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Ann Thorac Surg 2007;84:473-478
© 2007 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Replacement of the Proximal Aorta Adds No Further Risk to Aortic Valve Procedures

T. Brett Reece, MD, R. Ramesh Singh, MD, Brendon M. Stiles, MD, Benjamin B. Peeler, MD, John A. Kern, MD, Curtis G. Tribble, MD, Irving L. Kron, MD*

Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia

Accepted for publication April 16, 2007.

* Address correspondence to Dr Kron, PO Box 800679, 1215 Lee St, Hosp. Expansion Bldg., Room 4066, Charlottesville, VA 22908 (Email: ikron{at}virginia.edu).

Presented at the Fifty-third Annual Meeting of the Southern Thoracic Surgical Association, Tucson, AZ, Nov 8–11, 2006.


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Discussion
 Acknowledgments
 References
 
Background: Aortic valve pathology is often associated with proximal aortic dilatation. Even after valve surgery, the proximal aorta can continue to dilate and thus be at risk for rupture, dissection, or later aortic replacement. We hypothesized that the addition of proximal aortic intervention adds no further risk to aortic valve surgery, which may avoid subsequent proximal aortic procedures or catastrophes.

Methods: Between 1996 and 2004, 430 aortic valve interventions alone and 146 aortic valves with proximal aortic replacements were identified in elective adult patients. The age in the valve-alone patients (68.8 years) was slightly higher than the valve-plus-aorta group (valve/aorta, 60.5 years; p < 0.01), but comorbidities were similar between groups. We compared groups based on hospital mortality and incidence of complications.

Results: The 30-day mortality was similar between groups (valve-alone, 3.8% versus valve/aorta, 2.7%; p = 0.5), as were rates for bleeding and operative revision (valve-alone, 6.7% versus valve/aorta, 9.5%; p = 0.5). Pulmonary (valve-alone, 23.0% versus valve/aorta, 11.6%) and renal complications (valve-alone, 8.2% versus valve/aorta, 2.7%) were higher in the valve-alone group (p = 0.02). Logistic regression demonstrated no additional risk of death, neurologic, or cardiac event with replacement of the proximal aorta.

Conclusions: Proximal aortic replacement adds no risk to the patient beyond the aortic valve intervention alone. These findings suggest proximal aortic replacement is safe for patients undergoing valve operations. Patients with a moderately enlarged proximal aorta that may dilate further should also be considered for aortic replacement at the time of valve procedures.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Discussion
 Acknowledgments
 References
 
Dilatation of the aortic root or ascending aorta, or both, is commonly diagnosed in conjunction with pathology of the aortic valve. The correlation between proximal aortic dilatation and valve disease can occur for different reasons. Proximal aortic dilatation has been demonstrated in both aortic stenosis and aortic insufficiency. Moreover, specific valve pathologies, such as bicuspid aortic valves and valves in patients with Marfan syndrome, may have structural abnormalities of the proximal aorta that are prone to dilatation even after the aortic valve is replaced [1]. Even patients without known structural abnormalities can experience further dilatation of the proximal aorta after a valve procedure, putting them at risk for rupture, dissection, or later aortic replacement [2].

Historically, there has been some hesitation to proceed with replacement of the proximal ascending aorta in patients undergoing surgical correction of aortic valve pathology. This sentiment was due to concerns about increased morbidity and mortality for primary procedures that included replacement of the proximal aorta [3–5]. However, many reviews of proximal aortic replacement included emergency procedures, which do not apply to the elective population undergoing primary aortic valve procedures and have falsely elevated the risk of the procedure. Furthermore, some of these patients with larger proximal aortas will progressively dilate, leading to reoperation with the ensuing risks. We have believed that the risk of a second procedure was a reason to proceed with proximal aortic replacement at the time of the initial aortic procedure. We hypothesized that the addition of proximal aortic intervention adds no further risk to aortic valve surgery.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Discussion
 Acknowledgments
 References
 
After gaining approval for this study from the Human Investigation Committee at the University of Virginia (with waiver of consent), all aortic valve procedures were identified from our retrospectively collected aortic database, including cases performed from July 1996 through December 2004. From more than 800 cases in the database, all dissections, endocarditis, and redo procedures were excluded. After these exclusions, 430 primary aortic valve interventions alone were identified, and 146 primary aortic valve procedures with proximal aortic replacements were identified in elective adult patients.

To show similarities between groups, comorbidities were compared. These comorbidities included age, history of diabetes, cerebrovascular disease, peripheral vascular disease, chronic renal insufficiency, current hemodialysis, and chronic obstructive pulmonary disease; in particular, cardiac characteristics including a previous history of coronary artery disease, arrhythmia, and nonaortic valve disease as well as known history of Marfan syndrome and rheumatic disease.

Cardiopulmonary bypass (CPB) was used for all procedures. Aortic valve procedures were performed on all patients. The type of valve intervention was specified by one of the operative surgeons included in this study and was recorded for group comparison. Proximal aortic replacements included replacement of the aorta above or below the sinotubular junction, or both. For the purposes of this study, the furthest extent of the proximal aortic replacement was the innominate artery takeoff. The type of aortic replacement, as well as the size of the aortic root or ascending aorta, or both, was also evaluated for group comparison. Adjunct procedures and operative times were noted for each patient.

The outcomes in the two groups were compared by hospital mortality, intensive care unit stay, hospital stay, and incidence of complications, including intraoperative, cardiac, neurologic, pulmonary, and renal.

Statistical analysis was performed by an independent statistician using the Student t test, {chi}2 analysis, and the Fisher exact test. Logistic regression was performed for the outcomes of mortality, neurologic events, and cardiac events using the predictors of root, ascending aorta above sinotubular junction, age older than 70, male sex, peripheral vascular disease, diabetes mellitus, chronic renal insufficiency, history of arrhythmia, and coronary artery bypass grafting (CABG). These predictors were based on significant factors of complications in other studies [4, 6–8].


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Discussion
 Acknowledgments
 References
 
Preoperative
The age in the valve-alone patients (68.8 ± 0.6 years) was slightly higher than the valve/aorta group (60.5 ± 1.1 years, p < 0.01), but comorbidities were similar in incidence of diabetes, pulmonary disease, chronic renal insufficiency, hemodialysis, cerebrovascular disease, coronary artery disease, and degree of heart failure. Predictably there were more patients with Marfan syndrome in the valve/aorta group. These comorbidities are summarized in Table 1.


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  		Table 1 Patient Comorbidities
 
All patients underwent aortic valve replacement with similar rates of mechanical and bioprosthetic valves between the groups. During the period of the study, we had been aggressive toward replacing the proximal aorta. In this cohort, aortic replacement was originally done for all aneurysms exceeding 5 cm. More recently, aneurysms exceeding 4.5 cm were replaced. The mean size of the aorta in the valve-alone group was 6.6 cm (range, 4.5 cm to 11 cm) at the time of replacement. In the valve/aorta group, 58 patients underwent root replacement, and 88 underwent replacement of the aorta above the sinotubular junction. Other than the ascending aortic procedures, the groups had similar adjunct procedures, with the exception of CABG, which was more likely in the valve-alone group (p < 0.01). The adjunct procedures are summarized in Table 2.


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  		Table 2 Operative Procedures
 
Intraoperative
Intraoperative variables, including cross-clamp time and CPB time, were similar between groups. However, the valve/aorta group included 17 cases that included a time on hypothermic circulatory arrest, which averaged 22 minutes. The aneurysms in 5 of these patients encroached upon the innominate artery takeoff, requiring circulatory arrest for completion of the distal anastomosis. The ascending aortas of the remaining 12 patients were significantly calcified; this prohibiting clamping, so hypothermic circulatory arrest was used for the completion of the distal anastomosis of the ascending aortic graft. No patients in the valve-alone group underwent hypothermic circulatory arrest. The intraoperative variables are summarized in Table 3. In terms of root replacements, there were eight homografts, 11 aortic valve resuspensions, and 29 Bentall, and 10 "bio-Bentall" procedures.


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  		Table 3 Intraoperative Variables a
 
Postoperative Complications, Hospital Variables, and Mortality
Hemorrhage and operative revision rates were similar between the groups. There were no differences in infection, stroke, myocardial infarction, or other complications. The rates of confusion and pulmonary and renal complications were higher in the valve-alone group. The valve-alone patients tended to stay longer in the intensive care unit and the hospital before discharge; however, there was no difference in in-hospital or 30-day mortality between the two groups (Table 4). The mean follow-up was 33.4 months (range, 1 to 115 months), during which time no patient required reoperation to replace any part of their ascending aorta and no patient had a late complication from the proximal aortic replacement.


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  		Table 4 Complications, Hospital Variables, Mortality a
 
Logistic Regression: Mortality, Neurologic and Cardiac Events
Binary logistic regressions was performed for mortality, neurologic events, and cardiac events using the predictors of root replacement, replacement of the ascending aorta above sinotubular junction, age older than 70 years, male sex, peripheral vascular disease, diabetes, chronic renal insufficiency, preoperative arrhythmia, and concomitant CABG.

For the mortality regression, the Pearson (p = 0.149) and Hosmer-Lemeshow (0.09) goodness-of-fit tests were not significant, indicating an adequate model fit. The significant predictors for mortality included diabetes (p = 0.055), chronic renal insufficiency (p = 0.002), and preoperative arrhythmia (p = 0.011). The complete table of p values and odds ratios for all predictors of mortality is given in Table 5.


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  		Table 5 Logistic Regression: Mortality
 
For the neurologic event regression, the Pearson (p = 0.710) and Hosmer-Lemeshow (0.848) goodness-of-fit tests were not significant, indicating an adequate model fit. The significant predictors for stroke included peripheral vascular disease (p = 0.002), diabetes (p < 0.001), chronic renal insufficiency (p = 0.010), and concomitant CABG (p = 0.011). The complete table of p values and odds ratios for all predictors is given in Table 6. Although a regression for cardiac events was performed, none of the predictors included in the model for cardiac events were significant. This is probably secondary to the low number of cardiac events rather than true lack of significance.


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  		Table 6 Logistic Regression: Neurologic Events
 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Discussion
 Acknowledgments
 References
 
Aortic dilatation is frequently associated with aortic valve disease. The proximal aorta is often dilated in patients with aortic valve pathology. Proximal aortic dilatation may occur in response to the aberrant mechanical forces caused by deranged flow through the aortic valve or may be due to inherent abnormalities of the tissues associated with a specific valve pathology. Aortic stenosis and regurgitation both lead to erratic blood flow through the aortic valve. Natural history studies have documented the propensity for proximal aortic dilatation distal to an abnormal aortic valve.

Patients with bicuspid valves are particularly predisposed to developing aneurysms of the ascending aorta as well dissection and rupture [9, 10]. Although this predisposition may be partly due to the flow through the poststenotic bicuspid valve, some evidence shows that this process can continue independently of the valve pathology [11–13]. This suggests that patients with bicuspid aortic valves have structurally abnormal ascending aortas prone to dilatation unrelated to the abnormal hemodynamics. For this reason, patients with bicuspid aortic valves require a more aggressive approach to replacement of the proximal aorta. Along the same lines, it is generally thought that patients with Marfan syndrome are at significant risk for proximal aortic catastrophe at a smaller aortic diameter [14]. Thus, many of the patients are at risk for aneurysmal degeneration of the proximal aorta.

The argument against replacement of the proximal aorta at the time of aortic valve intervention has been that there may be an additional risk to the patient of replacing the proximal aorta. However, some of these patients may need a second reoperative procedure, with further risk to the patient, or they may sustain an aortic catastrophe in this area. Recent studies have shown that the aortic root and ascending aortic replacement can be done with acceptable risks to patients with previous cardiac operations [2, 6]. However, the perioperative risk for these patients has been demonstrated to be consistently higher than at the original operations [2, 7, 8]. The risk for patients increases with subsequent operations. In addition, most of these reports compare outcomes between first and second procedures, when the actual risk to the patients undergoing reoperation is cumulative. Thus, this comparison should include the risk of both procedures rather than just the reoperation. Of note, none of the patients followed up in this study required a second procedure to address their proximal aorta. This finding suggests that the algorithm for proximal aortic replacement used in this study may prevent the need for future replacement.

This study provides a legitimate comparison of aortic valve intervention alone with aortic valve intervention plus proximal aortic replacement. Our comparable results between these two groups reiterate the arguments of others that replacement of a dilated proximal aorta should be considered in any patients undergoing aortic valve intervention [1, 15, 16]. We have shown with both simple statistical comparisons and logistic regression models that the addition of proximal aortic replacement may add little, if any, risk to aortic valve intervention alone. Furthermore, when the proximal aortic replacements were separated into root replacements and ascending aortic replacements, the additional procedure added no risk to the aortic valve procedure.

The risk of a second operation may be not only excessive, but also unnecessary when the proximal aorta can be dealt with at the original operation. Proximal aortic replacement can be accomplished without adding significant further risk to the patient. Thus, these data show that replacement of the proximal aorta should be considered in conjunction with aortic valve interventions when the proximal aorta is dilated, has a propensity to dilate later, or has a tendency toward dissection or rupture.

This study included any replacement of the aneurysmal proximal aorta, including both roots and ascending aortas. The definition of proximal aorta was chosen because the root, the ascending aorta, or both, can dilate in patients with aortic valve pathology. Although the numbers are relatively small, we found no differences in outcomes when we compared which part of the proximal aorta was replaced. Because both procedures will be considered when evaluating the patient undergoing aortic valve intervention, they can reasonably be included with any comparison. For this same reason, even patients undergoing hypothermic circulatory arrest were included in the study. Furthermore, others have used the same approach when evaluating the risk of a subsequent operation [6]. Both the root and ascending aorta can play a role in the evaluation and eventual treatment of this pathology, so they should both be considered when comparing aortic with valve intervention alone.

Older studies demonstrated that proximal aortic diameters of less than 6.0 cm are at considerable risk for rupture and should be replaced [17]. All would agree that aortas of this size should be replaced whether or not the aortic valve is involved. The risk of rupture in aortas with diameters between 5.0 and 5.9 cm is still higher than for smaller diameter aortas. These too should be replaced at the time of aortic valve surgery [2]. Patients with bicuspid aortic valves and Marfan syndrome have a tendency for both higher rates of dilatation and risk for dissection or rupture at smaller diameters [14, 18].

Our data suggest that the addition of proximal aortic replacement to aortic valve intervention is safe, so we advocate a low threshold for replacement of the proximal aorta. Hence, we believe that any proximal aorta with a diameter of 5.0 cm or greater should be replaced at the time of aortic valve intervention. Furthermore, patients with bicuspid aortic valves or Marfan syndrome deserve proximal aortic replacement at diameters of 4.5 cm or greater [18]. Finally, patients undergoing aortic valve intervention who are younger than 50 years old or who have a family history of ascending aortic aneurysm or dissection should perhaps also be considered for proximal aortic replacement at smaller sizes because they should have a longer postoperative life expectancy in which their proximal aorta can continue to dilate [14, 19].

This study does have limitations. It is retrospective, which can add inherent bias, including the choice of procedure. The procedure performed was by surgeon preference, although the indications appear to be fairly uniform according to our data. The preoperative size of the proximal aorta was well documented in the valve/aorta group. However, aortic size was not as well documented in the valve-alone group. From the data available, all patients with a proximal aorta greater than 5 cm did undergo aortic replacement.

For this study, we used aortic dilatation as the marker for abnormal aortic tissue, so our results only support replacement of the aneurysmal proximal aorta. Because our practice is to replace only dilated proximal aortas, these results may not be extrapolated to replacement of the normal-caliber proximal aorta, which can be even more challenging.

The groups had comparable comorbidities; however, the valve-only group was twice as likely to undergo coronary revascularization. This potential difference in the groups did not appear to be significant in the outcomes because the groups had similar rates of cardiac complications, except that CABG was found to be a risk factor for postoperative neurologic events by logistic regression. The increased use of CABG in the valve-alone patients may explain the lack of difference in intraoperative times between the two groups which would otherwise assumed to be longer in the valve/aorta group. Despite these limitations, these data demonstrate that replacing the ascending aorta can be done for patients undergoing AVR with little or no additional risk.

In conclusion, these data from a high-volume aortic center suggest that proximal aortic replacement adds no risk to the patient beyond the aortic valve intervention alone, including both root and ascending aortic replacement. These conclusions support previously published recommendations for a low threshold to replace the aortic root or the ascending aorta in patients requiring aortic valve replacement, not only to avoid the chance of a second operations but also because it can be done with little or no additional risk to valve surgery.


   Discussion
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
Acknowledgments
 References
 
DR JOSEPH S. COSELLI (Houston, TX): I believe your presentation addresses an extremely important problem, which is frequently a conundrum for the operating surgeon who is often faced with only intraoperative information having inspected the relative size of the aorta at the time of procedure. This is particularly important in the more modest sizes that you address in your presentation. I do have a few questions.

Twelve percent of your patients who required hypothermic circulatory arrest were primarily due to the extent of the aortic aneurysm or as a consequence of severe aortic calcification, and in these cases what are your current practices regarding cannulation and adjunctive brain perfusion, et cetera, if any?

Your series goes over 81/2 years, and I would wonder, were there any of the patients in the valve-only group who ultimately required a second procedure for replacement of the proximal aorta with and without the development of aortic dissection? You tried to address an issue in your last slide. Is it your feeling that virtually all patients with bicuspid valves should be managed in a similar fashion to patients with Marfan syndrome and replace the ascending aorta, valve, and root at the an initial procedure?

There are those who would be proponents of aortic valve repair; for example, the various ramifications of the David procedure. I wonder how this fits into your approach to the aortic valve when you do valve repairs? Do you, under these circumstances, use the same criteria for replacement of the ascending aorta?

Regarding a slightly different approach, there are some authors who would be proponents of ascending aortic annuloplasties and/or wrapping of the aorta. How would this approach fit into your analysis? I would like to think that the excellent results that you have presented here would be easily translatable into the experiences in institutions with somewhat lesser volumes, but that is always a source of debate.

Thank you for the opportunity to discuss your paper.

DR REECE: Thank you for commenting on the paper. In terms of the circulatory arrest, if we knew we were going to go into circulatory arrest, we would certainly cannulate through the axillary artery, but there are times when we are somewhat surprised by the findings or how far the aneurysm went, and they may go with retrograde perfusion or even sometimes, if it was short, with no perfusion and just circulatory arrest alone, although that was earlier in the experience rather than the more recent experience.

In none of the patients that we identified could we find that they had a later ascending aortic replacement; however, it was a short period of time and we may see them in the future, although we have been very aggressive about replacing the ascending proximal aorta at 5 cm or less.

In terms of the bicuspid, I think we would agree that there is some interstitial problem with the ascending aorta, but the degree of that problem is probably more indicative of the size. So we use the 4.5 cm cutoff as our marker that they have significant interstitial problems sufficient to replace the proximal aorta. We haven’t gone below that or to the point of replacing anything smaller than 4.5 cm at this time.

In terms of valve repair, most of these patients were getting replacement anyway. There are no valve repairs included in this study; however, I think we would follow a similar trend of trying to replace anything of 5 cm and 4.5 cm if there are special considerations.

In terms of the ascending aortic wrapping, we want to get rid of all of the abnormal tissue that we can, and in this situation, we prefer to replace it with Dacron and then tissue wrap the ascending aorta. And in terms of this being translatable, I think that the only way it will be translatable is if people become more aggressive and start doing this and show that the proximal aorta can be replaced safely and not give in to the pressure of cardiologists or colleagues about leaving some of these in terms of their proximal aorta at the time of the procedure. There is a possibility that they will have to have another operation and undergo another 5% to 6% mortality for the procedure. So I think we really need to push taking care of it at the first operation.

DR THORALF SUNDT (Rochester, MN): Very quickly I just want to clarify, so for the bicuspid valve, my understanding is that you are not advocating routine root replacement for all patients with bicuspid valve?

DR REECE: We did not do that in this study.

DR SUNDT: A patient with a bicuspid valve and a normal size root you think should have an aortic valve alone?

DR REECE: As long as it is not 4.5 cm is what our policy has been.

DR SUNDT: Thanks.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
 Acknowledgments
References
 
The study was funded with departmental funds.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
 Acknowledgments
 References
 

  1. Kouchoukos NT, Marshall Jr WG, Wedige-Stecher TA. Eleven-year experience with composite graft replacement of the ascending aorta and aortic valve J Thorac Cardiovasc Surg 1986;92:691-705.[Abstract]
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  3. Gott VL, Gillinov AM, Pyeritz RE, et al. Aortic root replacementrisk factor analysis of a seventeen-year experience with 270 patients. J Thorac Cardiovasc Surg 1995;109:536-544.[Abstract/Free Full Text]
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  9. Borger MA, Preston M, Ivanov J, et al. Should the ascending aorta be replaced more frequently in patients with bicuspid aortic valve disease? J Thorac Cardiovasc Surg 2004;128:677-683.[Abstract/Free Full Text]
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 Ann. Thorac. Surg.Home page
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Ann. Thorac. Surg., April 1, 2008; 85(4): 1502 - 1503.
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 Ann. Thorac. Surg.Home page
T. B. Reece and I. L. Kron
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Ann. Thorac. Surg., April 1, 2008; 85(4): 1503 - 1503.
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