hypertension, diabetes mellitus, chronic obstructive pulmonary disease, coronary artery disease, Marfan syndrome, prior history of cardiac operation, and New York Heart Association functional classification), operation date, the procedure being urgent or elective, the need for concomitant procedures (ie, coronary artery bypass grafting, mitral valve replacement, and repair of congenital defects), cardiopulmonary bypass time, aortic cross-clamp time, operative time, use and duration of hypothermic circulatory arrest with and without retrograde cerebral perfusion, intraoperative complications (need for reclamping the aorta, need for additional sutures on the proximal or distal anastomosis), total duration of the hospitalization, and hospital and late morbidity and mortality. All data have been collected from an aortic surgery database maintained at our hospital; it is the primary source of data for this report.

There were 205 (80.7%) male and 49 (19.3%) female patients. The age of the patients ranged from 14 to 78 years (mean, 48.3 ± 14.7 years). Clinical characteristics of the patients are presented in Table 1. There were 235 patients (92.5%) with aortic aneurysms, 226 (89.0%) with aortic regurgitation, 50 (19.7%) with aortic dissection, and 29 (11.4%) with calcific aortic stenosis. Hypertension was the most common preoperative medical disorder, with an incidence of 63.4%. Ascending aortic aneurysms with or without other aortic root pathologic entities were the most frequent indication for operation (92.5%). The mean diameter of the ascending aorta was 6.3 ± 1.2 cm (range, 2.5 to 11 cm). The aortic root replacement was performed as an emergency procedure in 24 patients (9.4%) with acute aortic dissection and electively in 230 patients (90.6%).

Anticoagulation
In the postoperative period, 150 mg of acetylsalicylic acid per day and 2.5 mg of warfarin sodium per day were started after extubation, and they were continued life-long. For patients receiving only a prosthetic aortic valve with sinus rhythm and without preoperative and postoperative thromboembolic complications, we chose a dose of anticoagulation with an international normalized ratio between 2.5 and 3. We continued anticoagulation in the remaining patients with an international normalized ratio between 3 and 3.5.

Follow-Up
Follow-up data were provided from the patients' and hospital records as of December 2008. Follow-up was 100% complete in 254 patients. No patient was lost to follow-up. Total follow-up was 1,589.1 patient-years, with a mean of 6.3 ± 4.5 years (range, 0 to 15.5 years). All patients underwent echocardiographic and computerized tomographic evaluation every 6 months.

Statistical Methods
The definition of complications and methods of analysis were consistent with the guidelines issued by Edmunds and colleagues [5]. Results are presented as mean ± standard deviation. Twenty-three variables were analyzed as independent factors affecting the dependent variables (early and late mortality and neurologic morbidity): age (60 years), sex, preoperative New York Heart Association functional class, indication for procedure (aneurysm, dissection, severe aortic calcification and aortic regurgitation), time of the operation (1996 or before and after 1996), associated diseases (coronary artery disease, hypertension, diabetes mellitus), emergency surgery, prior history of cardiac operation, need for concomitant procedures, cardiopulmonary bypass duration, aortic cross-clamp duration, use of hypothermic circulatory arrest with and without retrograde cerebral perfusion or antegrade selective cerebroplegia, and postoperative complications (repeat cross-clamp, low cardiac output syndrome, neurologic, renal, pulmonary, rhythm, infection). All the occurrences of cerebrovascular events and transient neurologic dysfunction were grouped as neurologic morbidity. Pulmonary complications were also counted as extended duration of mechanical ventilation, reintubation, and any need for extended pulmonary physiotherapy.

Logistic regression analyses were used to assess risk factors as independent predictors of neurologic complications and early and late mortality. For each dependent variable, all explanatory variables were analyzed with the logistic regression analyses. The cutoff probability values for the logistic regression analyses were 0.05 in each analysis. Survival was computed using the Kaplan-Meier method. Cox proportional hazard regression analysis was used to assess risk factors as independent predictors of patient survival. The log rank test for independent groups was used to test the significance of differences. Correlations were calculated by Spearman's test. Results are presented as mean ± standard error. A probability value less than or equal to 0.05 was considered statistically significant for all comparisons. A commercial statistical software package (SPSS for Windows, version 17.0; SPSS Inc, Chicago, IL) was used for data analysis.

	Results

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Operative Details
Intraoperative data of patients and the concomitant procedures are presented in Table 2. Aortic cross-clamp time was 111.1 ± 39.5 minutes (range, 55 to 294 minutes), cardiopulmonary bypass time was 169.7 ± 63.8 minutes (range, 65 to 508 minutes), and mean operation time was 276.2 ± 91.6 minutes (median, 4.2 hours). Seventy-two concomitant procedures were performed in 69 patients.

Late Mortality and Survival
Of the 224 surviving patients, 7 patients (3.1%) died during the follow-up period. The causes of the deaths are detailed in Table 3. Actuarial survival for the overall 254 patients (including hospital deaths) is 88.4% ± 2.1%, 87.4% ± 2.2%, and 84.5% ± 2.56% at 1, 3, and 10 years, respectively (Fig 1). Concomitant cardiac procedures did not worsen life expectancy. With logistic regression analysis, Marfan syndrome (OR, 41.67; 95% CI, 1.62 to 1000; p = 0.025) and reclamping the aorta (OR, 13.51; 95% CI, 1.18 to 142.86; p = 0.036) were found to be significant factors for late-term mortality; however, according to Cox proportional test in hazard regression analysis, only reclamping the aorta was a significant factor in terms of late-term mortality (OR, 2.53; 95% CI, 1.15 to 5.59; p = 0.021).

View larger version (8K): [in this window] [in a new window]   Fig 1. Kaplan-Meier survival curve.

Anticoagulant-related complications
Twelve patients had complications related to anticoagulant therapy. One of them died of cerebral hemorrhage, another 1 of severe gastrointestinal bleeding. We did not detect any other nonfatal anticoagulant-related complications. Freedom from anticoagulant-related complications was 98.4% ± 1.7%, 97.3% ± 2.2%, and 95.9% ± 2.1% at 3, 5, and 10 years, respectively.

Prosthetic endocarditis
After discharge 1 patient (1.1%) experienced prosthetic valve endocarditis and healed after medical therapy; however, another 2 patients who had prosthetic valve endocarditis (0.9%) died. Freedom from prosthetic valve endocarditis was 100%, 98.4% ± 1.3%, and 97.3% ± 1.0% at 1, 5, and 10 years, respectively (0.4% patient-years).

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

 
Composite graft replacement of the aortic root is the procedure of choice for aortic root pathologic entities. Different modified procedures have been proposed to prevent long-term events from complicating patient survival. We have been using a flanged modification of the Bentall de Bono procedure to overcome these problems as well as many others [2]. The previously reported mid-term results of our procedures have been satisfactory [3]. In this exclusive series of patients of aortic root replacements, we have analyzed the factors affecting on the long-term survival.

Thirty patients (11.8%) had in-hospital mortality, some of which can be explained by patient-related factors such as the high New York Heart Association class, prior cardiac operations, and postoperative infections, and a few of them by the learning curve of the procedure. Even though similar rates of mortality are reported [7], we investigated the reasons for this high mortality on the strength of the near-perfect results, especially in the recent years. Reclamping the aorta for bleeding control was found to be an important factor affecting the hospital mortality. The significant correlation between repeat cross-clamp and low cardiac output syndrome and pulmonary morbidity seem to be important in determining the hospital mortality because, as outlined in Table 3, the most common reasons for hospital mortality are low cardiac output syndrome and pulmonary complications. Most of these patients were operated on either before 1996 or in the initial years that we started to perform the flanged procedure. The preparation of the flanged composite graft and its effect on the operation results have been discussed before [2, 3]. In this analysis, again, we found the flanged operations had no adverse affect on the early and late-term mortality. As such, the higher percentage of the repeat cross-clamping in the inclusion method may be considered in favor of our flanged technique. The effect of repeat cross-clamping on the late mortality may be a result of the damage received by the patient by increasing the ischemic times and the duration of both the perfusion and the operation. Although preoperative ventricular function was found not to be related to the late-term mortality, the intraoperative damage may explain this association.

The review of the literature shows different independent risk factors for early and late death. Ivanov and colleagues [8] reported that factors such as advanced age, moderate to severe ventricular dysfunction, active endocarditis, previous cardiac surgery, and coronary artery disease were significant factors associated with death. We found no association with such factors. A similar association together with the extension of dissection is linked to death by some other authors [9], unlike our analysis. The causative factor showed no relation with the mortality except for Marfan syndrome, which is also reported by other authors [10]. There were 24 patients who underwent operation on an emergency basis. With the logistic regression analysis we could not detect a significant association either with the in-hospital (p = 0.369) or the long-term mortalities (p = 0.251), unlike some other reports [7, 11]. This lack of correlation does not decreasse the power of our analysis but expresses the importance of intraoperative factors on postoperative survival. Depressed ventricular function may be a risk factor, but the accurate management of the patient ensures improved survival.

The presence of Marfan syndrome is not associated with lower long-term survival in some other series [11]. Although Marfan syndrome has not been associated with death by many authors [12], a significant increase in the incidence of reoperations during follow-up (especially in valve-preserving series) is reported [13]. The reoperations in our series are mainly for new-onset aneurysms in other segments of the aorta rather than the perigraft segments [6].

Emergency operations were not a significant risk factor for mortality, but pulmonary complications were much more common (of the 24 cases operated on urgently, 11 had pulmonary morbidity). The Spearman's test gave a significant correlation with pulmonary and neurologic complications (11 of the 16 neurologic complications were seen in patients who had pulmonary morbidity). Considering the different risk factors determined for these complications, this correlation seems to be significant, which merits further investigation. We have not avoided using the flanged procedure in emergency cases; thus, the relation of our modification technique is not a risk factor in these patients.

Although the early mortality is lower than many of the published series in the literature [8, 9, 11], the long-term survival is comparable with many others [7–9, 11, 14]. Marfan syndrome and repeat cross-clamping have been significantly related to long-term mortality. Marfan syndrome is well known for its complicating course, and the surgery is mandatory for increased survival in these patients [6, 15]. The complicating course of Marfan syndrome itself poses as a risk factor in the long-term follow-up, different from other causes of aortic root replacements performed for other causes such as bicuspid valves [16].

Postoperative complications are also comparable with those of other series in the literature [7–9, 11, 14]. The additional suturing and reexploration variables that are found to be related to neurologic morbidity may be attributable to the extended surgical stress on the patient. Although the total number of patients with neurologic dysfunction was 16, the actual cerebrovascular event rate is much lower, as we have stated before. Considering the actual severe morbidity, our cases have a very favorable postoperative course.

The late-term complications are low comparable with other reports [10, 12]. The anticoagulation-related morbidity seems to be acceptable to us. Even though near-perfect results are reported by the highly experienced centers [17], some other highly respectful authors' candid statements about the unsatisfactory results with the valve-preserving procedures [13] may justify our late-term numbers. The avoidance of long-term morbidity and operation-related factors have improved the long-term results since the previous reports [18]. Our two long-term mortality occurrences were attributable to prosthetic valve endocarditis, whereas another two were because of the redissection of the aorta in another segment.

Composite graft replacement of the aortic root can be accomplished with low mortality and morbidity. Avoidance of intraoperative complications and refining the long-term follow-up will further increase the success of these procedures.

	References

Top Abstract Introduction Patients and Methods Results Comment References

 

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