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): Leonard N. Girardi Joseph S. Coselli Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Girardi, L. N. Articles by Coselli, J. S. Search for Related Content PubMed PubMed Citation Articles by Girardi, L. N. Articles by Coselli, J. S.

Ann Thorac Surg 1997;64:1032-1035
© 1997 The Society of Thoracic Surgeons

---

Original Article: Cardiovascular

Aortic Root Replacement: Results Using the St. Jude Medical/Hemashield Composite Graft

Department of Surgery, Baylor College of Medicine, The Methodist Hospital, Houston, Texas

Accepted for publication March 31, 1997.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Operative Management Postoperative Results Comment References

 
Background. Aortic root replacement remains a formidable operation. Although perioperative mortality has declined steadily, there is no consensus regarding the preferred method of reconstruction or type of composite to be used. We present our last 2 years' experience with aortic root replacement using the St. Jude Medical/Hemashield composite valve conduit.

Methods. A retrospective review of 52 consecutive patients undergoing aortic root replacement from February 1994 through October 1996 is presented. Both the open/exclusion and Cabrol methods of reconstruction were used.

Results. Thirty-one percent of the patients had undergone previous procedures of the aortic root. Thirty-seven percent required aortic arch replacement and 35% required concomitant cardiac or vascular procedures. Perioperative morbidity was low, as was perioperative mortality (3.8%). Both of the deaths that occurred were related to complications with the management of remaining thoracoabdominal aneurysms.

Conclusions. Using meticulous surgical technique and the St. Jude Medical/Hemashield composite valve conduit, one can expect low mortality and complication rates for complex aortic root reconstruction.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Operative Management Postoperative Results Comment References

 
Composite graft replacement of the aortic root remains a formidable technical undertaking. Many reports of repair of aortic root aneurysms and type A aortic dissections have been notable for their substantial morbidity and mortality [1–3]. Beginning with the introduction of the inclusion/wrap method by Bentall and DeBono in 1968 [4], evolving modifications in surgical technique have allowed surgeons to reduce the perioperative mortality rate for elective cases to less than 5% [5–9]. One problem that remained was profound hemorrhage through the interstices of the Dacron grafts. Cooley and colleagues [10] as well as others introduced methods for albumin coating and baking of the grafts at the time of the operation. This diminished hemorrhage to a degree, but it also eliminated the malleable nature of Dacron and increased the operative time. The introduction in 1994 of the composite valve conduit, incorporating the St. Jude Medical aortic valve (St. Jude Medical, Inc, St. Paul, MN) in a collagen-impregnated, double velour, woven Dacron Hemashield tube graft (Meadox Medicals, Inc, Oakland, NJ), virtually has eliminated the difficulties associated with manipulating and sewing a noncompliant graft. This prefabricated composite combines the superior hemodynamics of the St. Jude aortic valve with a hemostatic graft, reducing both the operative time and the transfusion requirement. Previous series of aortic root replacement have collected a surgical experience spanning decades with multiple types of valved conduits, including both mechanical and tissue valves. We present our experience with the St. Jude Medical/Hemashield composite valve conduit over the last 30 months.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Operative Management Postoperative Results Comment References

 
Two hundred ninety-two consecutive patients underwent operation on the ascending aorta, aortic arch, or both from February 1994 through October 1996. Fifty-two (18%) had replacement of the aortic root with a St. Jude Medical/Hemashield composite graft using either a modified Cabrol [11, 12] or open/exclusion technique [5], as previously described. A retrospective analysis of the charts of these 52 patients was performed, analyzing all perioperative data. Follow-up for all 52 patients was complete. Operative mortality was defined as death within 30 days of the procedure or before discharge from the hospital.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Operative Management Postoperative Results Comment References

 
Preoperative Patient Characteristics
Fifty-two patients underwent composite graft replacement of the aortic root. Their mean age was 45.1 years (range, 16 to 73 years). Preoperative risk factors are listed in Table 1. Four patients had concomitant thoracoabdominal aneurysms, 2 had innominate artery aneurysms, and 1 had an aneurysm of the innominate and left common carotid arteries.

Sixteen patients (31%) had undergone previous operations on the ascending aorta or aortic root. Thirteen operations were performed after coronary artery bypass or combined valve replacement and coronary artery bypass, 2 after previous aortic valve replacement, and 1 after previous aortic and mitral valve replacement.

	Operative Management

Top Footnotes Abstract Introduction Material and Methods Results Operative Management Postoperative Results Comment References

 
The technique for repair varied with the pathology involved. Thirty patients underwent a modified (exclusion/button) Bentall procedure (Fig 1), whereas 22 patients were reconstructed by a Cabrol technique (Fig 2). The Cabrol technique was used in all reoperations and in cases of extreme friability of the native main coronary arteries. Seventeen of the patients undergoing Cabrol reconstruction had their coronary arteries attached to the graft with a 10-mm Hemashield graft, 3 with an 8-mm Hemashield graft, and 2 with an 8-mm graft to the left main coronary artery and reversed autogenous saphenous vein grafts to the right coronary artery. Nineteen patients (37%) had involvement and repair of their aortic arch using profound hypothermia, circulatory arrest, and retrograde cerebral perfusion with electroencephalogram monitoring as previously described [13, 14]. Three of the arch replacements were performed using the "elephant trunk" technique [15]. An additional 18 procedures were performed at the time of insertion of the composite graft (Table 3).

View larger version (51K): [in this window] [in a new window]   Fig 1. . (A) Preoperative drawing and arteriogram of a patient with aortic valvular insufficiency and annulo-aortic ectasia. (B) Postoperative drawing and arteriogram after composite valve graft replacement using the open technique with coronary artery buttons.

View larger version (50K): [in this window] [in a new window]   Fig 2. . (A) Preoperative drawing and arteriogram of a patient with a 12-cm ascending aortic aneurysm, annulo-aortic ectasia, and aortic valvular insufficiency, secondary to chronic type II aortic dissection. (B) Postoperative drawing and arteriogram after replacement of the aortic root and ascending aorta using the Cabrol technique.

	Postoperative Results

Top Footnotes Abstract Introduction Material and Methods Results Operative Management Postoperative Results Comment References

 
There were 2 perioperative deaths (3.8%). The first occurred on postoperative day 16 as the result of an acute rupture of a thoracoabdominal aortic aneurysm in a patient who had undergone an elephant trunk arch replacement in addition to composite graft repair. The second was in a 73-year-old man who underwent repair of a large, extent II thoracoabdominal aortic aneurysm during the same hospital admission. Although he had no complications after aortic root replacement, he died of multiple organ failure after resection of a thoracoabdominal aortic aneurysm. Postoperative complications are listed in Table 4. Two patients required reoperation for postoperative hemorrhage. In both cases, the hemorrhage resulted from a technical error and was controlled easily. Neither patient had hemorrhage from the Hemashield graft. One patient with a cerebrovascular accident had complete resolution of his symptoms before hospital discharge. No patient experienced renal failure requiring dialysis or respiratory failure requiring tracheostomy.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Operative Management Postoperative Results Comment References

 
Advances in the understanding of cardiopulmonary bypass, blood product resuscitation, and critical care have reduced the morbidity and mortality of elective aortic root replacement. Evolution in surgical technique and improvements in the materials used for this procedure have played an even greater role in reducing the perioperative mortality of this complex reconstruction to less than 5%. Previous series of aortic root replacement have large numbers of patients with excellent follow-up, covering extended periods and using multiple surgical techniques and numerous composite grafts. This report focuses only on the St. Jude Medical/Hemashield composite valve conduit using two techniques over a recent period.

Transgraft hemorrhage was a major reason for the large transfusion requirement and high mortality seen with these procedures. The Bentall inclusion technique is a method for containing this hemorrhage, with an additional wrap to a right atrial shunt needed occasionally when bleeding persists. However, the accumulation of blood around the graft can lead to complications such as pseudoaneurysm formation or frank coronary artery dehiscence at the site of coronary artery anastomoses. The Hemashield collagen-impregnated graft has virtually eliminated transgraft hemorrhage, allowing us to adopt the open/exclusion and Cabrol techniques exclusively. None of our patients has required reoperation for pseudoaneurysm formation or valve dysfunction.

It is difficult to measure the effects of the Hemashield graft on blood product usage. In a small patient population, confounding variables such as reoperation, circulatory arrest, or the use of -aminocaproic acid or aprotinin can dilute any significant decrease in the transfusion requirement. However, improved hemostasis is obvious considering that only 2 patients required exploration for postoperative hemorrhage despite the fact that 31% were undergoing reoperation and 37% were undergoing an arch procedure. In neither case was transgraft bleeding the source of the postoperative hemorrhage. The presence of a prefabricated, hemostatic graft can reduce the number of blood products used and shorten the operative time. Using this device, we have been able to perform our last six primary aortic root replacements without transfusion.

The two deaths in our series deserve discussion. Neither death was related to the performance of the aortic root replacement. Both deaths occurred in patients with diffuse aneurysmal disease who required intervention for their remaining thoracoabdominal aortic aneurysms. The appropriate timing for sequential repair in this situation remains a management dilemma. Patients with Marfan's syndrome, chronic aortic dissection, and mega-aorta are particularly likely to have such extensive disease, with nearly 40% of patients with isolated ascending aortic disease and 70% of those with aortic arch involvement having multiple aortic aneurysms. Without treatment, only 39% of such patients survive beyond 5 years [16]. We traditionally have waited 6 to 8 weeks after the initial procedure before attempting additional aortic replacement, reserving same-admission repair for patients with symptomatic aneurysms. Although we have had experience with total aortic replacement as a single procedure, this technique would not be appropriate for the patient needing aortic root replacement. Perhaps percutaneous stenting of the descending thoracic component in the perioperative period could at least palliate patients requiring urgent repair of their entire aorta. Regardless of the approach used, this patient population will remain at high risk for operative mortality.

In summary, the St. Jude Medical/Hemashield composite valve conduit is a reliable device for use in aortic root replacement. The combination of superior valve hemodynamics and excellent graft hemostasis and pliability make it the composite graft of choice for this complex procedure. Its use, along with meticulous surgical technique, can keep perioperative morbidity and mortality to a minimum while allowing long-term, reoperation-free survival.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Operative Management Postoperative Results Comment References

 
Address reprint requests to Dr Coselli, 6560 Fannin, Suite 1144, Houston, TX 77030 (e-mail: coselli{at}bcm.tmc.edu).

	References

Top Footnotes Abstract Introduction Material and Methods Results Operative Management Postoperative Results Comment References

 

1. Crawford ES, Svensson LG, Coselli JS, Safi HJ, Hess KR. Surgical treatment of aneurysm and/or dissection of the ascending aorta, transverse aortic arch, and ascending aorta and transverse aortic arch. J Thorac Cardiovasc Surg 1989;98:659–74.[Abstract]
2. Lytle BW, Mahfood SS, Cosgrove DM, Loop FD. Replacement of the ascending aorta. J Thorac Cardiovasc Surg 1990;99:651–8.[Abstract]
3. Miller DC, Stinson EB, Oyer PE, et al. Concomitant resection of ascending aortic aneurysm and replacement of the aortic valve: operative and long-term results with "conventional" techniques in ninety patients. J Thorac Cardiovasc Surg 1980;79:388–401.[Abstract]
4. Bentall H, DeBono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338–9.[Abstract/Free Full Text]
5. Kouchoukos NT, Marshall WG, Wedige-Stecher TA. Eleven-year experience with composite graft replacement of the ascending aorta and aortic valve. J Thorac Cardiovasc Surg 1986;92:691–705.[Abstract]
6. Kouchoukos NT, Wareing TH, Murphy SF, Perrillo JB. Sixteen-year experience with aortic root replacement. Ann Surg 1991;214:308–20.[Medline]
7. Coselli JS, Crawford ES. Composite valve graft replacement of aortic root using separate Dacron tube for coronary artery reattachment. Ann Thorac Surg 1989;47:558–65.[Abstract]
8. 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]
9. 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]
10. Cooley DA, Romagnoli A, Milan JD, Bossart MI. A method of preparing woven Dacron aortic grafts to prevent interstitial hemorrhage. Cardiovasc Dis Bull Tex Heart Inst 1981;8:48–52.
11. Cabrol C, Gandjbakhch I, Cham B. Aneyrismes de l'aorte ascendante. Replacement total avec reimplantation des arteres coronaires. Nouv Presse Med 1978;7:363–5.[Medline]
12. Cabrol C, Pavie A, Gandjbakhch I, et al. Complete replacement of the ascending aorta with reimplantation of coronary arteries. New surgical approach. J Thorac Cardiovasc Surg 1981;81:309–15.[Abstract]
13. Coselli JS, Crawford ES, Beall AC, Mizrahi EM, Hess KR, Patel VM. Determination of brain temperatures for safe circulatory arrest during cardiovascular operation. Ann Thorac Surg 1988;45:638–42.[Abstract]
14. Coselli JS. Retrograde cerebral perfusion via superior vena caval cannula for aortic arch aneurysm surgery. Ann Thorac Surg 1994;57:1668–9.[Abstract]
15. Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis. Thorac Cardiovasc Surg 1983;31:37–40.[Medline]
16. Crawford ES, Coselli JS, Svensson LG, Safi HJ, Hess KR. Diffuse aneurysmal disease (chronic aortic dissection, Marfan and mega aorta syndromes) and multiple aneurysm. Ann Surg 1990;211:521–37.[Medline]

This article has been cited by other articles:

				L. N. Girardi, K. H. Krieger, C. A. Mack, L. Y. Lee, A. J. Tortolani, and O. W. Isom Reoperations on the ascending aorta and aortic root in patients with previous cardiac surgery. Ann. Thorac. Surg., October 1, 2006; 82(4): 1407 - 1412. [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]

				E. Prifti, M. Bonacchi, G. Frati, P. Proietti, G. Giunti, G. Babatasi, M. Massetti, and G. Sani Early and long-term outcome in patients undergoing aortic root replacement with composite graft according to the Bentall's technique Eur. J. Cardiothorac. Surg., January 1, 2002; 21(1): 15 - 21. [Abstract] [Full Text] [PDF]

				P. P. Urbanski, M. Wagner, M. Zacher, and R. W. Hacker Aortic root replacement versus aortic valve replacement: a case-match study Ann. Thorac. Surg., July 1, 2001; 72(1): 28 - 32. [Abstract] [Full Text] [PDF]

				A.I. Malashenkov, N.I. Rusanov, R.M. Muratov, R.A. Movsesian, B.A. Fursov, V.A. Bykova, and G.I. Tsoukerman Eight years clinical experience with the replacement of the ascending aorta using composite xenopericardial conduit Eur. J. Cardiothorac. Surg., August 1, 2000; 18(2): 168 - 173. [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]

				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]

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): Leonard N. Girardi Joseph S. Coselli Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Girardi, L. N. Articles by Coselli, J. S. Search for Related Content PubMed PubMed Citation Articles by Girardi, L. N. Articles by Coselli, J. S.