HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Cary W. Akins Gus J. Vlahakes Mortimer J. Buckley Joren C. Madsen David F. Torchiana Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hilgenberg, A. D. Articles by Torchiana, D. F. Search for Related Content PubMed PubMed Citation Articles by Hilgenberg, A. D. Articles by Torchiana, D. F.

Ann Thorac Surg 1996;62:1090-1095
© 1996 The Society of Thoracic Surgeons

---

Original Articles: Cardiovascular

Composite Aortic Root Replacement With Direct Coronary Artery Implantation

Cardiac Surgical Unit, Massachusetts General Hospital, Boston, Massachusetts

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Appendix 1. Acknowledgments References

 
Background. Composite aortic root replacement is accepted treatment for aneurysms of the ascending aorta involving the root with aortic valve regurgitation, but controversy continues regarding the best technique of operation. We excise the aneurysm, implant a composite valve graft, directly attach the coronary arteries to the aortic graft, and make the distal anastomosis to the divided aorta.

Methods. We reviewed the records and collected complete follow-up data on 110 consecutive patients having composite aortic root replacement with this technique from 1979 to 1995.

Results. Average age was 54 years. Marfan's syndrome was present in 22 patients, acute dissections in 26, chronic dissections in 11, and active endocarditis in 13. Operative characteristics were: 25 emergency procedures, 33 urgent procedures, 52 elective procedures, 24 reoperations, and 19 with coronary artery bypass grafting. Hospital death occurred in 8 patients (7.3%). Multivariate predictors of hospital death were postoperative renal failure and acute dissection. Actuarial survival was 70% at 10 years (standard error, 5%). Multivariate predictors of total mortality were porcine valve, Björk-Shiley valve, preoperative stroke, reoperation on a composite valve graft, and coronary artery bypass grafting. Only 3 patients required late reoperation, all for valve dysfunction. Actuarial freedom from reoperation on the aortic root was 97.3% (standard error, 1.9%) at 10 years. Late echocardiograms in 47 patients showed no anastomotic aneurysms.

Conclusions. Composite aortic root replacement with direct coronary implantation is effective and durable treatment for a variety of aortic pathologic conditions in elective and emergency situations.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Appendix 1. Acknowledgments References

 
Composite aortic root replacement involves replacing all aortic tissue from the left ventricular outflow tract to the distal ascending aorta or beyond with prosthetic or biologic materials for the treatment of aneurysms of the root of the aorta with associated valvular involvement. This procedure has become widely accepted as the preferred treatment of annuloaortic ectasia and other complicated aneurysmal and destructive diseases involving the aortic root. The early results have been favorable, with hospital mortality rates of 4% to 10% reported in recent series [1–5]. Several different techniques to accomplish the procedure have been described, and there is controversy concerning the relative merits and drawbacks of each.

In 1968, Bentall and DeBono [6] first described the operation that excludes all of the aortic root from the circulation. They sutured the sewing ring of an aortic valve prosthesis with an attached tube graft to the native aortic valve annulus, and then directly sutured the aortic tissue surrounding the coronary ostia to openings in the aortic tube graft. These anastomoses and the distal aortic anastomosis were all made within the interior of the aorta, and then the aneurysm wall was closed tightly over the repair; this is the inclusion technique. Pseudoaneurysm formation at the coronary artery and the aortic anastomoses has been a troublesome late complication of this technique [1, 7].

In an effort to decrease tension on the coronary anastomoses and to decrease bleeding, Cabrol and associates [8] placed an aortic valve prosthesis inside a tube graft, which was then attached to the native aortic valve annulus. A separate 8-mm Dacron graft was then placed between the two coronary ostia and attached side to side to the aortic graft. The distal anastomosis was made within the aorta, the aneurysm closed over the graft, and a fistula created between the perigraft space and the right atrial appendage. Kinking or compression of the prosthetic coronary graft has been the source of both early and late myocardial ischemic problems with this procedure [2], and persistence of the aorta to right atrial fistula has been reported [9].

Kouchoukos and associates [10] adopted an open technique in which the coronary orifices were detached from the aortic wall, the distal aorta was transected, a composite valve graft was attached to the native annulus, and both coronary arteries were sutured directly to openings in the tube graft. The distal anastomosis was made to the transected aorta, and the aneurysm wall loosely covered the prosthesis. Kouchoukos and associates [1] have associated this method with a decreased incidence of late technical problems.

We have used the open technique of aortic root replacement with resection of the aneurysm and direct implantation of the coronary arteries since 1979. To provide a comprehensive evaluation of this method, we reviewed our experience with the operation used to treat a variety of pathologic conditions involving the aortic root.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Appendix 1. Acknowledgments References

 
Patients
The series consists of 110 consecutive patients who underwent composite aortic root replacement at the Massachusetts General Hospital between October 1979 and November 1995 and who were identified from our computerized cardiac surgery database. Each patient's hospital record was reviewed and data abstracted by trained research nurses. Complete follow-up information was collected between June and November 1995 by one nurse who interviewed each surviving patient by telephone and obtained reports of late echocardiograms from their physicians. Information regarding each patient who died during follow-up was obtained from relatives by telephone interview and from death certificates. The data were entered into a spreadsheet program for analysis.

Statistical Methods
We used the BMDP Statistical Software version 7.0. Program LR was used for logistic regression analysis to define the predictors of hospital mortality and to assess factors possibly associated with reexploration for bleeding. Program 1L was used for life-table analysis, including creation of actuarial survival curves and determination of the rate of freedom from reoperation on the aortic root. Program 2L created the Cox proportional hazards models used to identify the predictors of total mortality. The factors analyzed are listed in Appendix 1.

Demographics
Among the 110 patients there were 75 men (68%) and 35 women (32%), and the average age was 54 years (range, 23 to 81 years). Marfan's syndrome was present in 22 (20%). The patients had either an ascending aneurysm involving the aortic root with aortic insufficiency or complicated endocarditis with extensive aortic root abscess formation. Causes of the aortic processes are detailed in Table 1. Twenty-four patients (22%) had had prior cardiac operations via a median sternotomy, and those procedures are summarized in Table 2. Of the 4 patients with prior composite root replacements, all had their initial operation performed at other institutions; 2 presented to us with endocarditis and 2 had pseudoaneurysms after Cabrol reconstructions. There were 52 elective operations (47%), 33 urgent procedures (30%), and 25 emergency cases (23%).

In all patients the coronary arteries were detached from the aortic wall, preserving buttons of aorta surrounding the ostia. The aneurysm wall was excised, and the main coronary arteries were then gently mobilized from surrounding tissues. The distal aorta was completely transected at the site of the anastomosis. In the patients with endocarditis, the aortic root was debrided extensively, excising all infected and nonviable tissue and all previously placed prosthetic material.

Three suture techniques were used to attach the proximal end of the valve graft to the patient's tissues (Fig 1). Interrupted braided 2-0 sutures, usually placed in mattress fashion with small felt pledgets, were used in 66 patients (60%). Running 2-0 polypropylene sutures interrupted at the three aortic valve commissures were used by some surgeons when the annulus was strong and pliable (33 patients; 30%). In the patients with endocarditis, interrupted simple 4-0 polypropylene sutures were placed deep in the left ventricular outflow tract and then into the aortic homograft annulus to provide secure approximation of the homograft to the irregular margins of the defect after aggressive debridement (11 patients; 10%). The coronary buttons were attached directly to openings made in the aortic tube graft with 4-0 or 5-0 polypropylene suture (Fig 2). Depending on the friability of the tissues, either a continuous suture, interrupted mattress sutures with small felt pledgets, or a combination of the two methods was used. The distal anastomosis of graft to transected aorta was made with continuous 3-0 or 4-0 polypropylene suture usually buttressed with a strip of felt on the outside of the aorta. In cases of acute dissection, strips of felt were placed both inside and outside the aorta and attached with a continuous mattress suture, then the graft was anastomosed to the felt and aorta. In patients receiving a homograft root for endocarditis, the coronary buttons were usually attached to openings created by excising the homograft coronary arteries and no felt was used in any of the suture lines.

View larger version (27K): [in this window] [in a new window]   Fig 1. . (A) Composite valve graft prothesis being implanted with interrupted mattress sutures with pledgets. (B) Composite valve graft prosthesis being implanted with continuous 2-0 polypropylene sutures beginning at each aortic valve commissure. (C) Homograft aortic root being implanted with interrupted simple 4-0 polypropylene sutures beginning at each aortic valve commissure.

View larger version (39K): [in this window] [in a new window]   Fig 2. . Coronary artery button being attached to aortic tube graft with continuous polypropylene suture.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Appendix 1. Acknowledgments References

 
Early Results
Hospital death occurred in 8 patients (7.3%). The causes of death are listed in Table 4. Considering subgroups of patients, hospital mortality in elective cases was 3.8% (two deaths in 52 patients) and the highest mortality occurred in the presence of acute dissection (four deaths in 26 patients; 15.4%). There has been a trend toward lower mortality in recent years, with no hospital deaths since 1991 in the last 51 patients; operation before 1991 was a univariate predictor of hospital mortality (p = 0.015). Multivariate predictors of hospital mortality were postoperative renal failure (p = 0.00005) and acute dissection (p = 0.007).

Transient neurologic deficits developed in 5 surviving patients in the immediate postoperative period, and all of these patients recovered completely. Five patients required tracheostomy and prolonged mechanical ventilation. Dialysis for renal failure was needed in 5 patients, and 7 patients had permanent pacemakers placed.

Late Results
The actuarial survival curve for all patients, including hospital mortality, is shown in Figure 3. Five-year survival is 78%, and 10-year survival is 70%. Nineteen patients died during follow-up, and the causes of the late deaths are summarized in Table 5. Multivariate analysis identified the following factors to be predictors of total mortality: porcine valve (p = 0.001), Björk-Shiley valve (p = 0.002), preoperative stroke (p = 0.004), reoperation on a composite valve graft (p = 0.015), and coronary artery bypass grafting (p = 0.039).

View larger version (18K): [in this window] [in a new window]   Fig 3. . Actuarial survival curve of all patients, including hospital mortality. Error bars indicate ± standard error. (n = number of patients completing each year of follow-up.)

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Appendix 1. Acknowledgments References

 
Table 6 shows a comparison of several aspects of this series to those of five other series of patients having composite root replacements published between 1990 and 1995. Differences in our series include an older average age, more than twice as many patients with acute dissection, and a high incidence of reoperations and concomitant coronary artery bypass grafting. Our hospital mortality is comparable to that cited in the other reports, reexploration for bleeding is higher, and late survival is excellent.

Late problems associated with the Cabrol procedure have mainly involved the Dacron graft, used to attach the coronary arteries to the aortic tube graft, with coronary insufficiency resulting from kinking of graft limbs or intimal hyperplasia [1, 11]. Obviously, these problems are completely avoided when the coronary arteries are implanted directly into the aortic graft and no prosthetic material is used in the coronary circulation. We have not encountered the situation in any of our patients in whom it was impossible to directly attach the coronary arteries to the aortic graft, even in the reoperations and the endocarditis cases. Once the coronary buttons have been detached from the aortic wall, it has been possible to mobilize the arteries from the surrounding tissues and obtain enough length for anastomosis without undue tension.

Composite root replacement is suitable treatment for a variety of pathologic conditions affecting the aortic root. Annuloaortic ectasia is the most frequent indication in our series and in all others reported in the literature. The results of elective operations in these cases have been excellent in patients with and without Marfan's syndrome, with an operative mortality of 0 to 4% in recent series, including ours [1, 5, 12]. The technique of composite root replacement has been extended to the treatment of selected patients with acute aortic dissection and to patients with complicated active endocarditis, generally with success but with increased risk compared with that for elective cases in some series [3, 13].

We have used root replacement for acute dissection when the intimal tear arises in a preexisting aneurysm or extends into the aortic root, in patients with Marfan's syndrome, and in those requiring aortic valve replacement who have extensive involvement of the aortic sinuses. However, we are able to repair and preserve the aortic valve and sinuses and insert a tube graft in most acute dissections. Operation for acute dissection was a significant predictor of hospital mortality in our series and in those of other authors [3, 5]. Although some authors have found long-term survival to be statistically less favorable after root replacement for acute dissection [3, 14], this was not a predictor of late mortality in our series.

Root replacement with cryopreserved aortic homografts appears to be particularly suitable for reconstruction of the substantial defects remaining after aggressive debridement of complicated aortic endocarditis, especially when prosthetic material such as valve conduits are involved. There were no hospital deaths in this group, and recurrent infection has not developed in any of the patients during follow-up extending to 2 years.

Bleeding remains a problem in our experience and in that of others (see Table 6). Availability of collagen-impregnated grafts and use of smaller anastomotic sutures have been helpful. We are evaluating the addition of a second sutured layer to help seal the annular suture line, as recommended by Copeland and associates [15]. We do pressurize the aortic graft with cardioplegia after the coronary arteries are implanted and find this maneuver helpful in identifying leaks [16]. We are also evaluating drugs to help preserve hemostatic function, specifically aprotinin and -aminocaproic acid. We have been cautious with aprotinin because of the findings of Sundt and colleagues [17], who reported thrombotic events, renal failure, and less favorable outcomes for patients receiving aprotinin undergoing aortic operations with hypothermic circulatory arrest. When using aprotinin, we use a high-dose heparin protocol and monitor the activated clotting time with kaolin tubes [18].

Mechanical valves have been the predominant valve substitutes used in the previously published series of composite root replacements. To avoid long-term anticoagulation treatment in our older patients, we have incorporated bioprostheses in conduits made at the operating table and have used these in 28% of our patients. Only 1 patient has required late reoperation for tissue failure. For reasons that are not entirely clear, porcine valve is a predictor of total mortality in our multivariate analysis. We are looking forward to more data from David and colleagues [19], who are preserving the native aortic valve in selected patients otherwise having an operation similar to a composite root replacement.

We conclude that composite aortic root replacement is effective treatment for aortic root aneurysms, dissections involving the aortic root, and complicated aortic valve endocarditis. Hospital mortality has been low in recent years. The technique of aneurysm resection and direct coronary button implantation results in a durable reconstruction whose long-term results are mainly dictated by the aortic valve prosthesis, the stability of the patient's distal aorta, and the severity of the underlying heart disease.

	Appendix 1.

Top Footnotes Abstract Introduction Material and Methods Results Comment Appendix 1. Acknowledgments References

 
Patient Variables Assessed As Predictors of Hospital Mortality, Reexploration for Bleeding, and Late Mortality in Multivariate Analysis

• Age
  
• Sex
  
• Year of operation
  
• Operative status: elective, urgent, emergency
  
• Dissection: none, acute, chronic
  
• Marfan's syndrome
  
• Prior cardiac operation
  
• Prior composite aortic root replacement
  
• Preoperative stroke
  
• Active endocarditis
  
• Congestive heart failure
  
• Diabetes mellitus
  
• Preoperative renal insufficiency
  
• Smoking history
  
• Hypothermic circulatory arrest
  
• Cardiopulmonary bypass time
  
• Concomitant coronary artery bypass grafting
  
• Reexploration for bleeding
  
• Postoperative renal failure
  
• Long-term warfarin therapy
  
• Type of aortic valve implanted
  

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Appendix 1. Acknowledgments References

 
We acknowledge the assistance of Ruthellen McKinnon for preparation of the manuscript, and John Newell, Director of the Cardiac Computer Center at the Massachusetts General Hospital, for the statistical analysis.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Appendix 1. Acknowledgments References

 
Presented at the Poster Session of the Thirty-second Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 29–31, 1996.

Doctor Akins is a consultant to the manufacturer of one of the valves implanted in patients in the study, Medtronic, Incorporated.

Address reprint requests to Dr Hilgenberg, Massachusetts General Hospital, Warren 1120, Boston, MA 02114.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Appendix 1. Acknowledgments References

 

1. Kouchoukos NT, Wareing TH, Murphy SF, Perrillo JB. Sixteen year experience with aortic root replacement. Ann Surg 1991;214:308–20.[Medline]
2. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Composite valve graft replacement of the proximal aorta: comparison of techniques in 348 patients. Ann Thorac Surg 1992;54:427–39.[Abstract]
3. Lewis CTP, Cooley DA, Murphy MC, Talledo O, Vega D. Surgical repair of aortic root aneurysms in 280 patients. Ann Thorac Surg 1992;53:38–46.[Abstract]
4. Aoyagi S, Kosuga K, Akashi H, Oryoji A, Oishi K. Aortic root replacement with a composite graft: results of 69 operations in 66 patients. Ann Thorac Surg 1994;58:1469–75.[Abstract]
5. Gott VL, Gillinov AM, Pyeritz RE, et al. Aortic root replacement. Risk factor analysis of a seventeen year experience with 270 patients. J Thorac Cardiovasc Surg 1995;109:536–45.[Abstract/Free Full Text]
6. Bentall HH, DeBono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338–9.[Abstract/Free Full Text]
7. Marvasti MA, Parker FB, Randall PA, Witwer GA. Composite graft replacement of the ascending aorta and aortic valve. Late followup with intra-arterial digital subtraction angiography. J Thorac Cardiovasc Surg 1988;95:924–8.[Abstract]
8. Cabrol C, Pavie A, Gandjbakhch I, et al. Complete replacement of the ascending aorta with reimplantation of the coronary arteries. New surgical approach. J Thorac Cardiovasc Surg 1981;81:309–15.[Abstract]
9. Cabrol C, Pavie A, Mesnildrey P, et al. Long-term results with total replacement of the ascending aorta with reimplantation of the coronary arteries. J Thorac Cardiovasc Surg 1986;91:17–25.[Abstract]
10. Kouchoukos NT, Marshall WG, Wedige-Stecker TA. Eleven year experience with composite graft replacement of the ascending aorta and aortic valve. J Thorac Cardiovasc Surg 1986;92:691–705.[Abstract]
11. Sekine S, Abe T, Seki K, Shibata Y, Yamagishi I, Kamada M. Dacron coronary graft obstruction after composite graft replacement of the aortic root. Ann Thorac Surg 1995;60:1123–6.[Abstract/Free Full Text]
12. Gott VL, Cameron DE, Reitz BA, Pyeritz RE. Current diagnosis and prescription for the Marfan syndrome: aortic root and valve replacement. J Card Surg 1994;9(Suppl):177–81.[Medline]
13. Glazier JJ, Verwilghen J, Donaldson RM, Ross DN. Treatment of complicated prosthetic aortic valve endocarditis with annular abscess formation by homograft aortic root replacement. J Am Coll Cardiol 1991;17:1177–82.[Abstract]
14. Lytle BW, Mahfood SS, Cosgrove DM, Loop FD. Replacement of the ascending aorta. Early and late results. J Thorac Cardiovasc Surg 1990;99:651–8.[Abstract]
15. Copeland JG, Rosado LJ, Snyder SL. New technique for improving hemostasis in aortic root replacement with composite graft. Ann Thorac Surg 1993;55:1027–9.[Abstract]
16. Bayfield MS, Kron IL. Reducing bleeding after replacement of the aortic root. Ann Thorac Surg 1995;60:1130–1.[Abstract/Free Full Text]
17. Sundt TM, Kouchoukos NT, Saffitz JE, Murphy SF, Wareing TH, Stahl DJ. Renal dysfunction and intravascular coagulation with aprotinin and hypothermic circulatory arrest. Ann Thorac Surg 1993;55:1418–24.[Abstract]
18. Wendel HP, Heller W, Gallimore MJ, et al. The prolonged activated clotting time (ACT) with aprotinin depends on the type of activator used for measurement. Blood Coagul Fibrinolysis 1993;4:41–5.[Medline]
19. David TE, Feindel CM, Bos J. Repair of the aortic valve in patients with aortic insufficiency and aortic root aneurysm. J Thorac Cardiovasc Surg 1995;109:345–52.[Abstract/Free Full Text]

This article has been cited by other articles:

				Aortic root replacement after previous surgical intervention on the aortic valve, aortic root, or ascending aorta. J. Thorac. Cardiovasc. Surg., March 1, 2006; 131(3): 601 - 608.

				F. Settepani, A. Eusebio, D. Ornaghi, A. Barbone, E. Citterio, E. Manasse, G. Silvaggio, and R. Gallotti Aortic root replacement with the Carboseal composite valve graft: analysis of risk factors Interactive CardioVascular and Thoracic Surgery, August 1, 2005; 4(4): 360 - 364. [Abstract] [Full Text] [PDF]

				F. Robicsek, J. W. Cook, M. K. Reames Sr, and E. R. Skipper Size reduction ascending aortoplasty: Is it dead or alive? J. Thorac. Cardiovasc. Surg., October 1, 2004; 128(4): 562 - 570. [Abstract] [Full Text] [PDF]

				M. Turina Composite graft replacement of the aortic root: 'button' technique MMCTS, December 4, 2003; 2003(1204): MMCTS.2003.000001. [Abstract] [Full Text] [PDF]

				A. D. Milano, S. Pratali, G. Mecozzi, P. Boraschi, G. Braccini, E. Magagnini, and U. Bortolotti Fate of coronary ostial anastomoses after the modified Bentall procedure Ann. Thorac. Surg., June 1, 2003; 75(6): 1797 - 1801. [Abstract] [Full Text] [PDF]

				A. D. Hilgenberg and B. N. Mora Composite aortic root replacement with a bovine pericardial valve conduit Ann. Thorac. Surg., April 1, 2003; 75(4): 1338 - 1339. [Abstract] [Full Text] [PDF]

				S. Gelsomino, R. Frassani, P. Da Col, G. Morocutti, G. Masullo, L. Spedicato, and U. Livi A long-term experience with the cabrol root replacement technique for the management of ascending aortic aneurysms and dissections Ann. Thorac. Surg., January 1, 2003; 75(1): 126 - 131. [Abstract] [Full Text] [PDF]

				S. A. LeMaire, D. J. DiBardino, C. Koksoy, and J. S. Coselli Proximal aortic reoperations in patients with composite valve grafts Ann. Thorac. Surg., November 1, 2002; 74(5): S1777 - 1780. [Abstract] [Full Text] [PDF]

				K. Kirali, D. Mansuroglu, S. N. Omeroglu, V. Erentug, I. Mataraci, G. Ipek, E. Alcinci, O. Isik, and C. Yakut Five-year experience in aortic root replacement with the flanged composite graft Ann. Thorac. Surg., April 1, 2002; 73(4): 1130 - 1137. [Abstract] [Full Text] [PDF]

				A. Panos, B. Amahzoune, J. Robin, G. Champsaur, and J. Ninet Influence of technique of coronary artery implantation on long-term results in composite aortic root replacement Ann. Thorac. Surg., November 1, 2001; 72(5): 1497 - 1501. [Abstract] [Full Text] [PDF]

				S. Yavuz, M. A. Celkan, M. Mavi, T. Turk, M. T. Goncu, and I. A. Ozdemir Acute Dissection of Ascending Aorta After Aortic Valve Replacement Asian Cardiovasc Thorac Ann, March 1, 2001; 9(1): 48 - 50. [Abstract] [Full Text] [PDF]

				L. G. Svensson, J. Longoria, W. A. Kimmel, and E. Nadolny Management of aortic valve disease during aortic surgery Ann. Thorac. Surg., March 1, 2000; 69(3): 778 - 783. [Abstract] [Full Text] [PDF]

				S. Westaby, T. Katsumata, and G. Vaccari Aortic root replacement with coronary button re-implantation: low risk and predictable outcome Eur. J. Cardiothorac. Surg., March 1, 2000; 17(3): 259 - 265. [Abstract] [Full Text] [PDF]

				K. M. Dossche, M. Erwin Tan, M. A. Schepens, W. J. Morshuis, and A. Brutel de la Riviere Twenty-four year experience with reoperations after ascending aortic or aortic root replacement Eur. J. Cardiothorac. Surg., December 1, 1999; 16(6): 607 - 612. [Abstract] [Full Text] [PDF]

				G. B. Luciani, G. Casali, L. Barozzi, and A. Mazzucco Aortic root replacement with the Carboseal composite graft: 7-year experience with the first 100 implants Ann. Thorac. Surg., December 1, 1999; 68(6): 2258 - 2262. [Abstract] [Full Text] [PDF]

				S. M. Langley, S. J. Rooney, M. J. R. Dalrymple-Hay, J. M. F. Spencer, M. E. Lewis, D. Pagano, M. Asif, J. R. Goddard, V. T. Tsang, R. K. Lamb, et al. REPLACEMENT OF THE PROXIMAL AORTA AND AORTIC VALVE USING A COMPOSITE BILEAFLET PROSTHESIS AND GELATIN-IMPREGNATED POLYESTER GRAFT (CARBO-SEAL): EARLY RESULTS IN 143 PATIENTS J. Thorac. Cardiovasc. Surg., December 1, 1999; 118(6): 1014 - 1020. [Abstract] [Full Text] [PDF]

				U. Niederhauser, A. Kunzli, B. Seifert, J. Schmidli, M. Lachat, G. Zund, P. Vogt, and M. Turina Conservative treatment of the aortic root in acute type a dissection Eur. J. Cardiothorac. Surg., May 1, 1999; 15(5): 557 - 563. [Abstract] [Full Text] [PDF]

				K. M. Dossche, M. A.A.M. Schepens, W. J. Morshuis, A. B. de la Riviere, P. J. Knaepen, and F. E.E. Vermeulen A 23-year experience with composite valve graft replacement of the aortic root Ann. Thorac. Surg., April 1, 1999; 67(4): 1070 - 1077. [Abstract] [Full Text] [PDF]

				D. A. Browdie and R. V. Bernstein Aortic root hemorrhage and presealed composite grafts with porous sewing cuffs Ann. Thorac. Surg., August 1, 1998; 66(2): 609 - 609. [Full Text] [PDF]

				C. Hahn, S. K.C. Tam, G. J. Vlahakes, A. D. Hilgenberg, C. W. Akins, and M. J. Buckley Repeat aortic root replacement Ann. Thorac. Surg., July 1, 1998; 66(1): 88 - 91. [Abstract] [Full Text] [PDF]

				U. Niederhauser, H. Rudiger, P. Vogt, A. Kunzli, G. Zund, and M. Turina Composite graft replacement of the aortic root in acute dissection Eur. J. Cardiothorac. Surg., February 1, 1998; 13(2): 144 - 150. [Abstract] [Full Text] [PDF]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Cary W. Akins Gus J. Vlahakes Mortimer J. Buckley Joren C. Madsen David F. Torchiana Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hilgenberg, A. D. Articles by Torchiana, D. F. Search for Related Content PubMed PubMed Citation Articles by Hilgenberg, A. D. Articles by Torchiana, D. F.