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Ann Thorac Surg 2004;78:858-861
© 2004 The Society of Thoracic Surgeons
a Department of Cardiovascular Surgery, Marmara University School of Medicine Foundation, Academic Hospital, Atasehir, Turkey
b Department of Cardiology, Maltepe University School of Medicine, Atasehir, Turkey
c Department of Cardiovascular Surgery, Maltepe University School of Medicine, Atasehir, Turkey
d Department of Radiology, Maltepe University School of Medicine, Istanbul, Turkey
Accepted for publication March 30, 2004.
* Address reprint requests to Dr Arsan, 37 Ada Inci-1 Blok, D.29 Atasehir, 34756 
stanbul, Turkey
arsans{at}superonline.com
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Abstract |
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METHODS: The study group consisted of 48 male and 14 female patients with a mean age of 59.3 ± 6.0 years. Measurement of the ascending aorta diameters was obtained at three points: before surgery, during the early postoperative period, and during the follow-up. The mean preoperative aortic diameter was 52.7 ± 0.5 mm. In all patients, the ascending aortic aneurysm was repaired by reduction aortoplasty with external wrapping.
RESULTS: Mean follow-up time was 39.6 ± 18.0 months. There was only one mortality (1.6%) as a result of septic multiple-organ failure and no major surgical complications in the 30-day postoperative period. Reduction aortoplasty of the ascending aorta with external wrapping resulted in a significant reduction of the ascending aorta in all patients (p = 0.000). There was an increase in the mean aortic diameter during the follow-up period (p = 0.000). Although this increase was statistically significant, all measurements of the follow-up period were still within normal range.
CONCLUSIONS: External wrapping of the aorta offers excellent results with very low mortality and morbidity, and it can be regarded as a safe and effective method for the treatment of ascending aortic aneurysm in selected patients. However, the patients should be carefully monitored for redilatation after the procedure.
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Introduction |
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This method may present a good compromise in some patients with a borderline dilated aorta, particularly during operations for other cardiac conditions in which a decreased aortic cross-clamp time is advantageous. In these selected patients, we performed a reduction aortoplasty with external wrapping.
The main goals of this article are to give the early and midterm results of reduction aortoplasty, to describe our own technique of reduction aortoplasty, and to define the specific aortic anatomy suited for this operation. We retrospectively reviewed our experience to analyze the midterm results of 62 patients.
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Material and methods |
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Indications for concomitant operation included coronary artery bypass grafting (CABG) or aortic valve replacement patients who have aneurysmal dilatation of greater than 4.5 cm.
The concomitant procedures are given as follows. Twenty-two patients underwent aortic valve replacement and 17 patients underwent CABG. Thirteen patients underwent both CABG and aortic valve replacement. Five patients had aortic and mitral valve replacement and tricuspid De Vega annuloplasty. Two patients underwent aortic valve replacement and open mitral commissurotomy procedures. Two patients underwent CABG, aortic valve replacement, and mitral valve replacement. Fifty-two patients had aortic valvular disease. The bicuspid aortic valve was detected in 4 (7.6%) of the patients.
Follow-up information was obtained by retrospective review of medical records or by direct telephone interviews or office visits. Follow-up was completed in 80.6% (n = 50) of the patients.
The study group consisted of 48 male and 14 female patients with a mean age of 59.3 ± 6.0 years. Measurement of the ascending aorta was obtained at three points: before surgery, during the early postoperative period, and during the late follow-up period of 8 to 78 months (39.6 ± 18 months; Table 1) . The diameter of the aorta (AD1) was measured by angiography before the operation. The diameter was measured at the level of the largest diameter between the aortic arch and aortic root. The second measurement (AD2) was taken at the first postoperative month by echocardiography in 51 patients, computed tomography in 9 patients, and magnetic resonance imaging in 1 patient of all 62 patients. The third measurements (AD3) of all 51 patients were made mainly by echocardiography. Mechanical valves used in aortic valve replacement patients were the Sorin Bileaflet. Valve sizes of 21, 23, and 25 mm were used. Bioprostheses were not used in the study group. All vascular grafts were Dacron tube grafts with a size of 30 mm.
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Operative technique
Standard median sternotomy and extracorporeal techniques were used in all of the patients. Femoral artery cannulation was used in 12.6% (n = 8) of the patients. Except for concomitant mitral valve cases, venous return was through a single atrial cannulation. Profound hypothermia and circulatory arrest were not used. Systemic (perfusate temperature of 25° to 28°C) hypothermia was used in all cases. A left ventricular sump was inserted through the right superior pulmonary vein, if it was necessary. A single dose of antegrade crystalloid cardioplegia or antegrade tepid blood cardioplegia was used in the study group.
If CABG or other concomitant surgical procedures were required, distal coronary anastomosis and concomitant surgical procedures were performed before the replacement or wrapping. Reduction aortoplasty with external wrapping was performed after the removal of the aortic cross-clamp and during the systemic warming period of the patient under low perfusion pressure. Concomitant CABG was performed in 32 patients.
The distal coronary anastomosis was first constructed to the most crucial stenosed coronary artery, so that additional cardioplegic solution could be delivered to the ischemic myocardium through the graft. Left internal mammary artery was used in 14 (43.7%) of 32 CABG patients.
In case of concomitant CABG, before reinforcement of the ascending aorta with external wrapping from the sinotubular junction to the aortic arch, a single proximal anastomosis was made to the aortic root (under aortic cross-clamp), aortic arch (with side-biting clamp after the aortic cross-clamp), or subclavian artery (with side-biting clamp after the aortic cross-clamp), or to the anastomosed internal mammary artery during the systemic warming period of the patient. The technique has been previously described by Arsan [2, 3]. It is shown in Figure 1.
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Results |
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The average follow-up period was 39.6 ± 18.0 months (range, 8 to 78 months). Two patients died during the follow-up period. The causes of late deaths were motor vehicle accident and emphysema (at 12 and 29 months). Ten patients did not have the third examination (8 patients were lost to follow-up and 2 patients died).
Preoperative diameter of the ascending aorta was 52.7 ± 0.5 mm. The mean diameter of the ascending aorta was 30.4 ± 0.5 mm at early postoperative period and 32.0 ± 0.5 mm at the follow-up period.
Reduction aortoplasty of the ascending aorta with external wrapping resulted in a significant reduction of the ascending aorta in all patients (AD1 versus AD2 and AD3, p = 0.000). There was also a statistically significant difference between the aortic diameters measured during the early and late follow-up (AD2 versus AD3, p = 0.000). However, all measurements in the AD2 and AD3 groups were still within the normal range.
There were no reoperations on the ascending aorta or other concomitant procedures during the follow-up period. The Kaplan-Meier patient actuarial survival curve is shown in Figure 2. Actuarial survival at the end of the follow-up period 94.1%. The patients at risk are shown in Figure 3. The upper row below the x axis shows the number of patients at risk.
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Comment |
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The enlargement of the ascending aorta with enlargement of the sinuses of Valsalva and the displacement of coronary arteries are generally best treated by Bentall, modified Bentall, and Cabrol techniques [4, 5].
Tubular aneurysms of the ascending aorta generally have smooth intimal linings without any thrombus or atheroma. This has allowed the use of aortic cross-clamping for repair of aneurysms confined to the ascending aorta with a low risk of embolic events.
In these cases, a less radical and simple operation may be performed without any fear of reformation of the aneurysm after correction of the concomitant diseases. The most conservative method is aortoplasty, which was first described by Robicsek [6]. This technique involves resection of an oval segment of the ascending aortic wall after longitudinal aortotomy followed by Dacron wrapping of the aorta.
These fusiform aneurysms mostly limited to the ascending aorta are suitable for reduction aortoplasty. In selected patients with aneurysmal enlargement generally confined to the tubular portion of the ascending aorta, we have performed a reduction aortoplasty with external wrapping.
Dacron wrapping has been used selectively in these patients and can be a useful adjunct to the operative procedure. The Dacron wrap may provide reinforcement for the attenuated wall of the ascending aorta. The use of external wrapping technique (rather than replacement) in case of moderately sized ascending aneurysm of the aorta is still controversial.
Series of patients operated on using different techniques are widely published in the literature, and the results are conflicting [7–10]. In cases with aneurysm formation caused by hemodynamic forces associated with congenital bicuspid aortic valve, this technique may also be applied after correcting the pathologic condition of the aortic valve [11]. Recently, the unsupported aortoplasty has been definitively abandoned because of high aneurysm recurrence rate [12]. There is strong evidence that this redilatation tendency is related to an underlying intrinsic wall deficiency as defined by Robicsek [13]. Reduction aortoplasty eliminates the aneurysm, but it does not prevent recurrence without any external support. Bauer and associates [14] reported a complication after reduction aortoplasty with external wrapping. The described technique used in the study group also prevents dislocation of the wrap and erosion of the aorta by fixing the Dacron wrap to the aorta with decreasing diameter.
This simple technique can easily be performed in patients with severe cardiac disease in whom prolonged cardiopulmonary bypass time and aortic cross-clamping can increase the mortality and morbidity.
An ascending aortic diameter of 6 cm emerges as the mean or the median diameter quite consistently in all reliable contemporary natural history studies [5]. Coady and associates [15] reported that a diameter of 6 cm is the "hinge point," beyond which there is a 30% increase in the probability of rupture.
The results of this study show that reduction aortoplasty for treating the dilated ascending aorta is a simple and alternative method to aortic graft replacement. To avoid later redilatation, the aortic size should be less than 6 cm as stated by Coady and colleagues [15].
We perform this less radical procedure routinely for moderately dilated aorta and older or high-risk patients in whom a short aortic cross-clamp time is advantageous. The reduction aortoplasty and external wrapping give sufficient evidence to suggest that when done properly, this procedure is a good and satisfactory solution in some patients with a borderline dilated aorta and without any underlying intrinsic wall deficiency, particularly during operations for other cardiac conditions.
However, the detected significant difference between postoperative measurements of aortic diameters was valid. The significant dilatation of the aorta postoperatively might be related to the use of different diagnostic tools such as transthoracic echocardiography, computed tomography, and magnetic resonance imaging in a few cases. The main implication of this report is all the aortic diameters of the patients were still in the normal range. Despite the achievement of satisfactory results, those patients should undergo a careful follow-up surveillance program for the redilatation of the aorta. Reduction aortoplasty with external wrapping technique is a simple and original technique that may benefit some qof our colleagues.
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