Ann Thorac Surg 2001;72:1497-1501
© 2001 The Society of Thoracic Surgeons
Original article: cardiovascular
Influence of technique of coronary artery implantation on long-term results in composite aortic root replacement
Aristotelis Panos, MDa,
Brahim Amahzoune, MDa,
Jacques Robin, MDa,
Gerard Champsaur, MDa,
Jean Ninet, MD*a
a Clinic for Cardiovascular Surgery C, Hôpital Cardiologique Louis Pradel, Université Claude Bernard, Lyon, France
Accepted for publication June 22, 2001.
* Address reprint requests to Dr Ninet, Clinic for Cardiovascular Surgery C, Hôpital Cardiologique Louis Pradel, B.P. Lyon-Montchat, 69394 Lyon Cedex 03, France
e-mail: jean.ninet{at}chu-lyon.fr
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Abstract
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Background. Long-term results after composite graft aortic root replacement may depend on the insertion technique. The aim of this study is to assess the influence of the technique of coronary artery implantation on long-term results in composite aortic root replacement.
Methods. One hundred fifty consecutive patients (mean age, 55 years; 119 men) with different disorders of the ascending aorta who underwent aortic root replacement with a composite graft prosthesis between January 1985 and December 1999 were retrospectively studied. Thirteen patients had previously undergone cardiovascular surgery. The open button technique was performed in 65 patients (43.3%, group 1) and the inclusion technique in 85 patients (56.7%, group 2). Mean follow-up was 70.5 months. Surgery was elective in 110 procedures (73%).
Results. Global actuarial survival was 76.1% ± 4.3% for group 1 and 73.7% ± 3.9% for group 2 at 10 years (p = 0.22). Freedom from reoperation excluding early deaths was 81% ± 3% for group 1 and 86% ± 2.2% for group 2 at 10 years (p = 0.62). Group 2 demonstrated a statistically significantly higher occurrence of pseudoaneurysm formation versus group 1 (p = 0.04).
Conclusions. Composite graft aortic root replacement is a safe and effective therapy for proximal aortic aneurysm and dissection, resulting in good early and long-term results irrespective of the anastomotic technique. However, the open button technique seems to avoid late false aneurysm formation at the anastomotic sites.
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Introduction
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Surgery of the ascending aorta remains a challenge despite major improvement in diagnosis, surgical techniques, and material in recent years. Different techniques have been developed because of the different disorders that may affect the ascending aorta and the aortic valve. The introduction of valved composite grafts by Bentall and de Bono [1] in 1968 helped to expand the possibilities for definitive surgical treatment of the aortic root. According to this technique, the aortic tissue surrounding the coronary ostia is directly sutured to the openings in the aortic tube graft. These anastomoses are all made within the interior of the aorta, and the aortic wall is then wrapped tightly around the graft. This is the inclusion technique. Its main late complication is reported to be the formation of pseudoaneurysms at the anastomotic sites [2, 3]. Kouchoukos and colleagues [4] in 1991 described the open technique, in which the diseased aorta is resected, and the coronary ostia excised with an aortic button and then sutured directly to openings in the tube graft. The purpose of this study was to assess the influence of the technique of coronary artery implantation on long-term results in composite aortic root replacement.
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Patients and methods
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Between January 1985 and December 1999, 150 consecutive patients (119 men) underwent replacement of the ascending aorta and aortic valve with composite graft prosthesis at the University Hospital Louis Pradel, Lyon, France. Age at operation ranged between 17 and 88 years (mean, 55 ± 14.4 years). We obtained clinical data by retrospective review of the hospital archives and follow-up data from telephone communication with the patients or their physician. Follow-up was complete in 128 of 136 patients who were early survivors (mortality, < 30 days) with a mean duration of 68.7 ± 45.5 months (range, 4 to 177.6 months). The indications for aortic root replacement are summarized in Table 1. Group 1 was composed of 65 patients (43.3%) operated on with the open button technique, and group 2 was composed of 85 patients (56.7%) operated on with the inclusion technique. Surgery was elective in 110 procedures (73.3%), 51 patients in group 1 and 59 patients in group 2. Forty procedures (26.7%) were emergencies, 14 in group 1 and 26 in group 2. Acute type A aortic dissection accounted for 33 of the 40 emergency procedures. Fourteen of 33 acute aortic dissections were in group 1 and the remaining 19 in group 1. The two techniques were compared in both groups for the variables mortality, late survival, postoperative bleeding, and reoperation. The procedure was a primary operation in 137 patients and a redo in 13 patients. An associated coronary artery bypass graft operation was simultaneously performed in 9 patients (6%).
Operative details
A median sternotomy was performed and cardiopulmonary bypass initiated by cannulation of the ascending aorta or femoral artery. In aortic dissection femoral cannulation was standard. Mild systemic hypothermia was used (30°C). When it was necessary to repair an extended to the aortic arch dissection (2 patients), we used profound hypothermia and total circulatory arrest at systemic temperatures of 20°C to 22°C. Antegrade cold potassium crystalloid cardioplegic solution was used in all cases given through the coronary ostia. The left ventricle was vented through a transmitral catheter or through the left ventricle apex. Preclotted woven valved (Hemashield Meadox-St. Jude; St. Jude Medical, Moulineaux, France) conduits were used for the entire study period. In group 2 (85 patients) the coronary ostia were not detached from the aortic wall, but were directly implanted side to side into the graft according to the initial Bentall and de Bono [1] technique. In group 1 (65 patients) the coronary arteries were excised from the aortic wall, preserving buttons of aorta surrounding the ostia, according to the open technique described by Kouchoukos and associates [4]. During the study period the two techniques were equally distributed. The proximal end of the valved graft was implanted with interrupted braided 2-0 mattress sutures reinforced with pledgets. The coronary ostia were attached directly to the openings made in the aortic tube graft with 4-0 or 5-0 polypropylene continuous sutures. No polytetrafluoroethylene (Teflon) felt strips (Boston Scientific, Yvelines, France) were used to buttress the coronary artery ostial anastomoses. The distal anastomosis of the graft to the native aorta was performed with continuous 3-0 polypropylene suture usually buttressed with strips of felt on the outside of the aorta. Fibrin glue (Tissucol; Baxter, Maurepas, France) was applied since 1987 to seal the suture lines around the aortic annulus and the anastomoses, 2 to 3 minutes before releasing the aortic clamp. The same fibrin glue was also used to readapt and reinforce the dissected layers of the aortic distal stump in case of dissection. For aortic valve replacement, 142 mechanical valves (95%) and 8 bioprostheses (4 stented and 4 nonstented; 5%) were used. Mean cardiopulmonary bypass time was 112.5 ± 28.5 minutes, and mean aortic cross-clamp time was 86 ± 19 minutes. The corresponding times for acute dissection were 132.3 ± 37.1 minutes and 95.5 ± 24.5 minutes, respectively.
Statictical analysis
Continuous variables are given as mean ± standard deviation. Univariate analysis was performed by 
2. A probability level of less than 0.05 was required to consider a result as statistically significant. Survival and event-free probabilities ± standard deviation were calculated by actuarial analysis according to the method of Kaplan-Meier.
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Results
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Early mortality (30 days)
Fourteen patients (9.3%) died within 30 days. The causes of death are summarized in Table 2. In acute dissection early mortality was 24.2% versus 5.4% in nondissection (p = 0.01). Group 1 in acute dissection had an early mortality of 21.4% versus 26.3% for group 2 (p = 0.56). Mortality in group 1, for nondissection patients was 3.9% and in group 2, 6.8% (p = 0.42). Survival at 30 days was 92.3% for group 1 and 89.4% for group 2 (p = 0.49). Reexploration for bleeding was performed in 4.6% of the patients operated on with the open technique, group 1, and in 7.2% of the patients operated on with the inclusion technique, group 2 (p = 0.4). Reexplorations for hemorrhage in the acute dissection patients was 15.1% compared with 3.4% in the nonacute dissection patients (p = 0.04).
Late survival
The mean duration of follow-up was 70.5 ± 51.1 months. Global actuarial survival was 89.2% ± 1.7% for group 1 and 79.4% ± 1.3% for group 2 at 5 years and 76.1% ± 4.3% and 73.7% ± 3.9% for groups 1 and 2, respectively, at 10 years (p = 0.22), as depicted in Figure 1. A total of 10 late deaths occurred among the 136 early survivors. Four patients died of terminal heart failure, 2 were found dead at home (autopsy not asked from the family), 2 suffered from cerebral hemorrhage and died days after in the hospital of pulmonary complications, 1 developed colic neoplasm, and 1 died after pneumonia. Eight patients (5.9%) have been lost during follow-up. Mean time between operation and reintervention was 4.4 ± 3.6 years (range, 1.2 to 12.0 years). Reintervention was performed on 8 patients (6.2%), early reexplorations excluded. In patients with acute dissection this rate was 16% compared with 3.6% in the nondissection patients (p = 0.05). Additionally, 1.7% of the patients in group 1 were reoperated on compared with 9.2% in group 2 (p = 0.078). The reoperation rate in patients with Marfan disease was 13.3% compared with 7% in all other patients (p = 0.35). Reintervention was indicated in 2 patients (acute aortic dissection having caused the primary operation) for an extension of the aortic dissection to the distal aortic segment, in 3 patients because they had pseudoaneurysms on the coronary ostial suture line, in 2 patients because they had distal aortic graft pseudoaneurysm (Marfan disease), and in 1 patient because of mitral valve insufficiency. The 2 patients who presented an extension of the aortic dissection and the 1 with mitral valve insufficiency were in group 1 and were operated on according to the open button technique. The remaining patients (n = 5) who had pseudoaneurysm formations were in group 2, and were operated on according to the inclusion technique. The rate of pseudoaneurysm formation among the early survivors of group 2 was 6.7% whereas 0% of the patients in group 1 presented the same condition (p = 0.04). Overall mortality of reoperations was 37.5%. One patient died of cerebral hemorrhage 14.6 months after reoperation indicated for a false aneurysm of the left coronary ostium. The remaining 2 patients died at home of sudden death at 27 days and 35 months after reoperation, indicated for false aneurysm formation on the right coronary ostium as well. One of them suffered from Marfan disease. Freedom from reoperation excluding early deaths was 94% ±1.7% and 93.7% ± 1.3% for groups 1 and 2, respectively, at 5 years, while at 10 years these ratios were 81% ± 3% and 86% ± 2.2% for groups 1 and 2, respectively (p = 0.62; Fig 2).
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Fig 1. Global actuarial survival according to technique. Group 1 is composed of 65 patients operated on with the open button technique. Group 2 is composed of 85 patients operated on with the inclusion technique.
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Comment
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Composite valve and graft replacement of the aortic root is the most radical mode of treating a variety of proximal aortic conditions including aortic dissection and ascending aorta aneurysms. Although the use of composite grafts is now routine, the optimal method of anastomosing the coronary ostia to the tube graft is still a matter of debate [5–7]. Among our patients we used two different surgical approaches. Patients in group 1 were operated on with the open technique described by Kouchoukos and coworkers [2, 4], and patients in group 2 were operated on with the inclusion technique described by Bentall and de Bono [1]. Direct comparison between these studies is usually difficult as the patient groups may vary between the series. In our study both surgical techniques were equally distributed across the study period because of the simultaneous presence of surgeons using preferably only one or the other technique.
Replacement of the ascending aorta with a composite valved graft can be performed with an overall early mortality ranging between 18% and 5% [2, 8]. In the present study our overall early mortality (30 days) is 9.3%, which is in accordance with the above cited results. In nondissection patients the early mortality is 5.4% whereas in acute aortic dissection the early mortality is 24.2% (p = 0.01), which compares favorably with other published series. Indeed Kouchoukos and associates [2] and Svenson and colleagues [9] reported early mortality in acute dissection of 25% and 24%, respectively. Mingke and coworkers [10] in their study of 335 patients with acute and chronic dissections reported an acute early mortality of 17%. The older average age in our study, 55 years versus 47 to 50 years in these studies, may explain in part this difference in the mortality. One study reporting comparable patient demographics and similar inclusion and open technique rates is reported by Niederhäuser and colleagues [11]. Their study reports an early mortality of 17.4% in the dissection group and 3% in the nondissection group. The overall early mortality is 6.6%. In the same study, patients with an acute dissection graft inclusion had an early mortality of 16.1% compared with 20% for the open technique. This difference is not statistically significant. Our early mortality rates for the same conditions were 26.3% and 21.4%, respectively (p = 0.56), and again the difference was not significant. For patients without acute dissection the corresponding figures, in our study, were 6.8% and 3.9% respectively, (p = 0.42), whereas Niederhäuser and associates [11] reported early mortality of 2.6% and 3.4% for the inclusion versus open technique, respectively. Given the similitude of the variables between these two studies, this difference may be caused by the higher rate of urgent surgery in our population, 27% versus 24% in the study by Niederhäuser and colleagues [7]. Comparable results are also reported by Langley and coworkers [12], who report an early mortality of 7% in the subgroup of patients (28%) treated during emergency surgery on a total of 143 patients. In the same study the late survival at 4 years is 83%. Overall postoperative actuarial survival in our study was 89% at 1 year, 83% at 5 years, and 74% at 10 years (Fig 1). These results compare favorably with those of other studies [2, 5, 6, 9, 13, 14].
In series combining emergency and elective surgery, the reexploration rate for bleeding is between 6.1% [10] and 19% [8]. In our study this rate is 6.1%, comparable to that found by Mingke and colleagues [10]. To examine whether there are any differences in the bleeding incidence according to the operative technique, we have analyzed patients according to the criteria of acute dissection or not and graft inclusion or open button technique. In acute dissection patients, groups 1 and 2 had a reexploration rate of 4.6% and 7.2%, respectively, which is not significantly different (p = 0.39). These results are in accordance with those of Niederhäuser and colleagues [7], who reported a reexploration rate for hemorrhage of 21% and 19% (p = 0.87) with the inclusion and open button techniques, respectively, in acute aortic dissection. In contrast, our rates of reexploration for bleeding are much lower in general. Indeed the overall reexploration rate for bleeding in the acute dissection patients irrespective of the insertion technique is 15.1%, whereas in the study by Niederhäuser and coworkers [7] this rate is 20%. In the nonacute dissection patients, the corresponding rates were 1.9% versus 4.5% (p = 0.42). In series combining dissection and nondissection patients, similar results for the open technique were disclosed [2, 8, 9, 15]. We believe that the relatively low rate of reoperation for bleeding in our study was achieved by the extensive and generalized use of the fibrin glue around the anastomoses of the coronary ostia, aortic annulus, and distal aorta. Follow-up of our patients has shown a reoperation incidence of 6.2%. Comparison of reoperation rate between acute dissection and nondissection patients did not achieve statistical significance. The same was true for the patients of groups 1 and 2 (p = 0.078). Similarly, although no significant difference was noted for the overall reoperation rate between the two techniques, the incidence of pseudoaneurysm formation was higher in the inclusion graft technique (p = 0.04). For such local complications on the site of anastomosis, we can incriminate technical errors or malassessment of the initial aortic disease during the first intervention. Technical errors could be related to the operator’s learning curve effect, but their equally distributed occurrence throughout the review period negates this hypothesis.
In reviews by Kouchoukos and associates [2], Svenson and colleagues [9], and Niederhäuser and coworkers [7], no patient required reoperation for a coronary anastomosis complication when the open button technique was used. Mavrasti and associates [3] documented a pseudoaneurysm formation in 3 of 15 patients who underwent control angiography 6 to 58 months after operation. Niederhäuser and colleagues [7] reported a specific coronary ostia pseudoaneurysm formation in 3% of their patients, and in our study this complication rate was as high as 4.3%. We think that the real incidence of anastomotic complication, at least in our study, may be underestimated because of the lack of routine postoperative screening protocols.
In conclusion, we assume that composite graft aortic root replacement is a suitable treatment for most pathologic conditions affecting the aortic root. It is a safe and effective therapy for proximal aortic aneurysm and dissection, resulting in good early and late results. Despite the lack of difference in survival or reexploration rates for bleeding between the two groups of patients, the open button technique (group 1) seems to avoid late false aneurysm formation on the anastomotic sites.
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References
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|---|
-
Bentall H., de Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338-339.[Abstract/Free Full Text]
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Kouchoukos N.T., Wareing T.H., Murfy S.F., Perillo L.B. Sixteen year experience with aortic root replacement. Ann Surg 1991;214:308-320.[Medline]
-
Mavrasti M.A., Parker F.B., Randall P.A., Witwer G.A. Composite graft replacement of the ascending aorta and aortic valve. J Thorac Cardiovasc Surg 1988;95:924-928.[Abstract]
-
Kouchoukos N.T., Marschall W.G., Wedige-Stecker T.A. Eleven year experience with composite graft replacement of the ascending aorta and aortic valve. J Thorac Cardiovasc Surg 1986;92:691-705.[Abstract]
-
Lytle B.W., Mahfood S.S., Cosgrove D.M., Loop F.D. Replacement of the ascending aorta. Early and late results. J Thorac Cardiovasc Surg 1990;99:651-658.[Abstract]
-
Lewis C.T., Cooley D.A., Murphy M.C., Talledo O., Vega D. Surgical repair of aortic root aneurysms in 280 patients. Ann Thorac Surg 1992;53:38-46.[Abstract]
-
Niederhäuser U., Rüdiger H., Vogt P., Künzli A., Zünd G., Turina M. Composite graft replacement of the aortic root in acute dissection. Eur J Cardiothorac Surg 1998;13:8144-8150.
-
Lepore V., Larsson S., Bugge M., Mantovani V., Karlsson T. Replacement of the ascending aorta with composite valve grefts: long term results. J Heart Valve Dis 1996;5:240-246.[Medline]
-
Svenson L., Crawford E.S., Hess K.R., Coselli J., Safi H. Composite valve graft replacement of the proximal aorta: comparison of techniques in 348 patients. Ann Thorac Surg 1992;54:427-439.[Abstract]
-
Mingke D., Dresler C., Stone C.D., Borst H.G. Composite graft replacement of the aortic root in 335 patients with aneurysm or dissection. Thorac Cardiovasc Surg 1998;46:12-19.[Medline]
-
Niederhäuser U., Künzli A., Genoni M., Vogt P., Lachat M., Turina M. Composite graft replacement of the aortic root: long term results, incidence of reoperations. Thorac Cardiovasc Surg 1999;47:317-321.[Medline]
-
Langley S., Rooney S., Dalrymple-Hay M., 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 1999;118:1014-1120.[Abstract/Free Full Text]
-
Crawford E.S., Svensson L.G., Coselli J., et al. Surgical treatment of aneurysm and/or dissection of the ascending aorta and transverse aortic arch. Factors influencing survival in 717 patients. J Thorac Cardiovasc Surg 1989;98:659-674.[Abstract]
-
Gott V.L., Gillinov A.M., Pyeritz R.E., et al. Aortic root replacement: risk factor analysis of a 17-year experience with 270 patients. J Thorac Cardiovasc Surg 1995;109:536-545.[Abstract/Free Full Text]
-
Hilgenberg A.D., Akins C.W., Logan D.L., Vlahakes G.J., Buckley M.J., Madsen J.C. Composite aortic root replacement with direct coronary artery implantation. Ann Thorac Surg 1996;62:1090-1095.[Abstract/Free Full Text]
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Abstract
Introduction
