Composite Graft Replacement Research Articles

Aortic arch anerusym: New modification of aortic arch reconstruction and selective cerebral perfusion

Selective cerebral perfusion (SCP) has been widely used as the method for cerebral protection during aortic arch repair in the treatment of aortic arch aneurysms in our institution. Recently, we modified our technique of aortic arch reconstruction and SCP in order to reduce the neurological complication. Following institution of SCP into both innominate and left common carotid arteries at 22 degrees C, the distal graft anastomosis and left subclavian reconstruction were performed while the descending aorta was left opened. Then the antegrade perfusion with rewarming was started via the fourth limbs attached to the main graft instead of the femoral artery. The aortic arch was completely replaced with the graft with three limbs for arch vessels. During one-year period from December 1993 to November 1994, 30 patients were operated on for aortic arch aneurysms using this technique. The etiology of aneurysms was true aneurysms in 16 patients, and aortic dissection in 14 including 8 cases of acute dissection. The concomitant procedures included descending graft replacement in 11 patients, composite graft replacement in 5, CABG in 3, and AVR in 1. The hospital mortality was 3.3% (1 of the 30 patients). There was no neurological complication. We conclude that the present techniques are useful methods for preventing the neurological complication in the treatment of aortic arch aneurysms.

Mechanical left ventricular support in patients with Marfan's syndrome: a report of two cases.

Left ventricular assist device (LVAD) was utilized for the treatment of postcardiotomy heart failure in two patients with Marfan's syndrome. Patient 1 (a 22-year-old) with annuloaortic ectasia (AAE) and DeBakey type II dissection had been supported by LVAD for 87h after composite graft replacement of the ascending aorta and aortic valve. Patient 2 (a 52-year-old) with AAE and DeBakey type I dissection had been supported by LVAD for 91 h after aortic valve replacement. During the assist, both patients complicated bleeding from the fragile left atria near the sites of cannulation. Patient 1 died of multiple organ failure on the 62nd postoperative day, but patient 2 returned to work after surgery.

Composite graft (Medtronic-Hall) replacement of the ascending aorta and aortic valve in aortic aneurysms: what is adequate follow-up?

Between 1987 and 1994, 39 patients underwent 41 replacements (2 reoperations) of the aortic valve and ascending aorta by composite grafts with mechanical valves. One patient had annuloaortic ectasia, one had a sinus of valsalva aneurysm, 13 patients had a Debakey type I acute dissection, 10 had a Debakey type II acute dissection including two Marfan patients, and 14 had atherosclerotic aneurysms. 6 patients (15%) died within a postoperative period of 30 days. The mean follow-up time was 40 months (1-82 months). Twenty-six patients were restudied by clinical examinations and computed tomography of the chest (CT). Two patients required emergency reoperation due to disruption of the proximal aortic anastomosis and right coronary anastomosis. Both patients had been diagnosed to have Marfan disease. Anastomotic dehiscence of composite grafts has a potentially high risk of lethal complications. In follow-up examination computed tomography was performed as a simple and accurate method to detect complications such as pseudoaneurysms, but up to now did not give the indications for reoperation. We suggest that complications may occur not only in the early postoperative period so that regular CT-scan control studies (every 6 to 12 months) should be performed in all patients who undergo composite graft replacement.

Marfan syndrome: The variability and outcome of operative management

This study reviews the contemporary surgical outcome of 69 patients with Marfan syndrome who underwent one or more aortic operations between July 18, 1989, and April 14, 1994. During this 5-year period, 79 operations were performed including composite valve graft replacement (n = 28) and graft replacement of the thoracoabdominal aorta (n = 29). Fifty-seven additional operations had been performed before referral, for a total of 136 aortic operations in this group. Forty-two patients (60.9%) required multiple operations; 16 patients (23.2%) underwent three or more procedures. Follow-up was complete on all patients. The 30-day and long-term survival rates were 98.7% and 96.2%, respectively. Distal aortic replacement resulted in paraparesis in only one (2.6%) of 38 patients; no patient had development of paraplegia. No patient had a stroke after the use of profound hypothermic circulatory arrest. Aortic surgery prolongs survival in patients with Marfan syndrome and currently has low associated morbidity and mortality rates. Treatment often requires multiple staged operations. The variety and multiplicity of aortic manifestations in these patients demonstrate the necessity for lifelong cardiovascular surveillance to detect new or recurrent disease.

Composite valve graft replacement of the ascending aorta and the aortic valve by a modified button technique: the influence of aortic pathology on early mortality and late survival.

The risk factors for in-hospital mortality and mid-term survival in patients undergoing composite graft replacement of the aortic root with reimplant or coronary arteries by a modified button technique were evaluated with special emphasis on the underlying aortic pathology. Between 1985 and 1993 74 patients underwent replacement of the ascending aorta and the aortic valve following a modified button technique. The patients were divided into three groups according to aortic pathology: annuloaortic ectasia (43.58%), type A dissection (18.24%), and miscellaneous (13.18%). In-hospital mortality rates were 4.7%, 33.3% and 23.1%, respectively (P = 0.011). Univariate analysis showed that aortic pathology, NYHA class, emergency operation, redo operation, acute aortic dissection, preoperative cardiogenic shock, preoperative cardiac tamponade, longer cardiopulmonary bypass (CPB) and aortic cross-clamp times, and the need of femoral vein or femoral artery cannulation at intervention had univariate influence on in-hospital mortality. Multivariable stepwise logistic regression analysis identified CPB time odds ratio (OR) = 1.021/min, P = 0.007), the need of femoral vein cannulation at intervention (OR= 4.85, P = 0.008) and preoperative cardiac tamponade (OR = 3.11, P = 0.07) as independent predictors of in-hospital death. Follow-up ranged from 1 to 98 months (mean 39 +/- 30 months) with an actuarial survival rate of 75 +/- 9%, 52 +/- 13% and 67 +/- 14% at 5 years in annuloaortic ectasia, type A dissection, and miscellaneous patients, respectively (P = 0.18); when survival was evaluated in hospital survivors only, Kaplan-Meier survival rates were 77 +/- 9%, 79 +/- 14% and 89 +/- 10% at 5 years (P = 0.87). Comparing survival of annuloaortic ectasia patients (5-year survival 75 +/- 9%) versus survival of all other patients pooled together (5-year survival 55 +/- 11%), there was a statistically significant difference (P < 0.05); such a difference was no longer significant when comparing hospital survivors alone (5-year survival rate 77 +/- 9% annuloaortic ectasia patients vs 79 +/- 12% all other patients P = 0.61). Although aortic root replacement carries higher in-hospital mortality in some high-risk subgroups of patients, mid-term survival seems to be less affected by aortic pathology; high-risk patients are expected to have an out-hospital outcome comparable to the low-risk ones.

Surgical treatment of aortic arch aneurysms using selective cerebral perfusion. Experience with 100 patients.

Hundred consecutive patients were operated on for aortic arch aneurysms between January 1986 and October 1993. All operations were performed with the aid of extracorporeal circulation, blood cardioplegia for myocardial protection, and selective cerebral perfusion (SCP) for protection of cerebral ischemia during aortic arch repair. Forty-four patients (44%) had an emergency operation because of frank or impending rupture of aneurysms or acute aortic dissection. Eighty-three patients (83%) underwent total arch replacement, and 54 had concomitant procedures including aortic valve resuspension, aortic valve replacement (AVR), composite graft replacement and coronary artery bypass grafting (CABG). The overall early (30-day) mortality rate was 16%. Multivariate analysis revealed, as significant risk factors, preoperative cardiopulmonary resuscitation, renal-mesenteric ischemia due to acute dissection, previous ascending aorta/arch operation and preoperative stroke. Of the 71 (71%) patients who were free of these risk factors, only one (1.4%) died. One patient (1%), who was preoperatively in shock state, had a distinct stroke. The present data suggest that SCP is a useful method for aortic arch aneurysm operation requiring complex repair of the aortic arch.

Chronic disease of the ascending aorta

Abstract Between January 1979 and December 1991, we operated on 339 patients for chronic disease of the ascending aorta. The operation was elective in all. Endocarditis and its sequelae have been excluded. Thirty-one patients had a previous operation on the ascending aorta or the aortic valve; 268 patients had aneurysms of the ascending aorta without dissection; 71 had chronic aortic dissections, of whom 33 had a preexistent aneurysm. The patients included 272 men and 67 women. Mean age was 53.58 ± 7 years. Eight percent of the patients had clinical stigmata of Marfan's disease. A tubular graft replacement was used in 7 patients, a tubular graft and valve replacement in 72 patients, and a composite valve graft replacement with reattachment of the coronary arteries using a 8 mm Dacron graft was performed in 260 patients. Concomitant procedures were used in 74 patients: coronary artery bypass grafts in 25, mitral valve replacement in 9, and aortic arch reconstruction in 40. The 30-day mortality rate was 7.6% ( n=26). For the whole group, multivariate analysis using stepwise logistic regression showed that operative risk factors were concomitant coronary artery bypass grafting, age (increased), aortic valve regurgitation, and previous cardiac surgery. Follow-up was conducted in 303 patients, and risk factors for late mortality were studied. Long-term survival was 59.6% ± 3.7% at 9 years. It was 67% ± 3.5% at 9 years for patients without aortic arch reconstruction and 56% ± 4.5% for patients with aortic arch reconstruction ( p=0.0018). Reoperation was needed in 14 patients. Actuarial freedom from reoperation was 90% ± 0.2% at 9 years for all the patients. Only one patient with composite valve graft replacement and reattachment of the coronary arteries had required reoperation for problems related to this procedure. This technique is used routinely by our team, especially in patients with large chronic aneurysms, dissected or not, and in those who had previous operations. The long-term results are good. (J T HORAC C ARDIOVASC S URG 1994;108:747-54)

Chronic disease of the ascending aorta: Surgical treatment and long-term results

Between January 1979 and December 1991, we operated on 339 patients for chronic disease of the ascending aorta. The operation was elective in all. Endocarditis and its sequelae have been excluded. Thirty-one patients had a previous operation on the ascending aorta or the aortic valve; 268 patients had aneurysms of the ascending aorta without dissection; 71 had chronic aortic dissections, of whom 33 had a preexistent aneurysm. The patients included 272 men and 67 women. Mean age was 53.58 ± 7 years. Eight percent of the patients had clinical stigmata of Marfan’s disease. A tubular graft replacement was used in 7 patients, a tubular graft and valve replacement in 72 patients, and a composite valve graft replacement with reattachment of the coronary arteries using a 8 mm Dacron graft was performed in 260 patients. Concomitant procedures were used in 74 patients: coronary artery bypass grafts in 25, mitral valve replacement in 9, and aortic arch reconstruction in 40. The 30-day mortality rate was 7.6% ( n = 26). For the whole group, multivariate analysis using stepwise logistic regression showed that operative risk factors were concomitant coronary artery bypass grafting, age (increased), aortic valve regurgitation, and previous cardiac surgery. Follow-up was conducted in 303 patients, and risk factors for late mortality were studied. Long-term survival was 59.6% ± 3.7% at 9 years. It was 67% ± 3.5% at 9 years for patients without aortic arch reconstruction and 56% ± 4.5% for patients with aortic arch reconstruction ( p = 0.0018). Reoperation was needed in 14 patients. Actuarial freedom from reoperation was 90% ± 0.2% at 9 years for all the patients. Only one patient with composite valve graft replacement and reattachment of the coronary arteries had required reoperation for problems related to this procedure. This technique is used routinely by our team, especially in patients with large chronic aneurysms, dissected or not, and in those who had previous operations. The long-term results are good. (J THORACCARDIOVASCSURG1994;108:747-54)

Acute Type A Aortic Dissection—Diagnostic Aspects and Surgical Experience

Acute type A aortic dissection was surgically treated in 33 patients aged 20-65 years, all critically ill on admission to hospital. Transthoracic echocardiography revealed pericardiac tamponade in eight cases of extreme emergency, indicating surgery without need of additional imaging. Transesophageal echocardiography provided a definitive diagnosis in 16 cases, with excellent reliability and no false positive findings. Composite graft replacement with button technique was used in 24 patients and other methods of repair in nine. The perioperative mortality was 12% (4/33) and the late mortality 7% (2/29). The actuarial 5-year survival rate was 73%. No aortic root reoperation was required during follow-up for a mean of 4 years. Transesophageal echocardiography proved to be an accurate tool for speedy diagnosis of acute type A aortic dissection and open composite graft replacement with button technique highly satisfactory treatment, avoiding late aortic root problems.

Replacement of a prosthetic valve after the bentall procedure

Patients undergoing a composite graft replacement of the aortic root with reimplantation of the coronary ostia (Bentall procedure) are at risk for late prosthetic heart valve dysfunction: approximately 10% of the patients are expected to experience this complication at 10 years. Therefore, replacement of the prosthetic valve is indicated. This procedure involves technical problems related to the manipulation and the reconstruction of the composite graft without distortion of the coronary arteries. We describe a simple surgical approach to treat these particular patients.

Late Detection of Asymptomatic Chronic Perigraft Aortic Pseudoaneurysm

A fifty-five-year-old man presented with pseudoaneurysm five years after composite aortic graft replacement for aortic dissection. The transthoracic echocardiogram appeared to show a right atrial mass. Transesophageal echocardiography and magnetic resonance imaging correctly delineated the pseudoaneurysm. Cardiac catheterization and superior vena cavagraphy were confirmatory The diagnostic features and natural history of this complication are discussed.

Composite graft replacement of ascending aorta and aortic valve

Composite graft-valve replacement of the ascending aorta was performed in 18 patients over a 4-year-period. Sixteen (88.89%) patients were male and 2(11.11%) were female. Seven (38.88%) had dissection of aorta and 11 (61.12%) had annuloaortic ectasia. All patients had moderate to severe aortic incompetence. Aortic arch replacement was required in three patients in addition to ascending aorta replacement. Coronary artery implantation was done by the Cabrol technique in 12 (66.67%) patients and by the Bentall technique in 6(33.33%) patients. There was no hospital mortality. One patient died one year after surgery. Two (11.11%) required reexploration for bleeding. None of the patients required reoperation at a mean follow up of 29 months.

Massive perigraft aortic aneurysm late after composite graft replacement of the ascending aorta and aortic valve in the marfan syndrome

A major complication of the Marfan syndrome is the development of a fusiform aneurysm of the ascending aorta involving both its sinus and tubular portions. The fusiform aneurysm generally leads to aortic regurgitation, which may become severe, or to aortic rupture, which nearly always is fatal. Treatment of the aneurysm and aortic regurgitation consists of insertion of a composite graft, which involves a substitute aortic valve being sewn into the proximal end of a tube graft. The composite graft is then anastomosed proximally at the aortic valve position and distally to the ascending aorta beyond the aneurysm, and the wall of the aneurysm of the native aorta is wrapped around the composite graft. The coronary arteries are directly anastomosed to small orifices in the tube graft (Bentall operation 1). This report describes a patient who developed a massive perigraft aortic aneurysm late after operation.

Composite Graft Replacement of the Aortic Valve and Ascending Aorta with Cabrol Technique

Replacement of the aortic valve, root and ascending aorta with the technique first described by Cabrol was performed on 17 patients. In five cases the aortic arch was also replaced. The indications were type A aortic dissection with aortic insufficiency (8 cases, with acute dissection in 7), native endocarditis with severe aortic insufficiency and aortic root abscess (3 cases), prosthetic endocarditis (3), and true aneurysm of the ascending aorta with aortic insufficiency (3). Acute surgery was performed in 15 cases (88%). The overall operative mortality was 41%. For the patients discharged from hospital the mean observation time was 30 months. None died, but in one case the right leg of the interposition graft became occluded and reoperation was required 40 months after the primary operation for acute type A dissection. The described technique of aortic valve and root displacement can be used in all cases in which use of a composite graft is indicated, except in situations where the coronary ostia and arteries are damaged by acute dissection.

Composite valve graft replacement of the proximal aorta: Comparison of techniques in 348 patients

Composite valve graft replacement of the ascending aorta is being increasingly used, although it is not clear which technique, the Bentall, Cabrol, or button, is the best method for coronary artery ostial reattachment. We retrospectively analyzed our results with respect to these three techniques in 348 consecutive patients operated on between September 17, 1979, and January 29, 1991. Variables included aortic arch replacement in 88 patients (25%), need for deep hypothermia and circulatory arrest in 119 (34%), aortic dissection in 131 (38%), acute dissection in 34 (9.8%), reoperation in 79 (23%), and insertion of St. Jude prostheses in 270 (78%). The 30-day survival rate was 91% ( 316 / 348 ), the in-hospital survival rate was 90% ( 312 / 348 ), and the 30-day incidence of postoperative new transient (n = 6) and permanent (n = 6) stroke was 3% ( 12 / 348 ). The 30-day survival rates for each method were as follows: Cabrol, 92% ( 144 / 157 ); button, 91% ( 39 / 43 ); and Bentall, 91% ( 125 / 137 ). On stepwise multivariate logistic regression analysis with control for operative date and independent prognostic factors, operative technique was not an independent determinant of early mortality or stroke. On late follow-up, the Kaplan-Meier 5-year survival rate was 71% with no significant difference between the groups (3-year survival: Cabrol, 76%; Bentall, 79%; and button, 81%; p = 0.28). The 3-year freedom from reoperation was 95% (Cabrol, 97%; Bentall, 91%; and button, 100%; p = 0.17). We conclude that for patients undergoing reoperation or complicated repairs or when tension on the ostial anastomoses may occur, the Cabrol technique is preferable. If feasible, however, the button technique has better long-term results for both survival and rate of reoperation. An alternative technique is to use an interposition graft to reattach the left coronary artery and excise an aortic button for the right coronary artery reattachment. This has the advantages of technical ease in reattaching the left coronary artery, good results for reattachment of the right coronary artery, minimal tension on the anastomoses, and visualization of all anastomoses.

Technique for replacing the ascending aorta and aortic valve with a modified Bentall's operation

Composite graft replacement of the aortic root and valve poses the challenge of reimplanting both coronary ostia. The technique of sandwiching the freed button of aortic wall bearing the coronary artery ostium between an outer Teflon felt washerlike buttress and the inner composite graft provides a leak-proof anastomosis while reestablishing direct graft to coronary artery continuity regardless of the location of the coronary ostia or type of root pathology.

Graft Replacement of Ascending Aortic Aneurysms. Surgical Results in 84 Consecutive Patients

Between January, 1977, and March, 1990, 84 consecutive patients underwent graft replacement of an ascending aortic aneurysm. There were 22 women and 62 men patients, ranging in age from twenty-two to sixty-nine years (mean 44.3). Surgical procedures employed were as follows: composite graft replacement with coronary reimplantation in 53 cases, supracoronary graft replacement (SGR) in 23 cases, SGR + aortic resuspension in 2 cases, and SGR + aortic valve replace ment in 1 case. Twenty-eight patients (33%) underwent concomitant aortic arch replacement. Five cases were operated on by "elephant-trunk" technique for extensive aneurysms involving the ascending, arch, and descending thoracic aorta. In 71 cases, a shunt was inserted between the periprosthetic space and the right atrium. Hospital (thirty-day) mortality was 15.5%. Contemporary (1987-1990) mortality rate was 8.7%. After a mean follow-up period of 42.6 months (range three to one hundred eighteen), there were 2 late deaths (1.1%/patient-year). Late reoperation was necessary in 2 cases (1.1%/patient-year). Ninety-one per cent of the survivors were in NYHA class I or II. The long-term survival rate was 76% ± 12%. The type of operation (ie, composite graft replacement or SGR) or concomitant aortic arch replacement had no influence on surgical outcome. The periprosthetic right atrial shunt was found to be effective in avoid ing complications related to blood accumulating between the aortic graft and the aortic wraparound.

Dealing with dilated ascending aorta during aortic valve replacement: advantages of conservative surgical approach

Five to fifteen percent of patients undergoing aortic valve replacement (AVR) will have an ascending aortic aneurysm requiring a concomitant surgical procedure. On the other hand, a dilated ascending aorta is known to be a potential source of complications after AVR. From 1972 to 1988, 2278 AVR, either isolated or combined with a second cardiac procedure, were performed in our institution. In the same time interval, a dilated ascending aorta was treated in additional 291 consecutive patients during AVR. Three different surgical options were employed: aortic remodelling and external wall support in 164 patients (56.4%), composite graft replacement in 81 patients (27.8%) and a supracoronary graft in 46 patients (15.8%). Early mortality was 4.8%. Aortic remodelling plus external wall support had the lowest early mortality (1.8%) and the best 8-year survival (89.6%). Supracoronary grafting had a higher early mortality (6.4%) and lower 8-year survival (73.2%). The results of the composite graft were least favourable: early mortality was 9.8% and 8-year survival 76.5%. The results point out the necessity for instituting the appropriate surgical procedure for a dilated ascending aorta during AVR. They show that conservative aortic surgery with preservation of endothelial lining gives excellent early and late results.

大動脈炎によるＡＡＥに対する大動脈基部再建法での縫合不全予防の工夫

大動脈炎によるＡＡＥに対する大動脈基部再建法での縫合不全予防の工夫

Spontaneously ruptured middle colic artery aneurysm in a patient with Marfan's Syndrome

A 32-year-old male patient with known Marfan's Syndrome presented with acute abdominal pain 20 days following a composite graft replacement of the aortic root for dissection. He was anticoagulated after the operation and appeared to be recovering well, when he complained of severe upper abdominal pain accompanied by peripheral vasoconstriction which recovered rapidly after resuscitation. On examination there was generalised upper abdominal tenderness with guarding and stable vital signs. Investigations revealed a haemoglobin of 7 g% and a prothrombin time which was markedly raised with an INR of 5.9 (normal range 2-3). In view of the history, a further dissection of the abdominal aorta was suspected. An emergency CT scan showed no evidence of dissection but there was a mass in front of the pancreas, the cause of which could not be explained. The sudden drop in haemoglobin and the onset of acute abdominal pain suggested that intraabdominal haemorrhage had occurred but this was not confirmed by paracentesis. The patient was given blood and remained stable for the next 12 h. The pain continued and abdominal ultrasound showed a collection of fluid in the right sub hepatic region which was aspirated under ultrasonic control, confirming the presence of fresh blood. At laparotomy there was flesh free blood in the peritoneal cavity. The aorta and renal vessels were normal, but a large haematoma was found in the transverse mesocolon. The transverse colon was discoloured but Fig. 1. Aneurysmal dilatation of the middle colic artery is seen.