Ann Thorac Surg 2000;69:778-783
© 2000 The Society of Thoracic Surgeons
Original Articles
Management of aortic valve disease during aortic surgery
Lars G. Svensson, MD, PhDa,
James Longoria, MDa,
Wendy A. Kimmel, CCPa,
Edward Nadolny, CCPa
a Center for Aortic Surgery and Marfan Syndrome Clinic, Lahey Clinic, Burlington, Massachusetts, USA
Address reprint requests to Dr Svensson, Lahey Clinic, 41 Mall Rd, Burlington, MA 01805
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Abstract
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Background. Alternative management strategies for aortic valve disease and aortic operation include valve preservation and aortic repair (VPR), composite valve graft (CVG), or separate valve and aortic repair (SVR). We evaluated these approaches.
Methods. Of 250 ascending/arch operations, 151 patients had aortic valvular disease and dissection (n = 56, 37%) or aneurysms operated between November 1990 and January 1998. Sixty-seven patients underwent CVG insertion, 50 SVR, 13 VPR, and 21 only aortic repair alone (RA). Sixty (40%) patients also had aortic arch repairs and 53 (35%) coronary artery bypasses.
Results. The early 30-day survival and stroke rates were 99% (150 of 151) and 0% (0 of 151), respectively: CVG 100% (67 of 67), 0%; VPR 100% (13 of 13), 0%; SVR 98% (49 of 50), 0%; RA 100% (21 of 21), 0% (p = not significant [NS]). On late follow-up of all patients (5 to 92 months; 96% complete 1998), 3 CVG, 2 VPR, 6 SVR, and 0 RA patients died with respective 5-year Kaplan-Meier survival rates of 88.4%, 70%, 69%, and 100% (p = 0.07, log-rank test). The respective linear rates for stroke were 0%, 5.5% (n = 1), 0%, and 0%; for hemorrhage were 0%, 0%, 0%, and 0%; and for endocarditis were 2.2% (n = 3), 0%, 0%, and 0% (p = NS). There were 11 late deaths and no patient required reoperation or ruptured the ascending aorta or the aortic arch.
Conclusions. With careful selection of the appropriate method excellent early and late results can be achieved.
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Introduction
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Different approaches are being advocated for the management of patients with dissection, aneurysms, or degenerative disease of the aorta associated with aortic valvular involvement [1–16]. We have selectively used either valve preservation procedures, inserted composite valve grafts, repaired the aorta separately and replaced the aortic valve, or repaired the aorta and not done anything further for the aortic valve disease in these patients [17]. We evaluated the early and late results of these approaches to determine whether the mortality, stroke, event rates, and reoperation rates were different for the various methods.
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Material and methods
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Of 250 ascending/arch aortic operations, 151 were in patients with aortic valvular disease and dissection (n = 56) or medial degenerative disease operated between November 12, 1990, and January 20, 1998, by L.G.S. The patients were 103 men and 48 women with a mean age of 60.5 years (SD, ±14.4 years; range, 23 to 89 years). The clinical characteristics and associated diseases are shown in Table 1. Twenty-nine patients underwent immediate emergency operation on admission and 42 urgent operation on the next available operating room schedule. Twenty-five patients were graded, as reported previously [15, 17], as having severe unrelieved pain related to the aorta (grade 3) and 35 as having an acute life-threatening condition (aortic dissection, shock, rupture or tamponade, stroke, or myocardial infarct; grade 4). Of the 151 patients, 67 underwent composite valve graft insertion (CVG), mostly with a tube graft to the left main (n = 60) and right coronary artery button (n = 52), 13 had aortic valve preserving procedures with aortic repair (VPR), 50 had separate valve insertions (29 pericardial, 20 mechanical bileaflet, 1 stentless) and aortic repairs (SVR), and in 21 patients, the valvular disease, such as aortic regurgitation (less than grade 2) or aortic valve gradient (20 to 25 mm Hg) (n = 17), or old previous valve replacements (n = 4), were not deemed to require a further valvular procedure and the aorta was repaired alone (RA). These latter patients were included in the study because of the possibility that on late follow-up the valves may have caused problems and required repeat operation. The SVR procedures were used for older patients (mean age, 65 years; SD, ±12.7 years; p 
0.0001) in whom significant root dilatation was not expected to occur, ejection fraction was less than 20% to 25%, or there was no root enlargement. Composite grafts were used in younger patients (mean age, 55 years; SD, ±14.2 years; p < 0.0001). The operative technique for CVG insertion and the management of the coronary ostia have been described previously [16]. A 10 mm tube graft was sewn to the left main coronary ostium and the other end was attached to the right lateral aspect of the CVG. This was done particularly for reoperations, to bridge the gap for large aneurysms and to obtain better hemostasis, especially with a fragile aorta. Then the right coronary artery was attached as a felt buttressed button directly to the CVG as described previously [16]. All of the composite valves were St Jude grafts. All of these patients were placed on warfarin, and if anticoagulation had to be delayed, intravenous heparin was administered.
Patients who had VPR procedures were usually patients with less than approximately 5 cm aortic roots, 3+ aortic regurgitation, intact leaflets, or reparable bicuspid valves. Size of the sinotubular ridge was not a consideration because the prosthetic graft forms a neosinotubular ridge at the top of the incisions for the commissures. The mean age of VPR patients was 59 years (SD, ±16.9 years; p = not significantly [NS] different from the other patients). For those patients who had VPR operations, our decision was to select a tube graft size based on the size of the annulus, being careful to avoid undersizing. We then cut wedges in the tube graft to match the commissure height. The tube graft was both positioned and sutured to the aortic valve annulus without excising the aortic valve (Fig 1). We prefer to parachute the graft into position using two 5-0 polypropylene sutures per cusp base because this assures better hemostasis and annulus-to-graft anastomosis. Size 5-0 polypropylene was used because of the delicate tissues and limited space for suturing. This inclusion technique differs somewhat from the techniques described by David and Feindel [3, 14] and Sarsam and Yacoub [2], who have advocated excising the aortic wall. Our main reason for this is that we believe this is more secure, has a larger contact surface area, and results in less risk of bleeding. The coronary arteries are then attached directly to the graft with 4-0 Prolene (Ethicon, Somerville, NJ), although a small inferior flap of the graft at the opening is used to help bridge any potential gap between the graft and the coronary artery ostium and to improve hemostasis. This inferior flap should reduce the risk of late false aneurysm formation at the coronary ostia but remains to be determined on long-term follow-up. In 3 patients, bovine pericardium was used to repair aneurysms arising from one or two of the sinuses of Valsalva. This was done by suturing the pericardium to the annulus and up to the aortotomy incision to exclude the aneurysm, or in one case, the dissection and the perforation into the right pulmonary artery.
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Fig 1. Stages in aortic valve preservation repair and ascending aortic repair using an inclusion technique. (A) Exposure of valve and coronaries. (B) The graft has been cut at the commissures to accommodate the commissures once the graft is tied down onto the annulus; 5-0 sutures are used to parachute the graft into position. The commissures are shown as displaced because of the difficulty in illustrating this step. (C) Once the annulus sutures are secure, the coronary ostia are attached. (D) View of the aortic root with the graft in place of showing the relation of the graft to the valve leaflets and coronaries. (E) Completed repair.
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Of the 151 patients, 60 (40%) patients had aortic arch repairs in addition for aneurysms and 53 (35%) also required coronary artery bypass. Table 2 shows the additional procedures performed. For brain protection during circulatory arrest, deep hypothermia (< 20°C) alone, retrograde brain perfusion (central venous pressure < 25 mm Hg, ~500 mL/min), or antegrade brain perfusion was used as described previously [17, 18]. Antegrade perfusion was through the right subclavian artery and the left common carotid artery with balloon occlusion of the innominate artery origin. CO2 gas was run into the wound.
Patients were seen at regular intervals after surgery and all patients with repairs or composite grafts also had postoperative echocardiograms. Patients who had repairs had a repeat echocardiogram at 1-year and thereafter at 2-year intervals. Every year a two-page form was sent to patients for a complete evaluation of possible complications, their physical status, and self-assessment of effort tolerance. Patients not responding were phoned directly or their physicians contacted. All patients had at least 6 months follow-up and for 1998, follow-up was 96.7% (146 of 151) complete for a total of 6 to 92 months follow-up.
Data were collected prospectively on a data base, updated if necessary, and evaluated by t tests, Kaplan-Meier survival analysis, and log-rank test.
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Results
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The 30-day survival rate for 151 patients was 99% (150 of 151) and for the different operations: CVG 100% (67 of 67), VPR 100% (13 of 13), SVR 98% (49 of 50), and RA 100% (21 of 21). The overall in-hospital survival rate was 98% (148 of 151). No patient suffered a temporary or permanent stroke after surgery. One patient had a permanent visual field loss shown to be related to retinal damage without evidence of a stroke, one had a transient, 10-minute episode of amaurosis fugax, and another transient diplopia (Table 3). Less than 2% (3 of 151) of patients required reoperation for postoperative bleeding. In 77 patients, blood conservation measures as described previously were used, including autologous blood donation, with 85% not requiring operative homologous blood product transfusion [17].
On late follow-up, 3 CVG, 2 VPR, 6 SVR, and 0 RA patients died. The respective 5-year Kaplan-Meier survival rates were 88.4%, 70%, 69%, and 100% (p = 0.07, log-rank test; Fig 2). Figure 3 shows the Kaplan-Meier curve for patients who had CVGs. The causes of 11 late deaths (Table 4) were 2 unknown, 2 heart failure, 1 gastrointestinal sepsis from a gangrenous gallbladder, 1 late rupture of the descending aorta (the patient had refused a second-stage elephant trunk procedure), 1 carcinoma, 1 after angioplasty, 1 stroke, 1 "blood clot," and 1 cirrhosis. No patient died from rupture of the ascending aorta or aortic arch, and no patient required a reoperation on the ascending aorta or aortic arch. The linearized rates for CVG, VPR, SVR, and RA for stroke were 0%, 5.5% (n = 1, probably related to brain hemorrhage on chronic dialysis), 0%, and 0%, and for endocarditis were 2.2% (n = 3), 0%, 0%, and 0% (p = NS). None required reoperation for endocarditis and 1 was not proved definitely and may have been due to postcardiotomy Dressler syndrome. No patient had a hemorrhagic complication including those on warfarin, although 1 Marfan syndrome patient with a CVG after a fall had a cerebral hemorrhage from which he recovered. (The fall was not caused by the hemorrhage.) Five patients had preoperative visual disturbances that continued after surgery and 3 of the CVG patients reported late transient episodes of blurred vision, with no further events after adding aspirin to the anticoagulation therapy (warfarin) in the latter patients. On late echocardiograms, 2 of the VPR patients had 2+ aortic regurgitation. The rest had no or 1+ aortic regurgitation. No patient developed any root dilatation. At the time of last follow-up of alive patients, 95% (128 of 134) were in New York Heart Association class I/II, 5% (6 of 134) were in class III, and none was in class IV.
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Comment
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This study shows that good early and late results can be achieved in a diverse group of patients with aortic aneurysms and valvular disease by careful selection of aortic operative procedures and valve procedures. Clearly, the selection of the procedure needs to be based on several factors that include the patient’s preoperative status, valve pathology, root size, presence of Marfan syndrome, and age. With our current low operative risks, we recommend aortic repair in patients with an ascending aorta exceeding 5.5 cm in diameter unless comorbid disease substantially increases the risk of operation, and for Marfan syndrome patients, if the aorta exceeds 4.7 cm in diameter. The size criterion of 4.7 cm was originally recommended on the basis of careful analysis of aortic size in 102 patients with Marfan syndrome who also developed aortic dissection [19]. Subsequent prospective studies have shown that aortic dissection may occur at this size, particularly if there is a family history of aortic dissection in Marfan patients [17, 19]. For elderly patients with both aneurysm and valvular disease, but without Marfan syndrome, significant root dilatation, or aortic dissection, a separate aortic and valve procedure is a good alternative, as supported by our results and other studies [1]. Increasingly, we have used biological pericardial valves in these patients because of their long-term durability [20], although if root dilatation with loss of the sinotubular ridge or Marfan syndrome is present (as in 1 of our 70-year-old patients), then a CVG is usually inserted.
For younger patients, the preferred options are either CVGs or Ross procedures with distal prosthetic tube graft, or homografts with distal tube graft, or a tube graft with aortic valve preserving procedure. This group of patients then can be divided further into those with and without Marfan syndrome. In those patients with Marfan syndrome, if the aorta exceeds 6 cm in diameter or significant regurgitation is present, or if pregnancy is not contemplated, then a CVG is usually inserted. This remains a gold standard for these patients and the long-term results have been excellent, particularly in patients who are operated upon before aortic dissection occurs [4, 8, 10, 12, 13, 15, 17]. The incidence of late stroke also has been low in these patients, particularly with the St Jude valve [15]. The reason for the low incidence of late strokes with CVGs is probably because the annulus sutures are tied outside the bloodstream and the patients are younger compared with the patients with aortic valve replacements alone. Although we have preserved the aortic valve in conjunction with aortic preserving procedures in these patients, we caution that the root must be excluded completely and that transesophageal echo should be used to check an aortic valve preserving procedure. We would not preserve the valve in a patient with an aortic root exceeding 6 cm in diameter because of the likely risk of early failure. Inevitably, on histologic examination of valves that have been removed from Marfan syndrome patients, myxomatous degeneration is present. Thus, the long-term durability of the valves is not known in these patients. We do not favor a separate biological valve and tube graft insertion without root replacement because we have noted previously a high incidence of root dissection, rupture, and the need for reoperation in Marfan patients who have had this procedure [15]. Similarly, we have not used CVGs with a biological valve in these patients because of the concern over the high risk of reoperations, although good results have been reported for reoperations [5].
In young patients without Marfan syndrome, even with bicuspid valves, who are considering pregnancy or who have a social or professional lifestyle that precludes against prescribing warfarin, we consider valve preserving procedures to be a reasonable option. Our results in this study and the results of David [14] and Sarsam and Yacoub [2] would indicate that the early and up to 5-year results are good. Aortic valve repair for bicuspid valves also has been reported by Cosgrove and colleagues [20] and Fraser and colleagues [21] to result in good long-term results, and we expect that the addition of an ascending and root aortic graft with the valve repair as noted in this study should be durable.
The Ross procedure with a distal tube graft in these patients is another alternative, although the management of a discordant large annulus can be a problem [9, 11]. We have tailored the root down to 26 mm by placing horizontal pledgeted sutures at each commissure (each suture narrows the annulus by ±3 mm) and then positioning a prosthetic tube graft between the pulmonary autograft and the distal aorta. Nonetheless, we agree with the caveat of Kouchoukos and colleagues [9] against using the Ross procedure in Marfan syndrome patients and, similarly, the use of an unsupported homograft with distal prosthetic tube graft. In a few selected patients, this may be an occasional alternative, and Elkins and colleagues [11] have reported good results in operations using a distal tube graft and an external polyester supported Ross procedure in this situation.
Increasingly, CVG insertion has come to be regarded as a safe procedure as reported by us and several other groups [1, 4, 5, 8, 10, 12, 13, 15]. In this study, we had no early 30-day deaths and the 5-year survival rate was 88.4%. No strokes occurred in these patients, for the probable reasons elucidated previously, and none had bleeding complications related to warfarin usage alone. Although we have had 3 patients with new transient visual disturbances, these all responded to the addition of aspirin to the anticoagulation with warfarin.
Endocarditis of CVGs continues to be a long-term concern in these patients, although loosely approximating the aneurysm wall around the graft may reduce the risk of early graft infection [15]. Endocarditis occurred in 2 of our patients and was suspected in 1, although in the latter this occurred in the early postoperative period and a Dressler syndrome was suspected as no bacteria were cultured. An immunologic reaction to the graft sealant material was also a possibility. Whether newer silver impregnated CVGs will reduce the hazard of endocarditis will require further evaluation.
Increasingly, we have used our minimal access approach of a "J" or "j" incision for these operations, particularly reoperations, and, as a consequence, postoperative morphine requirements have been halved, patient discharge from hospital has been earlier, and it is our impression that patients have returned to work earlier [22]. Ideally, this should be evaluated by a prospective randomized study.
In conclusion, aortic surgery combined with aortic valve procedures has become a safer operative approach and both the early and midterm results, even with valve preserving operations, show good durability with a low incidence of late events.
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Accepted for publication August 18, 1999.
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Abstract
Introduction
