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Eur J Cardiothorac Surg 2001;19:601-605
© 2001 Elsevier Science NL

Mid-term follow-up of aortic root remodelling compared to Bentall operation

Department of Cardiac Surgery, Tor Vergata University, European Hospital, 700 Via Portuense, 0149 Rome, Italy

Received 8 October 2000; received in revised form 19 February 2001; accepted 1 March 2001.

Corresponding author. Tel.: +39-06-6597-5714; fax: +39-06-6597-5117
e-mail: cbassano{at}lycosmail.com

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Objectives: Aortic valve sparing with root remodelling has proven useful in cases of aortic regurgitation secondary to ascending aorta disease. An excessive rate of re-operation for recurrent aortic regurgitation after this conservative approach might compensate the prosthesis-related risk of the Bentall operation. Methods: From January 1995 to September 2000, 69 consecutive patients with aortic expansive aneurysm and concomitant aortic valve disease, were submitted to the Bentall operation (group A, n=37) in the presence of an abnormal valve, or to root remodelling (group B, n=32) in cases of secondary aortic incompetence. One patient in group A and four in group B had Marfan syndrome. The follow-up was 1021 patient-months (range, 1–68 months) in group A and 926 in group B (1–64 months). The event-free survival was calculated using the Kaplan–Meier method, and the difference between curves was evaluated using the Mantel–Cox log-rank test. Results: The operative mortality was 5% in group A and 0% in group B. One patient died at follow-up in group A and none in group B. Four patients (three Marfan) in group B were re-operated on because of recurrent aortic regurgitation. The 5-year event-free survival was 88±7% in group A and 82±8% in group B (P=0.58). Early residual aortic regurgitation remained stable over time only in patients with good early results. Conclusions: Mid-term follow-up failed to reveal statistically significant differences in the clinical outcome between remodelling and the Bentall operation. Our results support the widespread use of root remodelling, provided that an indication to this conservative approach is achieved after careful, case-by-case evaluation. A good early operative result is likely to remain stable over time.

Key Words: Aortic root remodelling • Bentall operation • Mid-term follow-up

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. Conference... References

 
The Bentall operation and its modifications were considered the gold standard in the surgical treatment of combined valve and ascending aorta pathology. Since their introduction [1,2], valve-sparing operations have become a relatively diffuse method for surgical correction of aortic root disease associated with secondary aortic regurgitation [3,4], because of the obvious advantages of preserving a healthy, native aortic valve. The durability and the long-term complication rate of these conservative techniques, as well as their applicability on patients with chronic, degenerative connective tissue disorders, such as Marfan syndrome, are still the subject of debate [4–6]. In this study, we compared the 5-year event-free survival of patients who had undergone aortic root remodelling with that of patients submitted to composite graft replacement of the aortic root in the same period.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. Conference... References

 
From January 1995 to September 2000, 69 patients were submitted to aortic root surgery for expansive aortic aneurysm and concomitant aortic valve disease at our institution. Patients with complex disease (re-Bentall, concomitant aortic arch aneurysm, major cardiac associated surgical procedures) were excluded from the study. If the aortic valve was macroscopically healthy, with the valve insufficiency being secondary to root dilatation (32 patients), a Yacoub-type remodelling of the aortic root (without annuloplasty) was performed [7].

Since our first presentation [7], several aspects of our surgical technique have been changed: (1), all of the sinus wall was cut out, this allowed a more correct resuspension of the three commissures, in order to evaluate the presence and amount of cusp prolapse; (2), the dimension was obtained by measuring the length of the free margin of the leaflets; (3), the last 15 patients (seven remodelling procedures and eight composite graft replacements) were operated on using a modified vascular graft designed by one of our surgeons. This graft has a truly expandable root, which allows easier fitting of valve remnants, provides large, spherical-shaped sinuses with a well-defined new sino-tubular junction, and allows less tension on the coronary anastomoses [8].

In cases of primary valve disease, including the presence of severe cusp prolapse or large fenestrations in the leaflets, a composite graft replacement of the valve and the aortic root was performed (37 cases). The pre-operative characteristics of the patients are described in Table 1. Continuous data are expressed as mean values±1 SD.

Pre-operative, post-operative and follow-up (every 6 months for remodelling patients and every year for Bentall patients) trans-thoracic echocardiographs were performed in all patients by the same cardiologist. We measured the grade of aortic insufficiency (grade 1, trivial or mild; grade 2, mild-to-moderate; grade 3, moderate; grade 4, severe), and the annular and root diameters, at the level of the upper part of the left ventricular outflow tract and at the largest site of the sinuses of Valsalva, respectively.

The follow-up was 100% complete and reached 1021 (range, 1–68 months) and 926 patient/months (range, 1–64 months) for Bentall and remodelling groups, respectively (total, 1947 patient/months).

The pre-operative characteristics were compared using the two-tailed t-test for unpaired data or ² analysis, as appropriate. The event-free survival was calculated using the Kaplan–Meier method and the differences between curves were evaluated with the Mantel–Cox log-rank test.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. Conference... References

 
The most common post-operative complications are reported in Table 2: there were no statistically significant differences between the two groups.

Three Marfan patients in the remodelling group required re-operation because of progressively increasing aortic regurgitation or onset of symptoms. Two of them showed early suboptimal results (residual aortic regurgitation of grade 3; Fig. 1), but early trans-thoracic echocardiography failed to reveal the exact mechanism of the technical failure. The third patient was discharged home with an aortic regurgitation of grade 2. At re-operation, prolapse of the cusps with lack of central coaptation was found in all cases: one secondary to progression of annular dilatation; one to redundant leaflet tissue, probably due to insufficient cranial displacement of the commissural attachments; and the third with prolapse limited to the left coronary and non-coronary leaflets, probably due to asymmetric tailoring of the vascular graft.

View larger version (30K): [in this window] [in a new window]   Fig. 1. More than 90% of the patients submitted to aortic root remodelling had a pre-operative aortic regurgitation of grade 3 or 4. At pre-discharge echocardiography, only two patients showed disappointing results (residual insufficiency of grade 3) and entered a close-interval, follow-up protocol: they showed increasing residual aortic regurgitation and were re-operated on. A third patient, whose aortic insufficiency increased from grade 2 to 3 had his valve replaced. All these patients had Marfan syndrome. A fourth patient developed a sudden increase of residual regurgitation from grade 2 to 4 because of the formation of a large pseudoaneurysm with commissural detachment and was re-operated on. In the other cases (28/32; 88%), the residual aortic regurgitation remained stable over time.

Echodoppler study showed a normally functioning prosthetic valve in all patients in the Bentall group. Finally, there were no instances of thromboembolism. The event-free survival was comparable in the two groups (Fig. 2).

View larger version (9K): [in this window] [in a new window]   Fig. 2. The event-free survival probability at 5 years is comparable between remodelling (thin line) and Bentall (thick line) groups.

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. Conference... References

 
In many cases, the mechanism of aortic regurgitation is secondary to a root disease. In the case of root expansive aneurysm, the dilatation of the sino-tubular junction is responsible for the loss of central coaptation of the aortic leaflets. In the case of acute aortic dissection, the valve insufficiency is due to the loss of wall support causing cusp prolapse. In such clinical settings, the valve is anatomically normal and its replacement with a prosthesis should not be considered as the best treatment, because of the well-known, prosthesis-related, long-term complications. Nonetheless, for many years, the composite graft replacement of the aortic valve and root has been the standard method to surgically correct concomitant aortic insufficiency and root aneurysm or dissection. In recent years, different types of valve-sparing operations have been proposed [1,2], with many scientific papers addressing the surgical anatomy and the physiology of the aortic root, as well as the operative results [3–7,9].

We reviewed our own series of patients submitted to aortic root remodelling and compared it with a relatively homogeneous group of patients whose native aortic valves were replaced with composite grafts. The operative results are encouraging and the mid-term, event-free survival probability is similar in both groups. Obviously, the quality of life is better in patients that do not require antithrombotic therapy and coagulation activity monitoring. If the early results are good in terms of residual aortic incompetence, the correction is expected to remain stable over time. Actually, the three patients that have been re-operated showed a non-negligible residual aortic regurgitation early after the operation, and entered a close-interval, follow-up protocol. Re-operation was soon undertaken when increasing aortic regurgitation or left ventricle diameters were noted upon echocardiographic examination, or if medical therapy failed to control symptoms. These patients were all affected by histologically demonstrated Marfan syndrome.

Several factors might be the cause of these procedural failures. Based on the observation that the aortic leaflets are often stretched and elongated in long-lasting, advanced aneurysmatic disease, we hypothesized that a small graft could cause geometrical constraint of the reconstructed aortic root [7]. This may lead to relative redundancy of the cusp tissue and predispose to prolapse. Moreover, if the commissure's resuspension is even slightly inadequate — both in the lateral and longitudinal direction — the free margins of the leaflets may not lay exactly on the same plane, resulting in a ‘relative prolapse’ due to malalignment. Whatever the cause, a technical inaccuracy invariably produces prolapse of the aortic leaflets, with residual aortic regurgitation. If the early results are not satisfying, a progressive worsening of aortic insufficiency should be expected.

Of note is the fact that all of these patients were operated on during our early experience, and a learning curve factor should also be considered, as demonstrated by the difference in the re-operation rate in our early series compared with the latest cases. Contrary to our disappointing findings, other surgical groups with a wider experience reported excellent results in patients with Marfan syndrome [4–6], indicating that the presence of this connective tissue disorder is not a contraindication to the conservative approach. Possibly, alternative surgical techniques, such as aortic valve reimplantation or remodelling with the adjunct of a direct aortic annuloplasty, can be helpful in the most complex cases. It has been proposed that that Marfan patients need more aggressive management of their root disease [10], since the involvement of the fibrous subvalvular tissue is very common (true annular ectasia). In our early series, we observed that, although simple remodelling induced significant annular diameter reduction, it usually failed to restore really normal annular dimensions [7]. Based on this observation and on published papers [5,10], we now believe that, in true annulo-ectasia, some kind of direct annular surgery (annuloplasty or valve reimplantation) would be appropriate.

There is no question about the fact that these operations require remarkable technical skills and surgical experience. Several aspects are of crucial relevance in achieving optimal results: appropriate diameter of the graft, trimming of its proximal end, evaluation of the valve leaflets, judgement of the annular ectasia. Possibly, the reimplantation of the aortic valve could be more susceptible to technical standardization [11]. Nevertheless, it has one major disadvantage: the absence of the aortic sinuses and sino-tubular junction, which are essential for the physiological function of the leaflets [12]. However, the new Dacron graft, with a modified proximal end that re-creates the sino-tubular junction and large, spherical-shaped, neo-sinuses of Valsalva, completely eliminates this drawback [8].

In conclusion, aortic root remodelling is a safe and presumably durable method for the surgical correction of aortic root aneurysm with concomitant, secondary aortic regurgitation, and it should be preferred to the classic Bentall operation whenever the aortic valve is definitely healthy.

However, an amount of residual aortic regurgitation, although often of a mild grade, is quite common and might influence the long-term clinical results. These aspects must be kept in mind when balancing the advantages and pitfalls of this type of conservative surgery. A longer follow-up will clarify these aspects and provide stronger information about the stability of the correction.

In more complex cases with advanced disease, this operation is still precious, although the indications must be carefully evaluated. A modified aortic graft might contribute to achieve better results, as well as standardization of the surgical techniques, so that different surgical options are available for the most difficult cases.

	Footnotes

 
Presented at the 14th Annual Meeting of the European Association for Cardio-thoracic Surgery, Frankfurt, Germany, October 7–11, 2000.

	Appendix A. Conference discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Dr U. Von Oppell (Cape Town, South Africa): In terms of the Yacoub remodelling technique that you used, how many of your patients had remodelling of all three sinuses, as opposed to only one or two sinuses?

Dr Bassano: Of the 32 patients, 30 were submitted to complete replacement of the three sinuses and two underwent a partial remodelling, one of the right coronary sinus and one of the non-coronary sinus.

Dr H.C. Alhan (Istanbul, Turkey): Do you have any experience with bicuspid aortic valves?

Dr Bassano: Not yet. In this series, there were no bicuspid valves.

Dr W. Harringer (Hannover, Germany): From our experience with somewhat 30 Marfan patients, I think we should strongly recommend some kind of annular stabilization in these patients. Annular ectasia might pose a problem when performing simply a Yacoub type of operation. Now, do you agree with this conclusion? Would you, ongoing with your surgery, include annular stabilization in these patients, for example, switching to a David-type repair or adding some kind of annular ring or felt to stabilize the procedure?

And question number two: one of the advantages of root remodelling or valve preservation, especially in mid- and long-term results, is the lack of bleeding complications in these patients.

Dr Bassano: Excuse me, the lack of?

Dr Harringer: Bleeding complications due to anticoagulation; at least, that is what we had observed in our series. Could you comment on that? Did you observe it, was it of a clear significance in these patients, and do you have any experience with stress type protocols to see how the valve gradients behave in the long-term?

Dr Bassano: For the first question, I personally agree with you that perhaps in Marfan patients, especially in those patients in whom the disease is already advanced at the time of operation, some kind of annular stabilization could be a proper technique. Unfortunately, all of our four patients were operated on early in our series, and we didn't operate on Marfan patients since 1997. So we don't have much experience about that. Now, we are approaching the David reimplantation technique for this kind of patient, using a new prosthetic graft designed by one of our surgeons, and we think that, in the near future, we will do either a modified Yacoub-type remodelling or a David reimplantation more often.

Your other question was about bleeding. We didn't have any late in the series, but of course, the remodelling patients did not make any kind of anticoagulant therapy. They did not suffer from thromboembolic events or hemorrhagic complications. There were some cases of peri-operative bleeding, but nothing catastrophic. On the other hand, one patient submitted to Bentall died of cerebral haemorrhage consequent to anticoagulant therapy.

Dr Harringer: And exercise protocols, any stress testing on these patients?

Dr Bassano: There is a study on late left ventricle performance studied with echo stress tests, which is actually ongoing, and I hope the data will be available in the near future.

Dr M. Sarsam (Belfast, UK): I just want to comment actually on the difference between Marfan and non-Marfan. We have been doing this operation for about 8 years now, and approximately 80% of our patients are Marfan's, and we really have no difference between the Marfan and the non-Marfan group. I don't believe you need to do any annular things, because the determining factor is the sino-tubular junction, which is really the size of the graft, and that cannot dilate afterwards. So, you must be doing something unusual in the Marfan group if you are getting those results.

Dr Bassano: I told you in the presentation that perhaps the slide would be a little bit misleading. I think, based not too much on our experience but on medical literature, that the true problem is not the presence of Marfan syndrome ‘per se’. The problem is if there is annular ectasia or not, and this is usually at least partially independent from Marfan syndrome. Marfan patients have quite advanced disease already in the early stage and they often present with annular dilatation. Indeed, the presence of an advanced-stage disease might predispose to remodelling failure.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. Conference... References

 

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6. Birks E.J., Webb C., Child A., Radley-Smith R., Yacoub M.H. Early and long-term results of a valve-sparing operation for Marfan syndrome. Circulation 1999;100(Suppl II):29-35.
7. Bassano C., De Paulis R., Penta de Peppo A., Tondo A., Fratticci L., De Matteis G.M., Ricci A., Sommariva L., Chiariello L. ‘Residual aortic regurgitation after aortic root remodeling without a direct anuloplasty’. Ann Thorac Surg 1998;66:1269-1272.[Abstract/Free Full Text]
8. De Paulis R., De Matteis G.M., Nardi P., Scaffa R., Colella D.F., Chiariello L. A new aortic Dacron conduit for surgical treatment of aortic root pathology. Ital Heart J 2000;1:457-463.[Medline]
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10. Schäfers H.J., Fries R., Langer F., Nikoloudakis N., Graeter T., Grundmann U. Valve-preserving replacement of the ascending aorta: remodeling versus reimplantation. J Thorac Cardiovasc Surg 1998;116:990-996.[Abstract/Free Full Text]
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