High-Volume Practice by a Single Specialized Team Reduces Mortality and Morbidity of Elective and Urgent Aortic Root Replacement

Gopal Soppa,Marjan Jahangiri,Jean-Pierre Van Besouw,Jeremy Smelt,Nada Abdulkareem

doi:10.12945/j.aorta.2013.13.001

Abstract

Elective aortic root replacement (ARR), or the Bentall procedure, is associated with significant mortality and complications. Recent studies have shown that high procedure volume has an inverse association with postoperative mortality. The outcomes of patients undergoing elective/urgent ARR by a single, high-volume surgical team were assessed in this study. Patients undergoing nonemergency, elective/urgent ARR for non-Marfan aortic root dilatation, from October 2005 to March 2011, were studied. Valve-preserving procedures, extra-anatomic bypass, and arch and descending aortic repairs were excluded. Patient demographics, operative details, and postoperative outcomes were collected prospectively. Surgical techniques included central cannulation and cardiopulmonary bypass (CPB) at 35°C. Following aneurysm excision, a composite valve-conduit reconstruction with coronary button reimplantation was performed. Tissue glue, Teflon pledgets, and blood products were seldom used. Patients were followed locally at 8 weeks, 6 months, and annually thereafter with echocardiography and computed tomographic (CT) scanning. From October 2005 to March 2011, 163 ARRs were performed. Of these, 131 (80%) were isolated first time procedures (four in pregnant women), six were redo (4%), and in 26 (16%) ARR was combined with concomitant valve or coronary artery revascularization procedures. Median age was 63 years (range 19-84). Median cross-clamp and CPB times were 73 (range 69-87) and 86 minutes (range 85-126), respectively. There was one in-hospital death (mortality = 0.6%), one patient underwent resternotomy for bleeding, two required hemofiltration, and there were no strokes. Median hospital stay was 6 days (range 5-11). Median follow-up was 2.9 years (range 6 months-4.3 years) with 100% freedom from reoperation. There was no late distal ascending aorta/arch dilatation. There were two late deaths (1.2%) due to pneumonia and stroke. High-volume surgery, with minimal use of hemostatic adjuncts and sustained follow-up, leads to excellent outcomes, with low morbidity and mortality following ARR.

Highlights

aortic root replacement (ARR), or the Bentall procedure [1], is performed for aortic root pathology, including aneurysm, dissection, connective tissue disorders, and atherosclerosis
131 (80%) were isolated first time procedures, six were redo (4%), and in 26 (16%) ARR was combined with concomitant valve or coronary artery revascularization procedures
The aim of this study was to assess the outcomes of patients undergoing elective or urgent ARR by a single, high-volume surgical team in a tertiary cardiac surgical unit performing 30 – 40 ARR annually

Summary

Introduction

ARR, or the Bentall procedure [1], is performed for aortic root pathology, including aneurysm, dissection, connective tissue disorders, and atherosclerosis. It is well-known that hospital procedure volume has an inverse association with postoperative mortality for a number of complex cardiovascular and thoracic surgical procedures [9,10,11,12,13]. Hughes et al reported on 13,358 elective aortic root and aortic valve-ascending aortic procedures performed between 2004 and 2007, obtained from 741 North American hospitals [14]. In this largest study to date, the overall unadjusted operative mortality was 4.5%. The conclusion of this study was increased risk-adjusted mortality for elective ARR or combined aortic valve-ascending aortic surgery at hospitals that performed fewer than 30 – 40 of such procedures annually [14].

Objectives

Methods

Results

Conclusion