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Ann Thorac Surg 2003;76:698-703
© 2003 The Society of Thoracic Surgeons
a DEPARTMENT OF Cardiothoracic Surgery, New York, New York, USA
b DEPARTMENT OF Biomathematics, Mount Sinai School of Medicine, New York, New York, USA
Accepted for publication March 17, 2003.
* Address reprint requests to Dr Griepp, Mount Sinai School of Medicine, Department of Cardiothoracic Surgery, One Gustave L. Levy Place, Box 1028, New York, NY 10029, USA
e-mail: chagl{at}hotmail.com
Presented at the Forty-eighth Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 8–10, 2001.
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Abstract |
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METHODS: One hundred forty-two elective patients younger than 65 years without concomitant procedures who underwent replacement of the thoracic aorta and aortic valve between 1989 and 2000 were studied; 85% were men, and the median age was 46 years (range, 13 to 64 years). Degenerative disease of the aorta was the most common cause requiring operation (86%, including 46% with a bicuspid aortic valve); 8% had chronic dissection, and 6% had atherosclerotic aneurysms. The ascending aorta was replaced in 94 patients (66%); 45 patients (32%) underwent hemiarch replacement, and in 3 patients (2%) the total arch was replaced. A mechanical valve was used in 88%, and a biologic valve, in 12%.
RESULTS: There were no intraoperative deaths. Two patients had a stroke postoperatively, one of which was fatal. Complications during follow-up included 2 cases of endocarditis, 1 peripheral thromboembolic event, and 10 instances of significant bleeding (requiring hospitalization or transfusion). Surgery for distal aortic segments was performed in 4 patients, but no patient required reoperation in the proximal aorta. Kaplan-Meier curves show overall survival is 0.95 (95% confidence intervals, 0.9 to 0.99) at 5 years and 0.93 (95% confidence intervals, 0.86 to 0.99) at 8 years, and event-free survival is 0.85 (95% confidence intervals, 0.78 to 0.92) at 5 years and 0.78 (95% confidence intervals, 0.68 to 0.88) at 8 years.
CONCLUSIONS: The button Bentall procedure can be performed with excellent short-term and long-term results in relatively uncomplicated elective patients in whom aortic valve disease is combined with dilatation of the ascending aorta. Results of this traditional operation are the standard against which the long-term outcome of newer approaches, such as valve-sparing operations, should be compared.
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Introduction |
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During the last 10 years, valve-sparing operations have become an attractive alternative to replacement of the aortic root, in the hope that they will result in improved survival and fewer complications. But it has yet to be determined whether this procedure is suitable only for patients with specific indications or is more widely applicable, and whether long-term evaluation in a variety of patient groups will uphold the promising results reported in early follow-up studies primarily involving relatively young patients.
The present retrospective study was performed to assess outcome in a series of consecutive patients from a single institution who underwent a button Bentall procedure for a variety of aortic root diseases to see whether we could define a subset of patients comparable to those who might currently be considered for valve-sparing operations. With this objective, we analyzed all patients younger than 65 years of age who underwent elective Bentall procedures but did not require concomitant procedures. Our focus was on defining long-term event-free survival to provide a basis for comparison with the results of new surgical techniques for dealing with diseases of the aortic valve and ascending aorta.
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Material and methods |
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To compare our results with the outcome of valve-sparing procedures, we thought it would be most appropriate to consider only the subset of patients who might currently be considered for these newer approaches. We therefore restricted our further analysis to 142 patients younger than 65 years of age without previous operations who underwent an elective Bentall operation without requiring a concomitant procedure. Of these patients, 46 (32%) were younger than 40 years of age, 82 (58%) were between 40 and 60 years, and 14 (10%) exceeded 60 years of age; the mean age was 46 years. The majority of patients were men (85%).
The underlying disease was degeneration in 122 patients (86%), chronic dissection in 11 patients (8%), and arteriosclerosis in 8 patients (5.6%). A bicuspid aortic valve was found in 66 patients (46%). Features of Marfan syndrome were present in 10 patients (7%). Further patient characteristics, and the risk profile for the group as a whole, are shown in Table 1.
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Briefly, cannulation for cardiopulmonary bypass was through the femoral artery in the majority of the patients, although in the last 2 years, cannulation of the right axillary artery has become the standard approach. To protect the heart, crystalloid cardioplegia solution was infused directly into the coronary ostia, and topical cooling was performed. Thorough systemic cooling to a temperature of 12° to 15°C was carried out to avoid an upward drift of the temperature during the period of circulatory arrest. A vent was placed in the left ventricle to allow decompression of the heart.
After sizing the aortic annulus, a series of pledgeted mattress sutures were placed from the ventricular to the aortic aspect of the annulus for fixation of a heterograft in an epiannular position. For a prosthetic valve, the sutures were placed from the aorta to the ventricular aspect of the annulus to effect intraannular fixation of the valve. A composite of a St. Jude valve (St. Jude Medical, St. Paul, MN) and a Hemashield graft (Boston Scientific Corp, Wayne, NJ) was used in cases for which a mechanical valve was indicated. In cases in which a biologic valve was chosen, a home-made composite, consisting of a pericardial (Edwards Lifesciences LLC, Irvine, CA) or porcine valve (Medtronic Inc, Minneapolis, MN) and a Hemashield graft, was used.
After the proximal suture line was completed, the diseased aortic segment was resected, and buttons including the coronary ostia were excised. The first centimeter of the coronary arteries was mobilized, and the buttons were implanted in an-end-to-side fashion with a running suture incorporating a polytetrafluoroethylene (Teflon) felt strip to reinforce the adventitial surface of the coronary arteries.
To allow the open distal anastomosis or the total aortic arch reconstruction, the head was placed downward, cardiopulmonary bypass was discontinued, and the aorta was trimmed appropriately for the extent of the replacement. The anastomosis between the trimmed polyethylene terephthalate fiber (Dacron) graft and the aorta was performed with a 3-0 Prolene (Ethicon, Somerville, NJ) running suture, reinforced by an outer Teflon felt strip. Before resuming cardiopulmonary bypass, the head vessels were carefully aspirated to remove air and particulate debris. In a few cases, selective cerebral perfusion using the Mount Sinai Y-arch technique, as previously described in detail [4], was carried out. In cases thought to have an especially high risk of embolization, a brief period of retrograde perfusion through the superior vena cava, at a pressure of 20 mm Hg, was performed. Cardiopulmonary bypass was discontinued when an esophageal temperature of 35° to 36°C was reached.
Statistical methods
Data were entered in an Excel (Microsoft Corp, Redmond, WA) spreadsheet and transferred to a SAS (SAS Institute, Cary, NC) file for data description and analysis. Characteristics are described as percentages or as means and standard deviations. Kaplan-Meier life tables were calculated for the risk of death and of event-free survival. Follow-up time for survival was measured from the date of the operation to the earlier of the date of death or of last contact alive, and for event-free survival, to the earlier of the first event or last contact alive. Events included death and morbid conditions defined in Edmunds and coworkers: stroke, hemorrhage requiring transfusion or hospitalization, peripheral embolization, or endocarditis. The death rate per 100 persons per year was estimated as 100 times the number deaths divided by the total person-years of follow-up. The rate of first morbid event or death per 100 persons per year was estimated as 100 times the number of persons with at least one event divided by the sum of the years from operation to first event.
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Results |
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Six patients (4.2%) died during follow-up for a variety of reasons: 4 among the patients with mechanical valves, and 1 patient with a biologic valve. The most common cause of death during follow-up was myocardial infarction, which occurred in 3 patients (2.1%), but was not thought to be related in any of the patients to problems with the coronary anastomoses as assessed at the time of yearly aortic computed tomographic scan. Fatal neurologic events occurred in 2 patients (1.4%): 1 patient had intracranial hemorrhage, and the other an ischemic insult. In 1 patient, the cause of death is unknown. The survival curve for all patients is shown in Figure 1. The rate of death was estimated as 1.0 per 100 persons per year.
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During follow-up, no patient required reoperation because of a failure of the Bentall procedure. Four patients (2.8%) underwent subsequent operation as a result of aneurysms of the more distal part of the aorta; in one case, the second operation was for completion of the elephant trunk procedures planned at the time of initial surgery. Two patients suffered endocarditis, but survived without surgical treatment.
Event free-survival, in which the events include endocarditis, stroke, bleeding and thromboembolism, is shown in Figure 2. The frequency of an initial morbid event or death was 3.6 per 100 persons per year.
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Comment |
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Although results after the Bentall operation have been steadily improving, various different valve-sparing operations have become increasingly popular, especially for patients with uncomplicated annuloaortic ectasia. As it became apparent that dilatation of the sinotubular junction is frequently responsible for the loss of central coaptation of the aortic leaflets, operations involving reimplantation of the native, structurally intact aortic valve within a Dacron tube graft appealed as an elegant alternative to the Bentall procedure in some patients. David and coworkers [7] as well as Yacoub and associates [8] have invented different techniques in which the native aortic valve can be spared, and lifelong anticoagulation can be avoided or at least postponed. Midterm results with these techniques are promising in subsets of patients with disease of the aortic valve and ascending aorta [9, 10].
With increasing confidence in the valve-sparing technique, indications have become more generous [10, 11]. Schafers and coworkers [11] have shown that reconstruction of the regurgitant bicuspid valve in the presence of proximal aortic dilatation is feasible, and have obtained good results by combining the root remodeling technique with valve repair. Inasmuch as patients with congenital bicuspid valves are known to be at higher risk for early aneurysm formation (46% of all patients in our cohort) and there is evidence that bicuspid valves may be the result of myxoid degeneration [12], long-term studies will be required to show whether the valve-sparing approach is justified in this subset of patients.
Similarly, the suitability of patients with connective tissue disease, such as Marfan syndrome, for valve-sparing operations remains an open question. These patients have a high risk for aneurysm formation or dissection and therefore warrant early intervention. In this generally younger subset of patients, the aortic valve looks macroscopically intact and makes sparing it attractive, although doubts remain because the underlying connective tissue abnormalities likely to be present in the valve may compromise its durability. Nevertheless, Birks and coworkers [13] reported 92 patients with Marfan syndrome who underwent valve-sparing operations (Yacoub technique), with no mortality in elective cases and 4.2% in emergencies: the 10-year freedom from reoperation was impressive at 83%.
In addition, interest in reconstruction techniques has led to better understanding of valve motion and the development of new prostheses. Zehr and coworkers [14] recently presented a novel Dacron prosthesis with compliant built-in sinuses that reestablish normal aortic root geometry with near-normal valve motion: they believe this special graft may enhance the future durability of the valve-preserving operation.
On the other hand, even the most optimistic surgeons must admit that all reconstruction techniques rely on intact aortic valves, and that there are patients with aortic valves that cannot be repaired because of structural defects or thickening of the leaflets. If the damaged aortic valve is combined with dilatation of the aortic root or a dissection, a composite valve graft will be required. The modified Bentall procedure is likely to remain the standard approach for this disease, and it is reassuring that this operation can now be undertaken with predictably good long-term as well as short-term outcome. The Bentall may also be the most appropriate choice, regardless of underlying disease, in centers with fewer patients, as it is less dependent on the surgeon’s expertise for a good result than the valve-sparing operations, which have a significant learning curve. Experience suggests that the early appearance of aortic insufficiency after a valve-sparing operation leads rapidly to progressive hemodynamic deterioration, making it a riskier alternative than a Bentall procedure in the presence of severe preoperative myocardial dysfunction. Patients with moderate or severe preoperative aortic insufficiency have also been reported to have poorer results after valve-sparing surgery than patients with mild aortic regurgitation [15].
In the present study, all patients received a button Bentall operation as described by Kouchoukos and coworkers [2], a technique we rely on in most of our cases and which avoids interposition of a coronary graft, which may undergo kinking, precipitating coronary thrombosis and early occlusion. The decision whether to use a mechanical or biologic valve was made on an individual basis by the surgeon and the patient. In general, tissue valves were used in only a small minority of these relatively young patients: those with a limited life expectancy, and patients unwilling to consider anticoagulant therapy, or with contraindications to anticoagulant use. A comparison between operations using biologic and mechanical valves was not a focus of this study, as only 12% of patients had biologic valves implanted.
With regard to the risks associated with anticoagulation, it should be noted that the patients in this series were managed by their cardiologists, and therefore had anticoagulation regimens reflecting the prevalent norms in the community. The recent introduction of home testing of coagulation status offers a new opportunity for improved follow-up of patients undergoing mechanical valve replacement. There are data that suggest that the ability to monitor the International Normalized Ratio at home results in greater maintenance of in-range values compared with a laboratory-based testing regimen [16], and may translate into a lower frequency of bleeding and thrombotic complications [17]. Furthermore, Schmidtke and coworkers [18] demonstrated that self-management of anticoagulation leads to a superior quality of life after mechanical valve replacement compared with conventional physician-monitored anticoagulation.
The 0.7% mortality and the stroke rate of 1.4% are low, as one would anticipate among relatively young patients undergoing elective operations without the need for concomitant procedures. We hope to reduce the incidence of strokes even further by cannulating from the axillary or subclavian rather than through the femoral artery in the future.
The early results with valve-sparing operations in our hands have also been excellent: among 30 patients who have undergone valve-sparing operations at our institution, there have been no deaths, and only 1 patient required subsequent valve replacement. But follow-up is quite short, with a median of only 1.5 years (range, 0 to 4.2 years), for a total of only 48 patient-years. These patients are quite comparable to the subset of Bentall patients reported here: they had a mean age of 47 years (versus 46 years), and 24 of these 30 patients had no concomitant procedures.
As in any group of patients with aneurysms or dissections, a significant number of patients in this series required subsequent operations for aneurysms elsewhere in the aorta. This reinforces previous observations indicating that conscientious postoperative follow-up of patients with disease in the ascending aorta is mandatory.
In the entire cohort of 456 patients, there were no failures of the Bentall operation during follow-up. Our practice of monitoring our patients with yearly computed tomographic scans makes us confident that the patients who suffered myocardial infarcts or died of coronary artery disease did not do so as a consequence of problems with the button anastomoses. The absence of technical failures in this series indicates that the Bentall technique is a safe and durable approach that can guarantee a low incidence of postoperative complications in a population with disease of the ascending aorta and aortic valve. The absence of a need for reoperation is in contrast with the results of valve-sparing approaches, in which significant aortic insufficiency develops in a variable proportion of patients.
Because the button Bentall operation can be performed with excellent short-term and long-term results, aggressive use of this operation is appropriate if aortic valve surgery is necessary in a patient with even mild ascending aortic dilatation. Results using the Bentall operation should be the standard against which outcomes of newer valve-sparing approaches to disease of the aortic root are judged.
| This article has been selected for the open discussion forum on the CTSNet Web site: http://www.ctsnet.org/discuss.
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Discussion |
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In your conclusion you raise a question, is there really a place for the valve-sparing procedure? In our own experience during the past 2 years, and Duke Cameron is doing virtually all of this surgery at Hopkins, the majority of the Marfan patients, adults and children, had the valve-sparing procedure; 60% of the patients had the valve-sparing procedure. There were 24 patients who had the valve-sparing procedure, 14 adults and 10 children, and basically they all did well. There were 2 early adults who subsequently needed a mechanical valve replacement for aortic insufficiency and the 10 children have been followed out for as long as 2 years; they, for the most part, have done well. One 10-year-old child needed a St. Jude valve a year later.
I know Duke Cameron has been a little concerned about enlargement of the annulus in the children. Basically he is doing the David II or the Yacoub procedure, and he has added the strip of Teflon but also placed a heavy Prolene suture at the bottom of the three Dacron tongues to prevent any further dilatation.
I did not see a breakdown in the data here: were there children included in your series, and what would you do for an 11-year-old or a 6-year-old child and possibly the young woman who would like to carry a pregnancy?
A superb paper. Thank you.
DR GRIEPP: Thank you very much, Vince. Coming from you, such comments are a great compliment. The Hopkins series in Marfan syndrome is clearly the benchmark.
In the child with Marfan’s, particularly if the child does not have any aortic insufficiency, we would do a Yacoub procedure. We have not reinforced the annulus in the way that Duke Cameron is doing it now. Maybe we will learn that we should be doing that in the future.
Some women in the child-bearing years have had a Ross procedure. We do offer this alternative, and have done it in a small number of patients. We have had some patients who have had a prosthetic valve and who have planned to modify their anticoagulation during pregnancy in accordance with the recommendations of their gynecologist. And we have had some young women in whom we have actually put tissue valves, planning to remove them later. None of the patients in this series were done long enough ago to have yet required taking the valve out.
But I think these are all options. And we also think that the valve-sparing procedures in young people with Marfan’s are promising. We are not sure how good the results with valve sparing are going to be in the long term, but we think we will just have to wait and see, and compare them with the Bentall group.
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