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Eur J Cardiothorac Surg 2001;20:77-81
© 2001 Elsevier Science NL

Valve sparing aortic root reconstruction versus composite replacement – perioperative course and early complications

Hannover Medical School, Division of Thoracic and Cardiovascular Surgery, Hannover, Germany

Received 10 November 2000; received in revised form 23 March 2001; accepted 9 April 2001.

Corresponding author. Tel.: +49-511-532-6581; fax: +49-511-532-5404
e-mail: kallenbach{at}thg.mh-hannover.de

	Abstract

Top Abstract 1. Introduction 2. Methods and patients 3. Results 4. Discussion Appendix A. Conference... References

 
Objective: In patients with aneurysm of the ascending aorta, dilatation of the sinotubular junction is the major cause of aortic valve regurgitation. Valve sparing aortic root replacement in patients without valvular structural defects offers a new form of treatment. The aim of this study was the assessment of the perioperative course and early complications of this method compared to composite replacement in a large single center cohort. Methods: From 1992 to 1999, valve sparing replacement of the ascending aorta (recon) has been performed in 78 patients, while 269 patients underwent replacement by a composite graft (comp). A comparison of matched pairs (n=52) with respect to age, gender, presence of Marfan's syndrome, aortic dissection as well as date of surgery, was chosen. Aortic insufficiency was 2.8±0.7 for recon vs. 2.2±1.1 for comp preoperatively. Course and length of hospitalization, echocardiographic follow-up, complications, and mortality were compared at 1-year follow-up. Results: There were no operative deaths. During follow-up, one patient (2%) died 5 months postoperatively (recon) vs. two patients (3.9%) in the comp group. Bypass-time (123±31 vs. 153±31 min, P<0.0001) and cross-clamp-time (82±22 vs. 120±23 min, P<0.0001) were significantly shorter in comp. Stay in ICU (1.9±1.6 for recon vs. 2.3±2.1 days for comp) and post-op hospitalization (18.3±5.7 vs. 21.2±11.1 days) were comparable. Improvement of NYHA-class was significant after both operations (recon 2.6±0.8 vs. 1.3±0.5 and for comp 2.4±0.6 vs. 1.5±0.7, both P<0.0001). One patient (1.9%) in the recon group had to be reoperated for valve failure. Thrombembolic or bleeding complications were observed in 6 patients (12%) in comp, zero in recon (P=0.027). Conclusion: Valve sparing aortic root reconstruction is feasible with low perioperative morbidity and mortality and good early results. Major advantages of recon are significant reduction of thrombembolic and anticoagulation related complications as opposed to longer cross-clamp and bypass times as well as a valve failure in one patient. Further follow-up is needed to confirm our data in a long-term perspective.

Key Words: Aorta • Valves • Aneurysm • Composite • Reconstruction

	1. Introduction

Top Abstract 1. Introduction 2. Methods and patients 3. Results 4. Discussion Appendix A. Conference... References

 
Aortic root aneurysm represent a relatively rare but potentially life-threatening cardiovascular disorder, which may develop on the basis of a diffuse, degenerative process of connective tissue involving the media of the aortic wall [1,2]. Typical underlying diseases are Marfan's syndrome and its forme fruste as well as atherosclerotic degeneration. Dilatation of the sinotubular junction and annular ectasia can cause secondary aortic valve regurgitation due to reduction of cusp coaptation, despite morphological unaffected valve cusps [3,4]. The natural history of aneurysm of the ascending aorta is characterized by either aortic complications such as acute dissection or rupture, or by congestive heart failure due to aortic valve regurgitation [5,6].

Composite graft replacement of the aortic valve and the aortic root has become the standard surgical therapy, correcting both the diseased aortic wall as well as the insufficient valve. With this technique, excellent results are achieved with low operative mortality and morbidity [7,8]. However, the lifelong need for anticoagulation led to the development of an alternative surgical strategy on the basis of valve-sparing aortic root reconstruction. Various techniques have been established to avoid the disadvantage of thrombembolic- and anticoagulant related complications of mechanical valve prostheses [9,10]. At our institution, we have used the reimplantation technique exclusively as reported by David et al. in over 150 consecutive patients with aneurysm of the ascending aorta and aortic valve regurgitation [11]. Our midterm results demonstrate a good durability of this repair in these selected patients [12]. To asses the value of this relatively new technique, we compared the perioperative course and early outcome to standard composite replacement of the aortic root using a case-matched analysis of 52 patients from both treatment groups.

	2. Methods and patients

Top Abstract 1. Introduction 2. Methods and patients 3. Results 4. Discussion Appendix A. Conference... References

 
Patients operated on with the diagnosis of an aneurysm of the ascending aorta were stratified by the surgical procedure. We identified 78 patients treated with aortic valve reconstruction using the reimplantation technique (recon), operated on during the time from June 1993 to December 1998. To compare these cases with the established composite method, we looked in our databank for a total of 269 patients that have been operated on in a comparable timeframe with composite replacement of the ascending aorta and aortic valve (comp).

Due to the heterogeneity of the cohorts, a comparison of matched pairs was chosen to compare individual cases presenting with similar preoperative conditions. For each individual patient operated in the recon group a matching patient from the comp group was identified. These patients were operated on during the time from January 1992 to June 1999. Matching criteria were: gender, age (±5 years), time point of operation (±2 years), presence of Marfan's syndrome and aortic dissection, subdivided by type (Stanford classification). Using this method, 104 patients in 52 matched pairs were identified. Demographic data of patients in the final study group are listed in Table 1. Therefore, 26 patients in the recon group could not be matched due to divergent demographic characteristics or presence of Marfan's syndrome not combined with aortic dissection, as typical for patients in the comp group. Average age was 55±13 years, the youngest 20, the oldest 77 years old. Four patients matched from both groups showed typical signs of Marfan's syndrome. From eight patients matched with an aortic dissection Type A, five were acute (AADA) and three chronic (CADA). Grade of aortic regurgitation was significantly higher in the recon group (2.8±0.7 vs. 2.2±1.1) due to 12 patients with aortic stenosis in the comp group.

2.1. Surgical technique
Standard median sternotomy and extracorporal circulation were used in all patients. Myocardial protection was performed with repetitive doses of cold blood or crystalloid cardioplegia in an antegrade and/or retrograde fashion, according to individual surgeon's preference.

2.1.1. Valve sparing aortic root reconstruction
The operative technique used for this procedure, originally published by David [11], was recently described by our group [12]. In brief, after assessing the suitability of valve reconstruction, excision of the coronary ostia and resection of aortic sinuses up to a remnant of 2–3 mm, as well as extensive external dissection and mobilization of the aortic root, followed. Prosthesis diameters were calculated from the diameter of the left ventricular outflow tract and the height of the aortic cusps. Practically, the annulus was sized with a Heger dilatator and the sinotubular junction with a valve sizer (St. Jude Medical^®, St. Paul, MN, USA). Valve coaptation was considered ideal if 30–50% of the cusp area was involved after modification of the sinotubular junction.

Proximal anastomosis was performed with 12 threads of 3-0 coated polyester fiber (Ethibond^®, Ethicon Inc., Hamburg) used as a horizontal mattress suture placed circumferentially through the annulus underneath the valve. The valve cuff was then reimplanted into the Dacron prosthesis using three 4-0 polypropylene sutures (Prolene^®, Ethicon Inc.). Utmost care was taken to achieve correct cusp geometry and sufficient height of commissural resuspension within the prosthesis. Reimplantation of coronary ostia button completed the aortic root reconstruction. In cases with more extensive ascending aortic or arch replacement, a second prosthesis was used.

2.1.2. Composite graft replacement of the aortic root
The operative technique as used at our institution has been described previously [7]. Briefly, the valved conduit is anchored in the aortic annulus using pledgetted 2-0 everting mattress sutures. Reimplantation of coronar ostia was then performed by either Bentall or button technique. In cases with more extensive ascending aortic or arch replacement, a second prosthesis was used.

2.2. Follow-up
Patients undergoing root reconstruction received either acetylsalicylic acid or coumadin for 3 months postoperatively according to surgeons preference. Anticoagulation was given to prevent thrombembolic complications until the suture lines were reendothelialized. Thereafter, anticoagulation therapy was discontinued. Patients undergoing composite replacement received anticoagulation therapy with coumadin with a target INR of 2.5–3.5.

Routine intraoperative control of aortic valve function was determined with transesophageal echocardiography for all patients undergoing the valve sparing procedure. Before hospital discharge and after 1 year postoperatively, valve function was re-evaluated using transthoracic color Doppler echocardiography. Valve morphology and systolic and diastolic function were assessed in accordance with published criteria [13,14]. Aortic regurgitation was assessed semiquantitatively as follows: 0, none; I, minimal; II, mild; III, moderate; IV, severe. Infectious, thrombembolic, and bleeding complications were recorded as required by the guidelines of the American Association for Thoracic Surgery/Society of Thoracic Surgeons [15]. Performance was assessed either directly or in a telephone-interview in regard to the classification of the New York Heart Association (NYHA).

2.3. Statistical analysis
Continuous variables are expressed as mean±SD. The statistical significance of differences in AI between preoperative and postoperative echocardiograms was tested using Wilcoxon's signed rank test for not normally distributed data. Student's t-test for independent variables was used to test normally distributed variables between the composite and the recon group. The Mann–Whitney test was applied for not normally distributed variables. Statistical comparison of anticoagulation related complications between both groups was performed by using Fisher's exact test. A value of P<0.05 was considered significant.

	3. Results

Top Abstract 1. Introduction 2. Methods and patients 3. Results 4. Discussion Appendix A. Conference... References

 
3.1. Perioperative data and complications
No patient died during the hospital stay. Intraoperative variables showed significant shorter cardiopulmonary bypass and aortic cross-clamp times for patients undergoing composite replacement compared to patients treated with the reconstruction method (122±31 vs. 153±39 min for bypass time and 82±22 vs. 120±23 min for cross-clamp time; P<0.0001). Circulatory arrest for those patients who needed additional aortic arch repair or replacement (16 patients in the David-, 13 patients in the composite-group) was comparable with no significant difference (19±7 vs. 25±14 min).

Complications requiring surgery occurred in three patients of the recon group early postoperatively. Two patients underwent reoperation due to bleeding, another had to be treated with a subxiphoid drainage due to late pericardial effusion. In the composite group, three patients required a pacemaker postoperatively, two were treated with a subxiphoid drainage due to pericardial effusion and one patient had to be reoperated for bleeding. In two further patients the sternotomy had to be refixed due to instability. One patient of the recon group suffered from a transitoric ischemic attack (TIA) at the first postoperative day without any residue. He reported about similar events preoperatively. No further neurological event was documented in either group during the perioperative period.

There was no significant difference between the two groups regarding the length of stay on ICU (1.9±1.6 days for recon vs. 2.3±2.1 days for comp) nor the overall postoperative stay in the hospital (18.3±5.7 vs. 21.2±11.1, respectively).

3.2. Follow-up data and complications
In the composite group, two patients died during follow-up of 1 year. One man died from sudden cardiac death with an infection of the composite graft 4 months postoperatively. The second patient died 7 months postoperatively due to massive pulmonary embolism during hospitalization following a car accident.

In the recon group, a 76-year-old patient died 5 months postoperatively of septic endocarditis. Although it was reported that he went twice through bacterial endocarditis, there were no residues for such event observed during reconstruction. He developed acute endocarditis with perforation of both the aortic and mitral valve, an abscess at the base of the anterior mitral leaflet and an aorto-atrial fistula, requiring mitral valve replacement and composite graft replacement due to acute MI and AI. He finally died of septic shock 3 days after the second operation.

Preoperative grade of aortic insufficiency was 2.8±0.7 for David reconstruction and 2.2±1.1 for composite replacement. In patients with aortic root reconstruction the average grade of AI was reduced significantly (pre-op 2.8±0.7 to early post-op 0.35±0.52; P<0.0001). At 1 year follow-up, average grade of AI has slightly increased (0.44±0.7, P=0.44), with one patient demonstrating aortic insufficiency grade III (Fig. 1) . This patient suffered of Wegener's disease with the need for chronic hemodialysis. Although the valvular cusps appeared undamaged at the time of the first operation, the patient consecutively developed inflammatory cusp changes leading to significant AI III. He finally received a mechanical aortic valve replacement 11 months postoperatively. Patients undergoing composite replacement were not evaluated by echo postoperatively.

View larger version (29K): [in this window] [in a new window]   Fig. 1. Grade of aortic insufficiency (AI) pre-, early postoperatively and at 1 year follow-up in patients undergoing valve sparing aortic root reconstruction. Absolute numbers of patients are given (n pts). P-values describe statistical differences between the groups (mean±SD, see text).

View larger version (25K): [in this window] [in a new window]   Fig. 2. Comparison of the performance, expressed in NYHA-classes, preoperatively (pre-OP) and at 1 year follow-up (post-OP) of patients undergoing valve sparing aortic reconstruction (recon) or composite graft replacement of the aortic valve and ascending aorta (comp). Absolute number of patients are given (n pts).

	4. Discussion

Top Abstract 1. Introduction 2. Methods and patients 3. Results 4. Discussion Appendix A. Conference... References

 
Composite graft replacement of the aortic valve and root represents the therapeutic gold standard for patients with aortic insufficiency and aortic root aneurysm [7,16,17]. However, the typical long-term risk of a prosthetic valve insertion as well as the observation that in at least half of the patients the native aortic valve cusps are undamaged led to the development of different valve sparing aortic root reconstruction techniques. Good mid- and long-term results have been reported by several groups [11,18–21]. However, a comparison of results of both techniques has not yet been performed.

For both operative techniques our results show comparable low perioperative mortality and morbidity as well as at 1 year follow-up. As expected, significant performance improvement, analyzed by NYHA classification, occurred in both groups. Significantly longer bypass- and cross-clamp times were observed in patients undergoing valve sparing aortic root reconstruction, but had no impact on mortality, performance or length of hospital stay in our series.

A proposed disadvantage of reconstruction methods is the reoccurrence of AI. We had to reoperate on one patient after valve sparing reconstruction due to AI III with an aortic valve replacement. Modification of the surgical technique with radical root mobilization, high reimplantation of the commissures within the prosthesis and exclusion of patients with systemic inflammatory diseases has prevented the need for reoperation during the last 3 years. Adequate cusp adaptation area (30–50%) and only minimal AI at intraoperative echocardiography seems to add further to the durability of the reconstruction. Early cusp degeneration as well as cusp contact, as described by Leyh et al. [22], was neither observed immediately postoperatively nor at 1 year follow-up. Overall, out of 52 patients, 45 (86.5%) had no or minimal AI at 1 year follow-up.

Anticoagulation related complications like bleeding and thrombembolism contribute to 75% of valve related complications with mechanical aortic valve prostheses [23], an annual incidence of 2 and 4% has been reported in the literature [23–25]. We observed six such events during 1 year follow-up in patients that received a mechanical valve with the composite graft. One patient suffered of a left sided cerebral accident on the day of discharge and did not recover from hemiplegia completely. Among 335 consecutive patients undergoing composite replacement at our institution, an incidence of 7% for central nervous system complications like cerebral infarctions and cerebral hemorrhage was found during a mean follow-up time of 61 months postoperatively [7]. In contrast, no thrombembolic or bleeding complications have been observed in patients operated with the valve sparing aortic root reconstruction technique during 1 year follow-up. It can be postulated that the incidence of thrombembolic or bleeding complications in this patient group may be similar to the average population. Therefore, major advantage of valve sparing aortic root reconstruction can be considered to be freedom of anticoagulation.

Thus, our results demonstrate a significant benefit for patients with valve reconstruction as early as 1 year postoperatively. Whether the potential risk of reoperation will outweigh these benefits requires further studies including true long-term observations. In our center, valve reconstruction has meanwhile advanced to be the procedure of choice in this patient group.

	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. Methods and patients 3. Results 4. Discussion Appendix A. Conference... References

 
Dr. C. Yankah (Berlin, Germany): I would like to make a comment on the postoperative aortic incompetence. I would first ask you a question. How do you close your aortomy? Do you wrap the reconstructed aortic root with the remaining native aorta as practised in homograft root replacement, such as the mini-root technique. Clinical experience has shown that if you wrap the native aortic root tightly after the excellent reconstruction of the root, you may crimp the aortic root and induce less coaptation of the leaflets, which will then cause postoperative valve incompetence. What is your opinion and comments on the pathogenesis of this aortic incompetence?

Dr. Kallenbach: Well, we routinely do an incomplete graft inclusion of the native aorta, and we have actually never seen any impact on the aortic valve. We usually do postoperatively an intraoperative echo, and we never saw any such problems. Mobilization of the aortic root as well as coronary reimplantation with the button technique does not allow homeostatic wrapping of the aortic prosthensis. Thus, development of hematoma with compression of the prostheis cannot occur.

	References

Top Abstract 1. Introduction 2. Methods and patients 3. Results 4. Discussion Appendix A. Conference... References

 

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