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Ann Thorac Surg 2002;73:720-723
© 2002 The Society of Thoracic Surgeons

Original article: cardiovascular

Reduction aortoplasty for dilatation of the ascending aorta in patients with bicuspid aortic valve

Matthias Bauer, MDa, Miralem Pasic, MD, PhD*a, Raymond Schaffarzyk, MDa, Henryk Siniawski, MDa, Friedrich Knollmann, MDa, Rudolf Meyer, MD, PhDa, Roland Hetzer, MD, PhDa

a Deutsches Herzzentrum Berlin, Berlin, Germany

Accepted for publication November 1, 2001.

* Address reprint requests to Dr Pasic, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany
e-mail: pasic{at}dhzb.de


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
 References
 
Background. Individuals with bicuspid aortic valve tend to develop a dilatation of the ascending aorta. It is controversial whether the dilated ascending aorta should be replaced with a tube graft or whether the diameter of the aorta should be reduced by reduction aortoplasty. Furthermore, it is unclear whether an external prosthetic support of the reduction aortoplasty is necessary. The aim of this study is to analyze the results of reduction aortoplasty with and without external prosthetic support.

Methods. Between 1985 and 1999, a total of 115 patients with bicuspid aortic valve and dilatation of the ascending aorta underwent reduction aortoplasty in combination with other types of open-heart procedure at our institution. The diameter of the ascending aorta was measured before and early after surgery and then later between 12 and 144 months (mean 40 months) postoperatively using echocardiography and computed tomography.

Results. The reduction aortoplasty decreased the internal diameter of the aorta from 48.7 ± 5.1 mm preoperatively to 36.9 ± 3.6 mm early after surgery (p = 0.0001). During follow-up, there was no increase of the aortic diameter either in patients with external prosthetic support or in 97 of 106 patients without external prosthetic support. The diameter increased only in 9 (8.5%) of 106 patients without external aortic support by 4 to 8 mm. In patients with postoperative diameter increase, the aortic diameter after operation had been higher than in patients without a postoperative increase of the aortic diameter (41.4 ± 3.1 mm vs 36.6 ± 3.4 mm; p < 0.0001).

Conclusion. Reduction aortoplasty showed good long-term results in patients with bicuspid aortic valve and dilatation of the ascending aorta. Redilation of the aorta occurred only in patients with a suboptimal diameter reduction.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 Acknowledgments
 References
 
Dilatation of the ascending aorta is found in 10% to 12% of patients with congenital bicuspid aortic valve [1–3]. Although aortic dilatation can be more diffuse and may involve the proximal aortic arch, the typical finding is local enlargement of the right aortic border at the convexity of the ascending aorta. It can be found even in the absence of a significant hemodynamic dysfunction of the valve. This aortic dilatation may lead to aortic rupture or dissection.

Surgical therapy of this entity is not clearly defined. Either the changed ascending aortic segment can be replaced with a graft, or the aortic diameter can be reduced by excision of the part of the aortic wall, and after simple closing of the aorta, its size becomes almost normal. In addition, the aorta may be externally supported by wrapping it with a prosthetic graft [4–8]. There is, as yet, no study that analyzes whether the ascending aorta dilates during the postoperative course. Therefore, the aim of this retrospective study was to analyze the diameter of the ascending aorta early postoperatively and later on during the postoperative course.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 Acknowledgments
 References
 
Patients
From May 1986 to March 1999, a total of 115 patients (36 female, 79 male) with bicuspid aortic valve and dilatation of the ascending aorta underwent reduction aortoplasty alone or in combination with another cardiac procedure (Table 1). The patients’ age varied from 18 to 85 years (mean 56 ± 13 years). In 106 patients (group I), reduction aortoplasty was performed without additional external prosthetic support of the aortic wall. In the remaining 9 patients (group II), the aorta was externally supported by wrapping the ascending aorta with a prosthetic graft. None of the patients had characteristics of the Marfan syndrome, as this surgical technique is contraindicated in patients with this syndrome. In all, 55 patients had aortic valve stenosis, 26 aortic valve insufficiency, and 28 combined aortic valve disease, whereas 6 had normal aortic valve function.


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  		Table 1. Operations Performed

 
Surgical procedure
The surgical protocol consisted of aorto-atrial cannulation for extracorporeal circulation and use of cold crystalloid cardioplegic solution and moderate hypothermia (30°C). The aortic cannula was placed in the proximal transverse aortic arch. The aorta was opened with a longitudinal incision beginning directly below the aortic clamp and directed along the anterior aortic aspect into the noncoronary sinus of Valsalva. The aortoplasty to normal diameter was performed by removal of an elliptical portion of aortic wall along the aortotomy incision (Fig 1). The aortotomy was closed in two layers using 4-0 polypropylene sutures (Fig 2). The reduction plasty of the ascending aorta was either left alone or additionally supported by wrapping the ascending aorta with a prosthetic Dacron (C. R. Bard, Haverhill, PA) graft (Figs 3 and 4). The decision whether to use external aortic support was left to the individual surgeons according to their subjective estimation of the quality and thickness of the ascending aortic wall.



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  		Fig 1. Technique of reduction aortoplasty begins with longitudinal incision of ascending aorta (A) and resection of oval segment of ascending aortic wall (B).

 


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  		Fig 2. After resection, longitudinal aortotomy is closed in two rows using polypropylene 4-0 suture (A). First row is continuous mattress suture (B), followed by over-and-over continuous suture (C).

 


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  		Fig 3. Preparation of Dacron tube graft for wrapping of ascending aorta. Prosthesis is cut longitudinally (A and B) and two pieces of the prosthesis are excised from the ends of the graft (C), forming a "butterfly" shape of the prosthesis (D).

 


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  		Fig 4. Wrapping of ascending aorta with prosthetic graft. Graft is pulled below aorta (A), oversewn with continuous suture, and fixed to aortic wall at ends (B).

 
Data measurements
We measured the diameter of the ascending aorta at three points: before surgery, during the early postoperative course, and during the follow-up period of 12 to 144 months (mean, 40 months). The diameter of the aorta was measured by echocardiography and by a computed tomographic scan of the chest. The diameter was measured at the level of bifurcation of the pulmonary artery.

Statistics and data presentation
For continuous data, means ± standard deviation are given. Repeated measures analysis of variance was applied to test for time and group effects and their interactions. Sidak’s method was used to adjust for multiple testing. Data from additional tests are reported unadjusted.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 Acknowledgments
 References
 
Thirty-day and hospital mortality
There were no perioperative or early postoperative deaths and no major surgical complications. Two patients died after 2 and 3 months, respectively, due to septic multiorgan failure.

Follow-up and late survival
The late follow-up period was between 1 and 12 years (mean, 3 years 4 months). The follow-up was complete in all patients. During the late postoperative course 3 patients died. The causes of the late deaths were myocardial infarction in 1 patient and cancer in 2. A total of 110 patients were alive at the time of the last follow-up examination, but 3 of them did not want to undergo the examination. There were no reoperations on the ascending aorta or aortic valve during the follow-up period. The 5-year survival rate was 94% ± 3.1% (Fig 5).



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  		Fig 5. Survival of patients after reduction aortoplasty (Kaplan-Meier curve ± 95% confidence interval). Number of patients at risk at each time point is given.

 
Ascending aorta diameter
The mean preoperative diameter of the ascending aorta for the whole group of patients was 48.7 mm ± 5.1 mm. There was a significant difference in the mean diameter of the ascending aorta between group I (aortoplasty without wrapping) and group II (aortoplasty with wrapping): group I, 48.4 mm ± 4.9 mm; group II, 52.0 mm ± 6.3 mm; p = 0.042. The variability of the mean diameter with regard to different types of measurements (echocardiography versus computed tomography) was only 0.8 mm ± 0.48 mm, with no difference between the median values (group I, 48 mm versus group II, 48 mm). The reduction plasty of the ascending aorta resulted in a significant reduction of the ascending aortic diameter in all patients (p < 0.0001). Early after surgery, the mean diameter of the ascending aorta was 36.9 mm ± 3.6 mm for the whole group. There was no difference between the groups (group I, 37.0 mm ± 3.6 mm; group II, 35.6 mm ± 2.9 mm; p = 0.27). After the mean follow-up period of 3 years 4 months (range, 1 to 12 years), the diameter of the ascending aorta was 38.0 mm ± 4.5 mm (group I, 38.1 mm ± 4.6 mm; group II, 36.6 mm ± 2.9 mm; p = 0.37). There was also no significant difference in the postoperative increase in diameter of the ascending aorta between the two groups (group I, 1.1 mm ± 1.8 mm; group II, 0.5 mm ± 0.76 mm; p = 0.37) after 1 to 12 years (mean, 3 years 4 months). The mean diameter of the ascending aorta during the follow-up is shown for the whole group (Fig 6) and for the two groups (Fig 7) as a function of time.



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  		Fig 6. Mean diameter (± standard deviation) of ascending aorta of all patients during follow-up period. Number of patients at risk at each time point is given. (OP = operation; preop = preoperatively.)

 


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  		Fig 7. Mean diameter of ascending aorta of group I (with no external support) and group II (with external support) during follow-up. There was no difference in mean diameter of ascending aorta between groups I and II during postoperative period. Numbers of patients at risk at each time point are given. (OP = operation; preop = preoperatively.)

 
During the late follow-up, a significant increase (> 4 mm) of the ascending aortic diameter was found in 9 patients (8.9%) from group I and in none from group II. The only variable that influenced the postoperative redilation of the ascending aorta was the early postreduction diameter. In those patients who later developed redilation, the diameter early after reduction aortoplasty was significantly larger than in patients without later redilation (patients with redilation, 41.4 mm ± 3.1 mm; patients without redilation, 36.6 mm ± 3.4 mm; p < 0.0001) (Fig 8). There were no other differences between the patients with redilatation of the ascending aorta and the other patients in group I with regard to age (p = 0.096), underlying aortic valve disease, gender, follow-up interval (mean 33.5 months versus mean 39.7 months; p = 0.53), and preoperative ascending aorta diameter (50.2 mm ± 2.4 mm versus 48.7 mm ± 5.3 mm; p = 0.417).



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  		Fig 8. Mean diameter of ascending aorta in patients with and without redilatation of ascending aorta (by > 4 mm) during follow-up. Numbers of patients at risk at each time point are given. (OP = operation; preop = preoperatively.)

 

   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
Acknowledgments
 References
 
Our study showed that reduction aortoplasty successfully shortened the ascending aortic size in most patients with dilated ascending aorta and bicuspid aortic valve. However, if the aortic size was not sufficiently reduced, the aorta was prone to redilation during the later postoperative period. Therefore, to avoid later redilation, a dilated ascending aorta should either be significantly reduced to a diameter less than 35 mm or should be externally supported with a Dacron graft.

There are several surgical techniques for treatment of a dilated ascending aorta in association with a bicuspid aortic valve, such as supported and unsupported aortoplasty, separate replacement of the aortic valve and ascending aorta [9], valve-sparing root replacement [10, 11], composite root replacement as described by Bentall and DeBono [12], and aortic root replacement with pulmonary autograft [13]. The most conservative method is the reduction aortoplasty that was first described by Robicsek [8]. This technique involves the resection of an oval segment of the ascending aortic wall after longitudinal aortotomy followed by Dacron wrapping of the aorta [8]. A modification is to shorten the diameter of the ascending aorta with an S-shaped incision and excision of the curves of the "S" [14]. This simple technique can easily be performed in patients with severe cardiac disease in whom prolonged cardiopulmonary bypass time and aortic cross-clamping cannot be tolerated [5]. In cases with aneurysm formation caused by hemodynamic forces associated with a diseased bicuspid aortic valve, this technique may also be applied after correcting the pathologic condition of the aortic valve [5, 7, 8, 15]. A technique that reduces the size of the ascending aorta is particularly important when the aortic valve replacement is performed by a stentless valve. It is well known that even slight dilatation of the sinotubular junction after implantation of a stentless valve will result in premature degeneration of the stentless prosthesis. However, because of possible recurrent dilatation of the ascending aorta, this method was considered only as a good compromise in older patients with a borderline dilated aorta, particularly during operations for other cardiac conditions [5, 14]. The results of this study show that reduction aortoplasty is a simple method to treat dilated ascending aorta. It is a possible alternative to aortic graft replacement. To avoid later redilation, the aortic size should either be less than 35 mm or the ascending aorta should be supported from the outside with a Dacron graft.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
References
 
We are grateful to Anne Gale for editorial assistance, to Julia Stein for help with the statistical analysis, and to Reinhold Giering-Jaensch for the illustrations.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Roberts W.C. The congenitally bicuspid aortic valve. A study of 85 autopsy cases. Am J Cardiol 1970;26:72-83.[Medline]
  2. Yosemite G., Moriyama Y., Toyohira H., et al. Congenital bicuspid aortic valve: analysis of 63 surgical cases. J Heart Valve Dis 1998;7:500-503.[Medline]
  3. Ando M., Okita Y., Morota T., Takamoto S. Thoracic aortic aneurysm associated with congenital bicuspid aortic valve. Cardiovasc Surg 1998;6:629-634.[Medline]
  4. Mueller X.M., Tevaearai H.T., Genton C.Y., et al. Drawback of aortoplasty for aneurysm of the ascending aorta associated with aortic valve disease. Ann Thorac Surg 1997;63:762-767.[Abstract/Free Full Text]
  5. Carrel T., von Segesser L., Jenni R., et al. Dealing with dilated ascending aorta during aortic valve replacement: advantages of conservative surgical approach. Eur J Cardiothorac Surg 1991;5:137-143.[Abstract]
  6. Barnett M.G., Fiore A.C., Vaca K.J., Milligan T.W., Barner H.B. Reduction aortoplasty for repair of fusiform ascending aortic aneurysm. Ann Thorac Surg 1995;59:497-501.[Abstract/Free Full Text]
  7. Egloff L., Rothlin M., Kugelmeier J., Senning A., Turina M. The ascending aortic aneurysm: replacement or repair?. Ann Thorac Surg 1982;34:117-124.[Abstract]
  8. Robicsek F. A new method to treat fusiform aneurysms of the ascending aorta associated with aortic valve disease: an alternative to radical resection. Ann Thorac Surg 1981;34:92-94.[Abstract]
  9. Yun K.L., Miller D.C., Fann J.I. Composite valve graft versus separate aortic valve and ascending aortic replacement: is there still a role for the separate procedure. Circulation 1997;96(Suppl 1):368-375.
  10. Sarsam M.A., Yacoub M. Remodelling of the aortic valve annulus. J Thorac Cardiovasc Surg 1993;105:435-438.[Abstract]
  11. David T.E., Amstrong S., Ivanov J., Webb G.D. Aortic valve sparing operations: an update. Ann Thorac Surg 1999;67:1840-1842.[Abstract/Free Full Text]
  12. Bentall H., DeBono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338-339.[Abstract/Free Full Text]
  13. Dossche K.M., de la Riviere A.B., Morshuis W.J., Schepens M.A.A.M., Ernst S.M., van den Brand J.J. Aortic root replacement with the pulmonary autograft: an invariably competent aortic valve. Ann Thorac Surg 1999;68:1302-1307.[Abstract/Free Full Text]
  14. Baumgartner F., Omari B., Pak S., Ginzton L., Shapiro S., Milliken J. Tailoring aortoplasty for moderately sized ascending aortic aneurysms. J Card Surg 1998;13:129-132.[Medline]
  15. Ergin M.A., Spielvogel D., Apaydin A., et al. Surgical treatment of the dilated ascending aorta: when and how?. Ann Thorac Surg 1999;67:1834-1839.[Abstract/Free Full Text]

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