Risk factors for coronary complications after stentless aortic root replacement.

ABSTRACT

Coronary complications after aortic root replacement (ARR) with pulmonary autografts have been reported to be more common than with other stentless biological conduits (homografts, xenografts). To verify this hypothesis, results with 84 consecutive patients having stentless ARR between January 1992 and January 1999 were reviewed. Fifty patients had autograft (Group 1) and 34 either homograft or xenograft (Group 2) ARR. Comparison of age (27+/-9 vs. 38+/-22 years, P = ns), prevalence of male sex (86% vs. 79%, P = ns), aortic root disease (30% vs. 44%, P = ns), congenital coronary anomalies (10% vs. 3%, P = ns), prior aortic procedure (16% vs. 15%), and need for associated procedures (26% vs. 24%, P = ns), did not disclose significant differences. Bicuspid aortic valve was more prevalent in Group 1 (56% vs. 9%, P = .001). Mean aortic crossclamp (154+/-28 vs. 120+/-24 minutes, P = .05) and bypass (216+/-30 vs. 192+/-58 minutes, P = .05) times were longer in Group 1. Early mortality was comparable (2% vs. 3%, P = ns) and caused by right ventricular ischemia in both groups. Overall prevalence of coronary complications was higher in Group 1 (10% vs. 3%, P = .04), all resulting in right heart ischemia. Intraoperative partial takedown of repair in 5 Group 1 patients, associated with CABG in 1, resulted in prompt resolution of myocardial ischemia in 4 (80%) and prolonged in 1, which ultimately died as a result of sepsis. Recovery was prompt in all 4 patients (mean ICU stay 35+/-28 hours) with no metabolic or echocardiographic evidence of myocardial infarction. At discharge echocardiography, satisfactory biventricular kinetics was found in all patients. Analysis of preoperative variables showed bicuspid aortic valve (83% vs. 33%, P = .01) and coronary anomalies (67% vs. 3%, P = .001) to be more prevalent in patients suffering from coronary complications. Stentless ARR is a safe procedure with low operative mortality, regardless of the type of biological conduit. Autograft ARR may be at greater risk of right ventricular ischemia in patients with bicuspid aortic valve and coronary anomalies. An aggressive intraoperative approach including partial takedown of repair may limit the morbidity of coronary complications.