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Eur J Cardiothorac Surg 2006;6:S44-S49
© 2006 Elsevier Science NL

Aortic root replacement: modifications of technique with improvements in technology

Department of Cardiac Surgery, Oxford Heart Centre, Oxford, UK

Potential morbidity remains substantial in aortic root replacement. The tissues are often fragile, contributing to the risk of haemorrhage and postoperative complications. In the past surgery has been directed towards minimising haemorrhage by wraparound techniques and the right atrial fistula method of Cabrol. However, recent use of aortic homografts, collagen-impregnated grafts and tissue glues have reduced bleeding and simplified operative technique. Profound hypothermia and total circulatory arrest allows aneurysm resection to extend into the aortic arch. Between 1986 and 1991 25 aortic root replacements were carried out at the Oxford Heart Centre in 21- to 76-year-olds, 13 for aorto-annular ectasia (4 due to Marfan's syndrome), 7 for aortic dissection (2 Marfan's syndrome) and 2 for complications of previous aortic valve replacement. Three patients had homograft root replacement for aortic root endocarditis. We implanted 14 Medtronic composite grafts, 1 St Jude conduit and 7 collagen-coated Dacron grafts (Hemashield, Meadox) into which a Starr-Edwards valve was sewn, as well as 3 homografts. One patient with a massive chronic dissection following previous aortic valve replacement required an interposition graft to the coronary ostia. In the others, the coronary ostia were mobilised from the native aorta and directly implanted into the conduit. In dissections a ring of pericardium or Gore Tex was used to buttress the coronary anastomoses. Six patients also required coronary artery grafting. Native aorta was excised and not wrapped around the conduit. Coagulation defects were corrected aggressively with platelets, fresh frozen plasma and cryoprecipitate. Two deaths occurred in patients referred late after aortic dissection; one followed displacement of an endotracheal tube 2 days postoperatively, and the second occurred 3 weeks postoperatively through multi-system organ failure. Aortic root replacement with excision of pathological tissue, mobilisation of the coronary ostia for reimplantation and modern haemostatic methods produces satisfactory results and has superseded wraparound and fistula techniques. False aneurysm formation cannot complicate coronary reimplantation.

Key Words: Aorta • Aortic root • Graft • Haemorrhage

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