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Eur J Cardiothorac Surg 2002;21:15-21
© 2002 Elsevier Science NL

Early and long-term outcome in patients undergoing aortic root replacement with composite graft according to the Bentall's technique

Edvin Priftia,b, Massimo Bonacchia*, Giacomo Fratib, Piero Proiettic, Gabriele Giuntia,d, Gerard Babatasie, Massimo Massettie, Guido Sania

a Divisione di Cardiochirurgia, Policlinico Careggi, Firenze, Italy
b I.R.C.C.S NEUROMED, Via Atinense, N.18, 86077 (Pozzilli ), Italy
c Istituto di Chirurgia del Cuore e dei Grossi Vasi, Università ‘La Sapienza’, Rome, Italy
d Divisione di Cardiochirurgia, Ospedale Maggiore della Carita, Novara, Italy
e Department of Thoracic and Cardiovascular Surgery, CHU, Caen, France

Received 26 June 2001; received in revised form 6 October 2001; accepted 6 October 2001.

* Corresponding author. Fax: +39-0573-985427
e-mail: edvinprifti{at}hotmail.com


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: The aims of this study were: (i) to evaluate the early and long-term outcome in patients undergoing aortic root replacement (ARR) with a composite graft; (ii) to identify the predictors for poor overall survival in this pool of patients. Material and methods: Between January 1989 and December 2000, 212 patients underwent ARR with a CG. Mean age was 56±14 years, ranging from 16 to 77. Annuloaortic ectasia was the most frequent cause of aortic disease in this series, 81 (38%) patients, followed by atherosclerotic aneurysm 57 (27%) and type A acute aortic dissection 52 (24.5%). Marfan's syndrome was present in 37 (17.5%) patients. Duration of follow-up ranged from 1 to 120 months, mean 59±35 months. Results: The overall hospital mortality was 16 (7.5%) patients. Eight of them had aortic dissection and four Marfan syndrome. The most frequently found complication resulted to be renal failure in 22 (10%) patients and low cardiac output in 15 (7%) patients. The incidence of perioperative myocardial infarction, neurological complications, respiratory complications, renal failure and coagulopathy incidence were significantly higher in patients with cardiopulmonary bypass (CPB) time >170 min, CA >40 min, and total aortic arch replacement. The actuarial survival at 1, 3 and 5 years resulted to be 91.8, 86 and 81.5%, instead the actuarial survival without re-operation resulted to be 89, 82 and 78%. The actuarial survival in patients with aortic dissection was significantly lower versus non-dissection (P=0.022). The multivariate analysis revealed the aortic dissection (P=0.03), age >65 years (P=0.014), associated coronary artery disease (P=0.002), NYHA functional class>=3 (P=0.027), LVEF <35% (P=0.002) and total arch reconstruction (P=0.003) as strong predictors for poor overall survival in patients undergoing ARR. Conclusions: The ARR with a CG offers acceptable early and long-term outcome. The predictors for poor overall survival in patients undergoing ARR seems to be preoperative aortic dissection extended into the aortic arch, older age, depressed left ventricular function and associated coronary artery disease.

Key Words: Aortic root replacement • Composite graft • Predictors • Long-term results


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
The surgical reconstruction of the aortic root with a conduit valve/composite graft (CG) was firstly described by Bentall and DeBono [1] in 1968 and subsequently modified procedures were reported by Cabrol et al. [2] and Kouchoukos et al. [3]. In the last decade, different new conservative surgical procedures of the aortic root have been successfully employed in patients with normal aortic valve [4,5]. Previous conservative methods of aortic root repair, such as aneurysm banding, plication, and supracoronary aortic replacement, were characterized by partial removal of diseased aortic tissue. The conservative surgery remains the best alternative procedure since the native aortic valve is not removed, however, it should not be employed in cases when the disease involves the aortic valve, annulus and sinuses of Valsalva. Various studies have shown that the Bentall's technique is safe and lasting procedure [6–15], however, the predictors for early and late death are not well defined. The aims of this study are: (i) to evaluate the early and long-term outcome in patients undergoing aortic root replacement (ARR) with a CG according to the Bentall's technique; (ii) to identify the predictors for poor overall survival in this pool of patients.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
Between January 1989 and December 2000, 212 patients underwent ARR with a CG according to the Bentall's technique. Patients were identified from a computerized (when available) patients’ registry and operative logbooks. All patients undergoing Cabrol's procedure and ARR with homografts were not included in the study. Data were collected retrospectively from operative records and hospital charts.

2.1. Patients characteristics
The mean age was 56±14 years (range 16–77 years). Annuloaortic ectasia was the most frequent cause of aortic disease in this series, 81 (38%) patients, followed by atherosclerotic aneurysm 57 (27%) and type A acute aortic dissection 52 (24.5%). Marfan's syndrome was present in 37 (17.5%) patients and seven of them presented aortic dissection preoperatively. We employed the De Paepe [16] classification as inclusion criterias into the Marfans group. All patients presented moderate to severe aortic valve regurgitation. The preoperative data are given in Table 1.


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  		Table 1. Preoperative characteristics

 
2.2. Anaesthesia and CPB
Anaesthesia consisted in propofol (3 mg/kg/h) combined with remifentanyl (0.5 to 1 g/kg/min). Femoral arterial cannulation was performed in patients with aortic dissection, ascending aorta aneurysm extending to aortic arch, and emergency status. In patients with severe atherosclerotic disease of the abdominal aorta or femoral arteries, the axillary cannulation was employed as previously described [17]. In other patients the CPB was instituted using ascending aortic cannulation and a two-stage venous cannulation in the right atrium. Intermittent antegrade and retrograde cold blood cardioplegia and moderate hypothermia were applied in all patients.

2.3. Surgical technique
Two hundred and seven patients underwent longitudinal median sternotomy. Five patients underwent superior ministernotomy approach as previously reported [18]. After clamping the ascending aorta, a longitudinal aortotomy was made and extended into the non-coronary sinus of Valsalva, away from the right coronary ostium. The CG (valve conduit) was sewn to the aortic annulus with a series of pledgeted matters sutures with 2-0 Ticron. We employed the classic Bentall's technique (side-to-side anastomosis, without excision of the coronaries from the aortic wall) in 87 patients (49 patients underwent ‘inclusion’ technique). The ‘Button technique’ for coronary reimplantation, consisting in end-to-side anastomosis of the coronary arteries to the CG was employed in 125 patients. The decision to undergo each of these two surgical alternatives for coronary reimplantation was mainly based on surgeons’ preference, however, when the coronary ostium was found to be low in the aorta, we preferred the ‘Button technique’. Suturing of the left coronary artery was carried out first, using a running 5/0 Prolene suture. The anastomosis of the right coronary ostium to the CG was carried out in a similar fashion.

Then, the distal ascending aorta was transected and anastomosed to the CG with continuous 3/0-4/0 Prolene suture and in some cases reinforced by a strip of teflon felt placed outside of the aorta. When deep hypothermic circulatory arrest was needed, we applied a retrograde selective cerebral perfusion, via the superior vena cava, or antegrade, via the brachiocephalic trunk and left carotid artery, for brain protection. Forty-one patients necessitating proximal aortic arch reconstruction or total aortic arch replacement underwent deep hypothermic arrest. The anterograde selective cerebral perfusion was employed in 24 patients, instead in 17 other patients was employed the retrograde selective cerebral perfusion. All 11 patients undergoing proximal aortic arch reconstruction underwent retrograde cerebral perfusion. Open technique was performed for distal anastomoses under hypothermia at 16–18°C. In patients undergoing ARR, a long tongue of the CG was cut to allow tangential replacement of the aortic arch along its lesser curvature.

Twelve patients presenting mitral valve regurgitation grade III–IV underwent concomitant mitral valve surgery, prior initiating the aortic root replacement. Five patients underwent mitral valve replacement and seven mitral valve reconstruction procedures. Forty-one patients with coronary artery disease (CAD) underwent concomitant coronary revascularization. The distal anastomoses of the vein grafts to the coronary arteries were performed prior initiating the ARR and at the end of the procedure were implanted to the aortic graft. The left internal mammary arteries were anastomosed after completion of the aortic root replacement procedure. Three patients with preoperative aortic dissection presented dissection extension to the coronary ostiums, requiring coronary artery bypass grafting. All the intraoperative data are given in Table 2.


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  		Table 2. Operative and early postoperative data

 
2.4. Postoperative data
Perioperative myocardial infarction, low cardiac output incidence, intensive care unit stay, complications and early death were determined (Table 2).

2.5. Follow-up
Survival status was determined by contacting all patients or next by telephone. Clinic follow-up data were obtained by means of direct contact with the patients, parents, their referring cardiologist and family physicians. Duration of follow-up ranged from 1 to 120 months, mean 59±35 months. The first control visit was performed within 1 year after surgery. All contacted survivors underwent exercise tolerance test, transthoracic or transesophageal colour flow doppler ecocardiography and/or computed tomography within 1 year after surgery.

2.6. Statistical analysis
Group statistics were expressed as mean±1 SD. The generalized Wilcoxon test was performed for the statistical analysis between groups. Fisher's exact test was used for the non-continuous variables. The relationship between preoperative and postoperative variables within the same group was assessed by the McNemar test. The univariate analysis was performed to identify risk factors for early and overall mortality. The multivariate logistic regression model was employed for the early mortality analysis. The multivariate Cox regression (including stepwise) (BMDP2L software) analysis was performed to determine independent variables associated with overall death at follow-up. Long-term survival rates were calculated using the Kaplan–Meier method and statistical significance was calculated by the log rank test. Significance between data was considered achieved when P<0.05.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
The overall hospital mortality was 16 (7.5%) patients. Preoperatively eight of them have had aortic dissection. The hospital mortality for patients with Marfan's syndrome was 4/37 (11%) (three of deaths presented aortic dissection preoperatively). The in hospital mortality in the subgroup of 139 patients undergoing elective surgery resulted to be five (3.6%) patients.

The postoperative morbidity is listed in Table 2. The most frequently found complication resulted to be renal failure in 22 (10%) patients. Twelve patients (5.7%) experienced postoperative neurological complication (temporary neurological impairment was found in seven of them and stroke in four other patients). The total postoperative morbidity resulted to be 37 (17.5%).

Two patients underwent reoperation within the first two postoperative weeks, due to false aneurysm at the coronary artery re-implantation sites. In both cases dehiscence of the anastomoses between the coronary ostiums and aortic graft was found. Both patients underwent Cabrol procedure. One of them died due to progressive heart failure.

The univariate analysis between survived patients and deaths revealed the age >65 years, aortic dissection, aortic rupture into pleura or pericardium, NYHA functional class, LVEF <35%, emergency/urgency status, re-operation and associated CAD as strong predictors of in-hospital mortality (Table 3). The incidence of perioperative myocardial infarction, neurological complications, respiratory complications, renal failure and coagulopathy incidence were significantly higher in patients with CPB time >170 min, CA >40 min, and total aortic arch replacement (Table 4).


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  		Table 3. Predictors for poor early postoperative survivala

 

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  		Table 4. Correlation between intraoperative variables and early postoperative morbiditya

 
Within the first year after surgery, all survivors were contacted. The mean NYHA class resulted to be 1.6±0.7, significantly lower than preoperatively (P<0.001). The exercise tolerance test was performed in 168 from 196 survivors at discharge, within 1 year after surgery. 154 (78.6%) patients were free from ischemic signs and symptoms and 14 (7%) patients interrupted the stress test due to chest pain with ST-segment elevation or depression >2 mm. Ten of them underwent coronary artery bypass grafting. The postoperative echo colour Doppler echocardiography or computed tomography did not reveal left-to-right shunt at the right atrial level and no pseudoaneurysm at the suture lines in 168 survivors within 1 year after surgery.

Four patients in 196 postoperative survivors were lost during follow-up. A complete follow-up was performed in 192 survivors. The actuarial survival at 1, 3 and 5 years resulted to be 91.8, 86 and 81.5%, instead the actuarial survival without re-operation resulted to be 89, 82 and 78% (Fig. 1). There were eight identified cardiac related death. Four (2%) late deaths were related to anticoagulant therapy. The statistical analysis demonstrated a significantly lower actuarial survival in patients with aortic dissection versus patients undergoing ARR not due to aortic dissection (P=0.022) (Fig. 2). Three patients with aortic dissection underwent coronary revascularization and two of them died postoperatively. Two other patients (dissection subgroup) experienced repetitive dissection and one of them died postoperatively. Another patient undergoing surgery for aortic dissection, presented an enormous aortic aneurysm at the anastomotic site at 3.5 years after the first surgical procedure. He died after reoperation.



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  		Fig. 1. Actuarial survival for all patients undergoing aortic root replacement with a valve conduit at mean 59±35 months follow-up. AS, actuarial survival; AS-R, actuarial survival without reoperation.

 


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  		Fig. 2. Actuarial survival between patients with aortic dissection and patients without dissection undergoing aortic root replacement with a valve conduit.

 
The actuarial survival in patients with Marfan syndrome resulted to be higher than the other but not statistically significant (Fig. 3). At follow-up, two other patients underwent re-operation due to late false aneurysm at the coronary artery re-implantation sites. One of them presented prosthetic endocartitis. Both of them underwent Cabrol technique and only one survived the surgical procedure. The incidence of postoperative endocarditis resulted to be five (2.6%) patients in 192 followed patients.



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  		Fig. 3. Actuarial survival between Marfan and non-Marfan patients.

 
The multivariate analysis revealed the aortic dissection, age >65 years, associated CAD, NYHA functional class >=3, LVEF <35% and total arch reconstruction as strong predictors for poor overall survival in patients undergoing ARR (Table 5).


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  		Table 5. Predictors for poor overall survival according to the multivariate analysisa

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
The introduction of ARR with a CG according to the classic and modified Bentall's techniques improved significantly the postoperative outcome, providing satisfactory early and long-term results, especially in patients with aortic dissection [19,20]. When the aortic valve and annulus are normal, the conservative techniques of the aortic valve suggested by David et al. [4] and Yacoub et al. [5] are indicated. We have employed successfully both techniques in 16 patients presenting almost a normal aortic valve. Seven of them had with Marfan syndrome. However, the mid-term outcome in patients with aortic disease including the aortic annulus, undergoing aortic root surgery with Valsalva sinuses preservation, were unsatisfactory due to recurrent aneurysmal formation of the proximal aorta side, needing re-operations. The alternative may be the ARR using an aortic homograft or pulmonary autograft with acceptable long-term results [21], but unfortunately such materials are not available in any cardiac surgical center. In such cases, the ARR with a valve conduit (CG) should be taken into consideration. However, such an alternative includes the replacement of the aortic valve with a valve prosthesis, associated with a series of possible postoperative complications such as thrombosis, endocarditis and haemorrhage.

Complete ARR with a CG has a number of advantages: first, all diseased aortic tissue is eliminated from the aortic root; and second, the operation is conceptually simple, well codified and easily reproducible technique. The main complication of such a technique may be a false aneurysm at the coronary artery re-implantation sites, due to coronary detachment from the CG, or obstruction and thrombosis when the Cabrol technique is employed [22]. In our series of patients we found two early false aneurysm due to suture's dehiscence and two other cases during follow-up. All of them underwent re-operation according to the Cabrol technique. The coronary ostium detachment from the CG is mainly due to tension between the graft and the coronary artery, probably related to less mobilization of the coronary artery. Other authors reported some modifications of the Bentall's technique by creating a fistula from the perigraft space to the right atrium, which would reduce the bleeding and late false aneurysm incidence [6]. However, we do believe that a ‘generous’ mobilization of the coronary arteries would be enough to reduce significantly the risk for coronary detachment from the coronary ostiums. Initially we believed that in cases undergoing ARR according to the Bentall's technique (side-to-side anastomosis), wrapping the aneurysmal sack around the prosthesis (inclusion technique) may reduce further the tension between the graft and coronary artery and also may prevent the catastrophic consequences secondary to coronary detachment. However, the outcome did not justify such a hypothesis (four from 49 patients undergoing inclusion technique presented early or late false aneurysm formation).

Overall hospital mortality was 7.5%, similar to the reported series of patients undergoing this surgical procedure [3,7,13,14,23]. Hospital mortality rate for patients undergoing operation in elective status was 3.6%; these results are gratifying given the high mortality and morbidity attending untreated ascending aortic aneurysm, dissection and root infection.

The early postoperative morbidity resulted to be high in this series of patients, due to a high presence of associated CAD and patients with depressed left ventricular function demonstrated by a low preoperative LVEF. We observed that the postoperative morbidity was strongly correlated with a long CPB time, long circulatory arrest and extended surgical procedure to the aortic arch. The strong correlation between the postoperative renal failure incidence and prolonged circulatory arrest time and total aortic arch replacement is probably related with longer CPB time that these procedures require.

In the reported series of patients, age >65 years, presence of aortic dissection, aneurysm rupture into pleura or pericardium, emergency status, previous cardiac intervention, associated CAD, poor preoperative NYHA functional class and LVEF <35% were strong predictors of early death. The multivariate analysis revealed the presence of preoperative aortic dissection, age >65 years, concomitant CAD, total aortic arch replacement, poor preoperative NYHA functional class and LVEF <35% as strong predictors for overall survival. Such predictors seems to be similar to the findings of Gott et al. [24], although with some differences. In reported study strong predictors for poor early and late survival resulted to be poor NYHA functional class, non-Marfan status, preoperative dissection and male gender [24]. In another study the emergency status and aortic arch replacement were identified as strong predictors for hospital death [23].

At 1 year follow-up, all survivors demonstrated a significant improvement of NYHA functional class. Other authors demonstrated that most of the patients after the ARR with a CG are in NYHA functional class I or II [3,13] similar to our findings. The echo colour Doppler and computed tomography revealed optimal results of the employed surgical procedures in all patients. However, 14 patients, age >55 years, presented a positive stress test due to myocardial ischemia. All of them did not undergo preoperative coronary angiography. With growing population undergoing cardiac surgery, the CAD is the most frequently found associated pathology in patients with aortic diseases. We do believe, that all patients >50 years old, undergoing elective ARR, or when the conditions can permit it, should undergo preoperative coronary angiography examination. This strategy will decrease significantly the perioperative mortality due to myocardial infarction and low cardiac output in this group of patients. All seven patients in our series, experiencing perioperative myocardial infarction, did not undergo preoperative coronary angiography. A postoperative study in four of them (who survived) demonstrated significant coronary lesions.

The high early and late mortality rate in patients with preoperative aortic dissection is closely related to the age, complex type of aortic disease leading to complex surgical procedure, poor perioperative hemodynamic, emergency status, presence of acute myocardial infarction due to dissected coronary sinuses, and repetitive aortic dissection. This was demonstrated in our study by a significantly lower actuarial survival in patients with preoperative dissection versus patients with non-aortic dissection undergoing ARR with CG.

Patients with Marfan's syndrome were evaluated as a subgroup in this series; overall hospital mortality rate was 11% similar to other reported study (2.7% for elective repair) similarly to the previous reports [25]. None of the survived patients with Marfan's syndrome needed re-operation; this data was in contrast with other surgical experiences [25], and can be due to younger age of the Marfan population (mean age 26±9.5 years), and a lower incidence of aortic dissection. Although the actuarial survival in this subgroup of patients was similar to the non-Marfan population.

The overall survival at mean 5 years follow-up resulted to 81.5%. The late morbidity and mortality is closely related to thromboembolism or haemorrhage risk; The total rate of thromboembolic events in our series was 2%; with regard to this, Gott et al. [24] reported an incidence of 0.42 events per 100 patient years; they attributed this lower incidence to the absence of pledgets and suture material in the bloodstream, and to a smaller amount of exposed sewing ring. Despite the employment of Ticron sutures with pledgets in our series, the incidence of thromboembolic events remained low.

In different reported series [3,24], prosthetic endocarditis is the most common late complication of CG replacement and occurs in 4–5% of patients followed for a period of 14–17 years; our results showed that, this complication occurred only in 2.6% of the followed patients, significantly lower than the previous reported results.

We may conclude that the ARR with a CG is an alternative technique to the aortic replacement with biological materials, offering acceptable early and long-term outcome. The long-term outcomes demonstrate a low valve prosthesis related morbidity. The predictors for poor overall survival in patients undergoing ARR seems to be preoperative aortic dissection extended into the aortic arch, older age, depressed left ventricular function and associated CAD.


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

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Right arrow Great vessels
Right arrow Valve disease

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