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Ann Thorac Surg 2010;89:81-86. doi:10.1016/j.athoracsur.2009.09.014
© 2010 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Reoperations on the Aortic Root: Experience in 46 Patients

Pietro G. Malvindi, MDa,*, Bart P. van Putte, MD, PhDa, Robin H. Heijmen, MD, PhDa, Marc A.A.M. Schepens, MD, PhDb, Wim J. Morshuis, MD, PhDa

a Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
b Department of Cardiac Surgery, St. Jan Hospital, Brugge, Belgium

Accepted for publication September 8, 2009.

* Address correspondence to Dr Malvindi, St. Antonius Hospital, Department of Cardiothoracic Surgery, Koekoekslaan 1, Nieuwegein, 3435 CM, the Netherlands (Email: pmalvin{at}tin.it).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: The increasing use of biologic conduits and the advances in reparative aortic root procedures has increased the number of patients who may require reoperation on the aortic root. Although the primary operation yields excellent results with a low risk for morbidity and mortality, reoperation on the aortic root is still challenging.

Methods: We reviewed retrospectively our experience in 46 patients (38 men; mean age, 57 ± 11 years) who underwent aortic root reoperations in the last 7 years. Of these, 42 had received prior aortic root replacement. The indications for reoperation included prosthesis infection in 16, false aneurysm in 16, and degenerative or postdissection aneurysm and valve prosthesis failure. Aortic root re-replacement was performed in 39 patients (85%) and closure of false aneurysm in 7. Univariate and multivariate analysis on 22 perioperative variables were performed.

Results: In-hospital mortality was 6.5% (3 patients). The postoperative course was complicated in 19 (41%). At multivariate analysis, perioperative myocardial infarction was a risk factor for hospital mortality (2 patients). Survival was 88% at 1 year and 74% at 5 years. No differences were found in survival according to redo indication. Freedom from reoperation on the aortic root was 100% at 1 year and 90% at 5 years.

Conclusions: Reoperation on the aortic root can be performed with acceptable mortality and good midterm and long-term outcome; however, the postoperative complication rate is still high.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
The first successful replacement of the aortic valve and ascending aorta was performed by Wheat and colleagues in 1964 [1]. Four years later, Bentall and De Bono [2] described a technique for total aortic root replacement using a composite graft containing a prosthetic valve while reimplantation of the coronary ostia was performed end-to-side. Surgical modifications and several technical improvements during the last 3 decades have made these procedures safe and reproducible, with an expected mortality in elective setting of less than 5% [3, 4]. The increased use of biologic conduits and the advances in reparative aortic root operations have increased the number of patients who may potentially require reoperation of the aortic root. Furthermore, prosthetic valve endocarditis and formation of false aneurysms are indications for repeat aortic root operations [5, 6]. Although these procedures yield excellent results as a primary procedure, reoperations in patients with previous cardiac procedures, and especially in patients with previous aortic root operations, are still challenging and result in a higher mortality rate [7–11]. The purpose of this study was to review our experience and clinical outcome in patients who underwent reoperation on the aortic root.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
The Ethics Committee of St. Antonius Hospital approved this study and waived the need for patient consent.

Patients
Between February 2002 and April 2009, 561 consecutive patients underwent aortic root operations. Within this group, 46 patients had undergone at least one previous aortic root operation, and their records were retrospectively examined. The mean patient age at the time of reoperation was 57 ± 11 years (range, 35 to 78 years), and 38 (83%) were men. The mean interval time between the last previous procedure and the actual operation was 7.8 ± 6.7 years (range, 0.17 to 22.9 years). Seven patients required an emergency operation.

All patients underwent coronary angiography before reoperation, and in 8 patients preoperative coronary artery disease was characterized by angiographic evidence of significant (>50%) coronary stenosis or previous myocardial revascularization by coronary artery bypass grafting (CABG) or percutaneous coronary intervention. Patient characteristics are summarized in Table 1.


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  		Table 1 Patient Characteristics
 
Prior Operation on the Aortic Root
The types of previous operation on the aortic root (the most recent in case of several previous operations) and concomitant procedures are listed in Table 2. Replacement of the aortic valve and the aortic root was done in 42 patients (91%). The coronary ostia were reimplanted using the button technique in 91%. Two patients required a saphenous vein graft on right coronary artery. One patient had a Cabrol shunt for both coronary ostia and 1 patient for the right coronary ostium.


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  		Table 2 Previous or Most Recent Operation
 
Indication for Reoperation and Surgical Techniques
The indications for reoperation are listed in Table 3. Aortic root replacement was the principal procedure in 39 patients (85%). Concomitant CABG was performed based on preoperative angiography in 4 patients. Table 4 describes the actual operative procedures performed.


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  		Table 3 Surgical Indication for Reoperation
 

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  		Table 4 Actual Procedures
 
The technique for aortic root replacement and aortic arch replacement has been described previously [12, 13]. Briefly, a median sternotomy was performed. The common femoral artery (41%) or ascending aorta/aortic arch (46%) were usually used as arterial inflow, and the right atrium (directly or via the femoral vein using a double staged cannula) was used as venous site of drainage. In 10 patients, cardiopulmonary bypass (CPB) was started before the reentry in the thorax, and in 4 patients, deep cooling (lowest rectal temperature was 19.5° ± 1.9°C) and a short period (range, 5 to 29 minutes) of deep hypothermic circulatory arrest (DHCA) was actuated before resternotomy. We reserved to start CPB before resternotomy only in case of a minimal space between the aorta or the heart and the posterior aspect of the sternum as shown by chest imaging. In 5 patients, a false aneurysm ruptured during resternotomy, in 3 patients, the preoperative imaging assessment had led us to establish CPB before the reentry; however, the blood loss in all 5 patients was successfully managed without hemodynamic imbalance.

Cardioplegia was administered selectively into the coronary ostia in 40 patients (87%) and was repeated when the ventricular septal temperature exceeded 10°C. Continuous topical cooling with cold Ringer's acetate was used during the cardiac arrest. The left ventricle was vented through insertion of a cannula in the right upper pulmonary vein. In only 1 patient cardiac cardioplegic arrest was not necessary because of closure of false aneurysm at an easily accessible site.

Coronary reimplantation using the coronary button technique was planned in all patients. In 3 patients, however, the Cabrol extension was required. The first patient had already received a Cabrol shunt during a previous operation, the second patient required extension to the right coronary ostium as in a previous aortic root replacement, and the third patient presented with a proximal false aneurysm that involved the right coronary ostium, with extensive tissue destruction.

Mean CPB time was 193 ± 50 minutes (range, 29 to 281 minutes), and the mean duration of aortic cross-clamping was 130 ± 36 minutes (range, 30 to 181 minutes). An open distal anastomosis was done in 17 patients. DHCA alone (lowest rectal temperature 19° ± 1°C) was used in 5 patients, with a mean duration of circulatory arrest of 28 ± 5 minutes (range, 23 to 35 minutes). DHCA with the adjunct of antegrade bilateral cerebral perfusion was established in 12 patients (lowest rectal temperature 22.5° ± 2.5°C) as described in previous reports [14]; in these cases, the mean duration in minutes of DHCA and of cerebral protection was, respectively, 54 ± 30 (range, 24 to 96) and 45 ± 28 (range, 19 to 94).

Statistical Analysis
Continuous variables were expressed as the mean ± 2 standard deviations. Univariate analysis (standard t test, {chi}2, or Fisher exact test, when appropriate) included 22 perioperative risk factors to determine whether any single variable influenced hospital mortality. These variables were sex, age, presence of Marfan syndrome, indication for prior operation, emergency status, presence of preoperative coronary artery disease, presence of chronic obstructive pulmonary disease, preoperative cerebrovascular accident, preoperative chronic renal failure, New York Heart Association functional class, left ventricular dysfunction, early reintervention, the number of previous operations, type of procedure; vascular graft, prosthetic valve, or valve infection; CPB time, cross-clamping time, postoperative revision for bleeding or tamponade, and postoperative renal failure, myocardial infarction (MI), cerebrovascular accident, and infection.

Each variable with a value of p < 0.05 was entered in a multiple logistic regression analysis model to study its independent predictability.

Survival rates and freedom from reoperation were calculated using the Kaplan-Meyer method. Statistical analyses were performed using the StatView 5.0 software (SAS Institute Inc, Cary, NC) and NCSS 2001 (Number Chruncher Statistical System, Kaysville, UT).


   Results
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 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Hospital Mortality
There were no intraoperative deaths, but 3 patients died before discharge, for an in-hospital mortality rate of 6.5%. The first patient was a 60-year-old man who had received an aortic root replacement with a prosthetic composite graft 13 years before. He underwent reoperation for a proximal false aneurysm, and an aortic valve replacement was also performed. He sustained a cardiac arrest on postoperative day 6 after an uneventful postoperative course. Emergency CPB was instituted. Despite adequate oral anticoagulation therapy and low-weight fractionated heparin, a massive thrombosis of the prosthetic valve involving both coronary ostia was found. After coronary revascularization, it was not possible to wean the patient from CPB. No coagulative disorders or heparin-induced thrombocytopenia were identified. Postoperatively, the patient received low-molecular-weight fractionated heparin, acetyl salicyl acid, and warfarin. Factor VII was not administered. This incident remains unexplained for us.

In the other 2 patients who died, preoperative prosthetic valve endocarditis had occurred. A postoperative MI in 1 patient resulted in low-output syndrome and sepsis. The other patient died of mediastinitis complicated by sepsis and multiorgan failure.

The mean postoperative hospital stay was 17.9 ± 20.6 days and was significantly longer for patients with prosthetic endocarditis than for other root disease (35.6 ± 29.8 vs 10.9 ± 9.1 days, p < 0.001).

After univariate analysis, postoperative MI and postoperative renal failure were independent risk factors for hospital mortality. After logistic regression analysis, postoperative MI retained significance (p < 0.001).

Hospital Morbidity
The postoperative course was complicated in 19 patients (41%). Early reoperation was necessary in 8 patients, in 6 (13%) for excessive bleeding or tamponade and in 2 (4.3%) for the removal of compress gauzes purposefully left in the thorax. Perioperative MI occurred in 2 patients (4.3%), cerebral stroke in 1 (2.1%) and transient ischemic attack in 4 (8.7%). Pulmonary infections occurred in 5 patients (10.8%) and postoperative sepsis in 2. We registered 1 patient with mediastinitis, and a permanent pacemaker implantation for complete AV block was necessary in 6 (13%).

Survival
All patients were followed up at the outpatient clinic of our department or at peripheral sites. Mean follow-up time was 18 ± 22.5 months (range, 1 to 85 months) and was 100% complete. There were 3 late deaths. The cumulative survival rates (excluding hospital mortality) were 88% at 1 year and 74% at 5 years. The survival rates after operations for vascular or valvular prosthesis infection were 92% at 1 year and 69% at 5 years. After operations for false aneurysm, we registered only one late operative death that accounted for an 89% survival rate at 1 and 5 years. The difference in survival between patients who underwent an operation for infection or false aneurysm (log-rank p = 0.96) was not significant. Freedom from reoperation (excluding early in-hospital operation for bleeding) on the aortic root was 100% at 1 year and 90% at 5 years, and freedom from reoperation on the ascending aorta and aortic root was 97% at 1 year and 70% at 5 years. Four other patients underwent further aortic procedures. In 2 patients a vascular endoprosthesis was placed in the descending thoracic aorta, and 2 patients underwent open thoracoabdominal aortic aneurysm repair.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Patients who have had previous aortic root operations may require reoperation for several indications. Although a first-time operation on the aortic root is performed routinely and with very low operative risk [3, 4], an operative mortality rate of up to 18% for reoperation has been reported [5–11]. Statistical analysis of previously published reports has identified a number of risk factors that contribute to poor outcome of this high-risk procedure. New York Heart Association functional class IV, age older than 75 years, chronic obstructive pulmonary disease, preoperative and postoperative renal dysfunction, coexisting coronary artery disease, CPB time, and urgent operation have all been shown to be predictors of death [5, 7, 10, 15, 16].

Interpretation of these studies is limited, however, because of the great variability in patient selection, such as differences in initial cardiac or aortic operations and reoperations. Some studies have included patients undergoing any type of proximal aortic procedure independently from the type of the previous cardiac operation [5, 15, 16]. Other groups have reported their experience on aortic root reoperation after any type of previous cardiac operation [9, 17, 18] or only after aortic root procedures [6, 19, 20]. In the latter case, the series presented a small number of patients [19, 20]. Joudinaud and colleagues [21] reported their experience in repeated operations for aortic homograft failure in a recent article. Table 5 summarizes the previously reported mortality rate and risk factors for mortality in patients undergoing a reoperation on the aortic root.


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  		Table 5 Mortality and Risk Factors (at Multivariate Analysis) for Reoperation on Aortic Root According to Previously Published Articles
 
Our study was undertaken to evaluate outcome and perioperative risk factors in a cohort of patients undergoing reoperation on the aortic root during a 7-year interval. Our results (in-hospital mortality rate of 6.5%) are encouraging considering the high complexity grade of the procedures performed, the emergency setting in 15% of the patients, and the indication of preoperative vascular or valvular infection in 35%. Raanani and colleagues [6] showed similar results, with an in-hospital mortality rate of 3.3% in 31 patients during a 20-year period. They were not able to identify any prognostic factor for mortality or morbidity. The indication for prior and redo operation in our series did not have significant prognostic value, confirming the results of Raanani and colleagues [6].

Surprisingly, preoperative vascular or valvular infection does not have significant prognostic value on mortality or morbidity. It could be affected by the limited number of infectious patients in our series, the predominant choice for homograft or biologic composite grafts reimplantation in case of infection, and further by the strict 6-week postoperative antibiotic regimen. Since the introduction of the biologic Bentall conduit, the popularity of the homograft decreased rapidly because of limited availability and severe calcification, despite similar results [22], explaining the limited number of homografts implanted.

Each step of the reoperation should be assessed and properly prepared to decrease the incidence of severe problems. Previous reports [5, 17] showed the number of previous operations, technical problems during resternotomy, and an interval between operations of less than 8 months as significant risk factors for death at univariate analysis. A proper preoperative assessment is fundamental for achieving a safe reentry into the chest. A preoperative computed tomography (CT) scan is mandatory in every patient to delineate the relationship between the aorta, the true or false aneurysm, the heart, and the sternum. Besides a CT scan, a lateral chest roentgenogram should help to establish the presence of retrosternal space. Because of this strategy, already described and similar to that reported by other authors [10], we were prepared for high risk at reentry in those 5 patients in whom a rupture of the false aneurysm adherent to the posterior aspect of the sternum occurred.

Myocardial protection is crucial for early outcome. Kirsch and colleagues [9] reported the need for unplanned CABG as significant risk factor for death. They documented "coronary problems" in 14 patients (25%). Half of these were linked to intraoperative and postoperative coronary malperfusion, and the early mortality rate for these patients was 70%. We prefer to deliver cold cardioplegia selectively into the coronary ostia, combined with continuous pericardial topical cooling while monitoring septal temperature, as mentioned before. In this setting, other authors suggested the use of retrograde cardioplegia [23] or continuous antegrade cold blood cardioplegia delivered by a soft cannula inserted in the coronary ostia [6] to overcome the risk for insufficient cardioprotection.

Multivariate analysis found that perioperative MI was the only variable that reached statistical significance as a risk factor for early death. However, in 1 of 2 patients, perioperative MI was a result of acute prosthetic valvular thrombosis. Unfortunately, cardiac enzymes were not routinely assessed in patients during their postoperative course. In patients undergoing CABG, troponin I was found to well characterize myocardial damage after cardiac arrest and emerged as predictor of early and midterm death from cardiac causes [24, 25]. A complete and systematic evaluation of myocardial damage through cardiac enzymes sample should guide postoperative care and myocardial protection strategy.

The management of coronary flow reestablishment is still demanding, with a failure for coronary reimplantation of up to 25% to 50% [6, 9, 18]. In our experience (except in 2 patients in whom a Cabrol was performed at the prior operation), we were forced to a graft elongation to the coronary ostia in only 1 patient, even if graft infection and false aneurysm were found in 70% of patients. In only 1 patient did we perform myocardial revascularization with a venous graft on the right coronary artery for intraoperative right ventricular failure, resulting in an uncomplicated postoperative course.

For a degenerative aneurysm, axillary artery cannulation may be the site of choice. This strategy could allow a lower risk of preoperative stroke and could be associated with a lower mortality rate [26]. In our experience, however, femoral artery cannulation was performed safely.

Preparation of the aortic root in a reoperation is a demanding and precise job. In our experience, direct injury of the pulmonary artery or trunk is a rare problem that is usually immediately recognized and oversewn. One patient, however, required reoperation 8 months after the root procedure for a false aneurysm of the right pulmonary artery, which was repaired with a patch plasty.

Although redo interventions on the aortic root can be performed with a low rate of operative technical problems and encouraging early survival, the postoperative morbidity rate is high. At least one major complication occurred in 19 (41%) patients, and 6 (13%) required early reoperations for excessive bleeding or tamponade. Six (13%) needed implantation of a permanent pacemaker for complete AV block, which is in the same range as described by Kirsch (9%) [9] and by Raanani (18%) [6]. Cerebrovascular accidents occurred in 5 patients and were transient or reversible in 4. Two of the 12 patients who underwent DHCA and antegrade bilateral cerebral perfusion sustained transient cerebrovascular accidents. This was a higher rate than that reported in our previous experience [14]; however, these patients had associated further risk factors, including the aortic procedure itself, the emergency setting, and previous cerebral vascular accident. One patient who required a repeated period of DHCA because of uncontrollable bleeding from a distal prosthesis suture sustained a stroke, with partial functional recovery.

Intensive outpatient clinic follow-up is mandatory for these patients. The need for continued long-term cardiovascular surveillance is accentuated by the fact that 9 of our patients needed a reintervention 15 years after the primary one. The mean interval of 7.8 years between the two interventions illustrates that patients remain at risk for later development of complications that require new repair, even if the first repair was a radical one. This warrants annual examination by the cardiologist or cardiovascular surgeon with echocardiography, CT scan, or magnetic resonance imaging.

The survival in our study at 1 year and 5 years of 88% and 74% is similar to the 93% and 71% reported in the Toronto General Hospital experience [6]. A worse outcome was reported by Kirsch [9] of 73% at 1 year and 66% at 5 years, but this was a cumulative survival including all three cohorts of their study and presenting 25% of patients with moderate to severe left ventricular dysfunction.

Reoperation on the aortic root is still a complex procedure that necessitates an extensive preoperative workup. Early and late survival and freedom from reoperation are good, but the postoperative course is characterized by a high morbidity rate. Perioperative MI is a significant predictor for early death.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Wheat Jr MW, Wilson JR, Bartley TD. Successful replacement of the entire ascending aorta and aortic valve JAMA 1964;188:717-719.[Abstract/Free Full Text]
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  12. Dossche KM, Schepens MA, Morshuis W, Knaepen P, Brutel de la Riviere A. A 23-year experience with composite valve graft replacement of the aortic root Ann Thorac Surg 1999;67:1070-1077.[Abstract/Free Full Text]
  13. Dossche KM, Defauw JJ, Ernst SM, Craenen TW, De Jongh BM, Brutel de la Riviere A. Allograft aortic root replacement in prosthetic aortic valve endocarditis: a review of 32 patients Ann Thorac Surg 1997;63:1644-1649.[Abstract/Free Full Text]
  14. Di Eusanio M, Schepens MA, Morshuis WJ, et al. Brain protection using antegrade selective cerebral perfusion: a multicenter study Ann Thorac Surg 2003;76:1181-1188.[Abstract/Free Full Text]
  15. Estrera AL, Miller 3rd CC, Porat E, et al. Determinants of early and late outcome for reoperations of the proximal aorta Ann Thorac Surg 2004;78:837-845.[Abstract/Free Full Text]
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  17. Dossche KM, Tan ME, Schepens MAAM, Morshuis WJ, de la Rivière A. Twenty-four years experience with reoperations after ascending aortic or aortic root replacement Eur J Cardiothorac Surg 1999;16:607-612.[Abstract/Free Full Text]
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  19. Hahn C, Tam SKC, Vlahakes GJ, Hilgenberg AD, Akins CW, Buckley MJ. Repeat aortic root replacement Ann Thorac Surg 1998;66:88-91.[Abstract/Free Full Text]
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  21. Joudinaud TM, Baron F, Raffoul R, et al. Redo aortic surgery for failure of an aortic homograft is a major technical challenge Eur J Cardiothorac Surg 2008;33:989-994.[Abstract/Free Full Text]
  22. Siniawski H, Lehmkuhl H, Weng Y, et al. Stentless aortic valves as an alternative to homografts for valve replacement in active infective endocarditis complicated by ring abscess Ann Thorac Surg 2003;75:803-808.[Abstract/Free Full Text]
  23. Byrne JG, Karavas AN, Leacche M, et al. Impact of concomitant coronary artery bypass grafting on hospital survival after aortic root replacement Ann Thorac Surg 2005;79:511-516.[Abstract/Free Full Text]
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