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Ann Thorac Surg 2000;70:1227-1233
© 2000 The Society of Thoracic Surgeons
a Department of Cardio-Thoracic Surgery, St. Antoniusziekenhuis, Nieuwegein, The Netherlands
b Department of Cardiological Epidemiology, St. Antoniusziekenhuis, Nieuwegein, The Netherlands
Address reprint requests to Dr Casselman, Department of Cardio-Thoracic Surgery, St. Antoniusziekenhuis, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
e-mail: casself{at}hotmail.com
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Abstract |
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Methods. From November 1976 to February 1999, 246 patients underwent surgical treatment for acute type A aortic dissection at our institution. In 121 patients (49%), all with acute type A dissection and aortic root involvement, the aortic valve was preserved and one or more of the sinuses of Valsalva were reconstructed. The mean age of this group was 59 ± 11 years and 70 (58%) were men. Thirty patients (25%) were operated in cardiogenic shock. Criteria for aortic root reconstruction were technical feasibility and surgeon preference. Techniques used for reconstruction were valve resuspension in all patients and additional reinforcement of the aortic root with Teflon (L.R. Bard, Tempe, AZ) felt (n = 21), gelatin-resorcinol-formaldehyde-glue (GRF-glue, Fii, Saint-Just-Malmont, France) (n = 103), or fibrinous glue (Tissu-col, Immuno AG, Vienna, Austria) (n = 5). Mean follow-up was 43.5 ± 46 months.
Results. The operative mortality was 21.5% (n = 26). Actuarial survival was 72% ± 4%, 64% ± 5%, and 53% ± 6% at 1, 5, and 10 years, respectively. Median aortic regurgitation in patients with retained native aortic valve at follow-up was 1+. All root reoperations included aortic valve replacement (n = 12). Freedom from aortic root reoperation was 95% ± 2% at 1 year, 89% ± 4% at 5 years, and 69% ± 9% at 10 years. The incidence of aortic root reoperation was 23%, 11%, and 40%, respectively, when Teflon felt, GRF-glue, and fibrinous glue were used for root reconstruction. Multivariate Cox proportional hazard analysis revealed the use of fibrinous glue (RR = 8.7; p = 0.03) as well as the presence of an aortic valve annulus more than 27 mm (RR = 4.2; p = 0.04) as independent risk factors for aortic root reoperation.
Conclusions. Aortic valve preservation in acute type A dissection provides relatively durable results. The use of fibrinous glue for root reconstruction seems to compromise the long-term durability of the repair compared with Teflon felt and GRF-glue. A dilated aortic annulus requires a more extensive root procedure.
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Introduction |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Material and methods |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Patient characteristics
The mean age was 59 ± 11 years (range, 24 to 81 years) and 58% (n = 70) were men. Two patients previously underwent coronary artery bypass grafting (CABG) and another patient had had a descending thoracic aorta replacement for a ruptured type B aortic dissection. Marfan’s syndrome was present in 2 patients. Table 1 shows the patient distribution per year. One fourth of the patients (n = 30) were operated in cardiogenic shock. Preoperative neurologic deficit was diagnosed in 19 patients (Table 2). However, this was transient and fully recovered at the time of operation in 10 patients. Associated procedures included partial or total arch replacement in 18 patients, CABG in 4 patients, and exploratory laparotomy in another 4 patients.
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Surgical technique
The technique changed somewhat over the years since a total of 11 surgeons operated on the patients included in this series. Usually the procedure started with a median sternotomy, followed by cannulation through the femoral artery and right atrial appendage. A left ventricular decompression line was inserted through the right superior pulmonary vein. In cases of hemodynamic instability or resuscitation, extracorporeal circulation (ECC) was usually initiated by arterial and venous cannulation in the groin using a long venous cannula, after which median sternotomy was performed.
Once the patient was on ECC, systemic cooling was initiated. In the early experience, the distal ascending aorta was clamped at 25°C to 28°C or earlier if ventricular fibrillation occurred. The proximal aorta was then opened to locate the intimal tear. If the intimal tear extended into the clamped area, the patient was cooled to a nasopharyngeal temperature of 16°C or, since 1982, until the electroencephalogram became isoelectric. The proximal reconstruction (see further) was performed during this cooling episode. The arch was then exposed under deep hypothermic circulatory arrest (DHCA) and partially or totally replaced if necessary. If it was unnecessary to replace the arch, an open distal aortoprosthesis anastomosis was performed and ECC was reinstituted.
If the intimal tear did not extend into the clamped aortic area, the reconstruction of the dissected portion was performed under aortic cross-clamping.
Since 1990, antegrade selective cerebral perfusion (ASCP) has progressively been introduced in our institution. The technique has been reported previously [9] and is currently our technique of choice for brain protection. Of the 121 patients involved in this study, a total of 69 had DHCA and 22 patients had ASCP.
Another modification that developed over the years is to avoid aortic cross-clamping. We currently cool the patient down to a nasopharyngeal temperature of 25°C at which point the ECC is discontinued. We then install the ASCP and subsequently protect the heart by cold crystalloid antegrade cardioplegia, which is administered directly into the coronary ostia. The eventual arch procedure and distal ascending aortic anastomosis are performed under total circulatory arrest. Once this is completed, ASCP is stopped and antegrade perfusion is resumed through a side arm of the prosthesis. Then air is removed from the prosthesis and the prosthesis is clamped. The proximal ascending aortic procedure is performed during the subsequent rewarming.
All of the patients included in this study had a reconstruction of one or more of the sinuses of Valsalva that were affected by the dissection. The decision to perform a root reconstruction rather than a Bentall procedure was made intraoperatively by the surgeon and was dependent upon his preference and estimation of the feasibility. The aortic root was reconstructed with either Teflon (L.R. Bard, Tempe, AZ) felt (n = 21), gelatin-resorcinol-formaldehyde-glue (GRF-glue, Fii, Saint-Just Malmont, France) (n = 103), or fibrinous glue (Tissu-col, Immuno AG, Vienna, Austria) (n = 5). The reconstructive material was put between the dissected aortic layers. The total number of applications outranges the total number of patients involved in the study as several patients had a combination of the root reconstructive techniques (Table 3). Two patients had a surprising combination of GRF-glue and fibrinous glue. This was due to unforeseen lack of stock, which only became apparent during the operation when additional glue was required for optimal apposition of the dissected layers.
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Mean aortic cross-clamp time, DHCA, and ECC were 101 ± 37, 36 ± 18, and 176 ± 61 minutes, respectively.
Assessment of repair and durability
The initial repair was assessed intraoperatively, at first by the hemodynamic parameters and from 1988 on also by transesophageal echocardiography (TEE) whenever available. However, this was not always the case in emergency conditions.
The repair durability was assessed primarily by the incidence of aortic valve and root reoperation. All reoperations were analyzed and the causes were noted. All other reoperations were also recorded. Causes of death were also analyzed to detect recurrent aortic regurgitation as a possible causative factor.
In addition, the latest available transthoracic echocardiogram (TTE) was used to determine the degree of aortic regurgitation and the presence of aortic root dilatation; TTE was available in 56 of 67 patients who retained their native aortic valve at the time of follow-up. In patients undergoing an aortic valve and root reoperation, the last TTE before the reoperation was used.
Postoperative follow-up
The 30-day mortality was 21.5% (n = 26). Ten of these patients were operated in cardiogenic shock. Causes of death are summarized in Table 4. None of the patients dying of heart failure had recurrent aortic regurgitation. Six of the 13 neurologic deaths occurred in patients who had had a preoperative persisting central neurologic deficit and 1 in a patient who had had a preoperative transient neurologic deficit. Actuarial survival at 30 days was 78% ± 4%.
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Follow-up was achieved either by yearly outpatient visit or by phone and letter to the patient and the referring physician. A file on current status, medication, morbidity, and mortality was completed for each patient. Follow-up was closed on June 1, 1999, and was 100% complete. Mean follow-up was 43 ± 46 months, with a maximum of 16 years in 2 patients.
There were 20 late deaths. The causes are summarized in Table 5. Four of these deaths occurred after an aortic valve reoperation (see Results). None of the patients died of recurrent aortic regurgitation. Actuarial survival was 72% ± 4%, 64% ± 5%, and 53% ± 6% at 1, 5, and 10 years postoperatively (Fig 1).
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2 or Fisher’s exact test when appropriate. A value of p less than 0.05 was considered statistically significant. Cox proportional hazard analysis was used to determine risk factors for aortic valve reoperation. Variables with p value less than 0.15 on univariate analysis were entered into the multivariate analysis. |
Results |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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At follow-up, 67 patients of 75 survivors had retained their native aortic valve. A TTE was available in 56 of these patients. As indicated in Table 7, the majority of the patients had no or 1+ aortic regurgitation. Median degree of aortic regurgitation was 1+. Twelve patients had 2+ and 2 patients had 3+ aortic regurgitation. They are currently asymptomatic but are followed carefully at regular intervals.
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Durability of root repair
Durability was assessed by the incidence of aortic root reoperation and by follow-up TTE. Advantages of preservation of the native aortic valve are avoidance of a valve substitute with its possible adverse effects and avoidance of a permanent need of anticoagulation in mechanical valve replacement. This need of anticoagulation impairs spontaneous thrombosis in the false lumen and persistent perfusion of the false lumen leads to aneurysm formation, which has been associated with decreased late survival [11]. The advantages of valve preservation have to be balanced against the risk of reoperation during follow-up. Freedom from aortic valve reoperation at 10 years has been reported to be as high as 95% [17] when valve preservation was performed. However, other reports cite 80% freedom from aortic valve reoperation at 10 years [4, 18]. Freedom from aortic valve/root reoperation at 10 years in the present series was 69%. This is somewhat lower than the previously mentioned reports.
Table 6 indicates that the use of GRF-glue did not prevent aortic root dilatation in some instances, contrary to a previous report [6]. In addition, follow-up TTE revealed 2 patients with 3+ aortic regurgitation and 10 patients with an aortic root diameter more than 40 mm. Undoubtedly some of these patients will need reoperation in the future. Therefore, further follow-up of this patient cohort is mandatory.
Risk factors for root reoperation
Multivariate Cox proportional hazard analysis revealed the use of fibrinous glue and the presence of an aortic valve annulus more than 27 mm as independent risk factors for aortic root reoperation. This negative impact of fibrinous glue is in sharp contrast with the results previously reported by Séguin and colleagues [5]. Their article reports on the use of fibrinous glue in 15 patients with type A dissection. There was 1 nonvalve-related operative death, and at a mean follow-up of 2.3 years the mean aortic regurgitation grade was 0.3. No reoperations were reported.
Most authors currently agree that Marfan’s syndrome and annuloaortic ectasia represent a contraindication to root preservation during operation for type A dissection [3, 4, 6, 14, 16, 18]. These patients should undergo a Bentall procedure [2] or alternatively the procedure described by David and associates [8]. Four of the reoperations in the current series occurred in patients having an aortic annulus more than 27 mm measured peroperatively. All of these initial operations were performed earlier in the series. In retrospect these patients should not have undergone a root reconstructive procedure, which would have decreased the reoperation incidence.
Although not statistically significant, the present series demonstrates a trend toward improved durability in patients treated with GRF-glue versus Teflon. The reoperation rate in patients treated with GRF-glue was 11% versus 23% when Teflon was used. Equally good results with GRF-glue have been reported by others, either reporting on a single experience with GRF-glue [3, 6, 14] or in comparison with Teflon [19]. The use of GRF-glue for the reapproximation of the dissected aortic layers decreases the incidence of reoperations as well as the persistence of false lumina thus increasing the event-free survival. However, in the article by Pessotto and coworkers [16], the use of GRF-glue had no impact on the incidence of reoperation, which increased with increasing preoperative aortic regurgitation. Another concern with regard to the use of GRF-glue is the recent report of Fukunaga and colleagues [7]. In a series of 148 patients in whom GRF-glue was used to reinforce the dissected layers, reoperations were necessary in 20 patients. In 9 of these patients, complications necessitating reoperation occurred in aortic segments that underwent reconstruction with GRF-glue at the first intervention. Root redissection was present in 7 patients and another patient presented with a rupture near the distal graft-aorta anastomosis. Macroscopically, the areas looked necrotic but histologic examination in 2 patients revealed media degeneration rather than necrosis. We have had no similar experience in our series. In particular, we have not seen redissection occurring in areas treated with GRF-glue. However, the report by Fukunaga and colleagues [7] raises an important concern that needs further follow-up; in particular, the formaldehyde component, when used excessively, seems to cause tissue necrosis [7].
Limitations of the study
The current series is a retrospective review covering a long time interval. Accordingly, many surgeons have operated on the patients included in this study. Although each surgeon might have a personal approach, the technique used to reconstruct the aortic root was relatively uniform, with the exception of the use of Teflon, GRF-glue, or fibrinous glue to approximate the dissected layers. In addition, the decision to perform a root reconstruction was made intraoperatively and was entirely dependent on the surgeon’s preference and estimation of the feasibility. This is, of course, very subjective and might have contributed to a selection bias of patients undergoing root reconstruction. In addition, the individual choice of the product used for root reconstruction resulted in different sample sizes and combination of different products. This bias, however, should have been accounted for by the statistical analysis.
Another limitation of the study is the absence of a grading system reflecting to what extent the aortic root was affected by the dissection. We initially aimed to do so but given the retrospective nature of the study, many operative reports did not mention to what extent the aortic root was affected and we abandoned this idea. We are therefore unable to determine whether reoperations occurred in the more heavily affected aortic root. It is our current strategy to reconstruct the aortic root only when one sinus is affected completely or two sinuses partially. If the dissection involves more than one sinus of Valsalva, we currently favor the reimplantation technique described by David and associates [8].
Conclusion
Aortic valve preservation and root reconstruction in patients undergoing operation for acute type A aortic dissection with involvement of the aortic root provides relatively durable results. Freedom from aortic root reoperation is 69% at 10 years.
The use of fibrinous glue seems to compromise the durability of the repair and there is a trend toward enhanced durability whenever GRF-glue is used versus Teflon.
We believe that an aortic valve reimplantation procedure according to David and associates [8] or a Bentall procedure [2] is more appropriate in patients with an aortic annulus more than 27 mm.
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