Composite graft with coronary button reimplantation: Procedure of choice for aortic root replacement

Abstract

Reconstitution of coronary flow in aortic root replacement has generally been accomplished by (1) the Bentall (inclusion) technique, (2) the Cabrol (graft) technique, or (3) the direct reimplantation of coronary artery buttons (button technique). The inclusion and graft techniques have at times required supplementation by a Cabrol fistula from the peri-graft space to the right atrium for control of bleeding. Our experience over an 8-year period comprises 33 composite graft replacements of the aortic root (24 male, 9 female, ages 16–79). Twenty-seven patients had aneurysm (annuloaortic ectasia), 5 had acute dissection, and 1 had advanced endocarditis. The Bentall technique was used in 7 patients, the graft technique in 7, and the button technique in 19. Five were reoperations and in an additional 5 patients, therapeutic coronary bypass or valve replacement needed to be performed. Hospital mortality was 4/33 (12.1%). Actuarial overall survival 1 year after the operation was 84.8%. Complications related to aortic root replacement occurred only in patients not operated with the button technique and included persistence of the Cabrol fistula requiring reexploration in a patient done by the graft technique, saphenous vein graft stenosis in a patient done by the graft technique, and postoperative bleeding in 3 patients done with the Bentall (2 patients) and the graft (1 patient) technique. In late follow-up, survival free of complications related to the aortic replacement was 94.7% in patients done with the button technique and 57.1% in patients done with the other techniques (p <0.02). This early and late technical experience suggests that the button technique is effective and obviates problems inherent in other procedures (bleeding in Bentall, stenosis in the graft technique, and persistent aortic-to-right atrial fistula with the Cabrol shunt). As no foreign material or saphenous graft is required in the direct button anastomosis, it is expected that the good early results will be durable in the long term. We have adopted the button technique as the procedure of choice for coronary reconstitution in composite graft replacement of the aortic root.