Bentall procedure after previous aortic valve or complete root replacement: Usefulness of self-assembled aortic valve conduit.

OBJECTIVES: The aim of this study was to evaluate surgical results of complete aortic root replacement using self-assembled valve composite graft in the setting of destroyed aortic annulus after previous valve replacement. METHODS: Aortic root pathology being addressed by complete root replacement was combined with partial or complete absence of annular tissue in 112 consecutive patients. Eighty-eight had undergone a previous replacement of the aortic valve and 24 had undergone root replacement with a valved conduit. Altogether, 31 patients (27.7%) presented with acute endocarditis, which was the indication for surgery in 75% of patients with prior root replacement. In all patients, the root replacement or re-replacement was performed with a self-assembled valved conduit using mechanical (n = 74) or, in patients with an advanced age, biological (n = 38) valve prostheses. RESULTS: In-hospital mortality was 11.6%, including a 30-day mortality of 6.3%. Resternotomy for bleeding was necessary in 5.4% of patients and about one-quarter did not need any blood transfusion. Estimated survival at 1, 5, and 10 years was 84.8% ± 3.4%, 75.7% ± 4.3%, and 57.1% ± 6.5%, respectively. Freedom from any valve-related events at 10 years was 86.2% ± 4.1%. During the follow-up time (mean, 63 ± 47 months), there was only 1 reoperation necessary 9 years after surgery (replacement of deteriorated biological valve prosthesis within the vascular tube leaving the conduit untouched). CONCLUSIONS: A self-assembled composite graft allows safe proximal fixation of the conduit in patients with destroyed aortic annulus, resulting in sufficient proximal anastomosis and a very low incidence of aorta-related reoperations.

Modified versus standard mechanical valved aortic conduit.

The aim of this study was to compare the hemodynamic characteristics and early clinical results of a commercially available standard aortic conduit with those of a modified valved composite graft, which consists of a mechanical valve prosthesis sewn into a vascular tube and placed in a supraannular position. The modified conduit was placed in 40 patients (group 1) and the standard conduit in another 40 patients (group 2). The early postoperative mortality rates (within 30 days after surgery) were 0% in group 1 and 5% (2 patients) in group 2; the difference was not statistically significant. The mean geometric orifice area of the valve prosthesis was significantly larger in group 1 than in group 2 (3.7 +/- 0.7 cm(2) versus 2.9 +/- 0.5 cm(2)). Early results showed a hemodynamic advantage of the modified conduit, with significantly lower transvalvular gradients.

[False aneurysms after button-Bentall procedure]. / Tetniaki rzekome po operacji Bentalla.

Between January 1995 and December 2000, 222 consecutive patients underwent complete aortic root replacement in the Department of Cardiovascular Surgery of the Hertz- und Gefaess- Klinik- Bad Neustadt (Germany). At the exception of 2 cases, all patients received the modified Bentallde Bono procedure with total excision of the ascending aorta and direct reimplantation of the coronary ostia using button technique. During the follow-up period of up to 6 years in 3 patients, a periprosthetic aneurysm was diagnosed. In two patients with clinical symptoms and a fistula between the prosthetic lumen and the spurium aneurysm, a reoperation was performed. Due to the complete absence of clinical symptoms or a fistula connecting the prosthesis and the aneurysm or progress in size of the aneurysm during the follow-up period the third patient was treated conservatively. The choice of proper treatment of this complication is difficult and should be based on continuous investigation of clinical symptoms and various technical examinations.

[Complete obliteration of false lumen in thoracic aorta after surgical treatment of acute type De Bakey I aortic dissection--a case report]. / Calkowite zamkniecie swiatla rzekomego aorty piersiowej po chirurgicznym leczeniu ostrego rozwarstwiajacego tetniaka aorty wstepujacej typu De Bakey I.

A case of a 62 year old male with acute type De Bakey I aortic dissection is presented. The ascending aorta, aortic valve and total aortic arch replacement were performed. Additionally the proximal descending aorta was replaced using elephant trunk technique, to close the entrance of the dissection. There was no patent false lumen in distal descending aorta in postoperative findings.

Long-term results after aortic root replacement using self-assembled valve composite grafts in patients with small aortic annulus.

OBJECTIVES: The study was aimed to evaluate operative and long-term results after complete root replacement using self-assembled valve composite grafts in patients with a small aortic annulus. METHODS: Among 547 consecutive patients who received the Bentall procedure between 2000 and 2012, a total of 29 patients (61 ± 10; range 42-79 years) had an annulus of ≤20 mm (mean 19.0 ± 0.9). Patients with a native aortic valve (22) suffered from stenosis, insufficiency or mixed defect in 10, 10 and 2 cases, respectively. Among the remaining 7 patients with an artificial aortic valve, there were 3 symptomatic prosthesis-patient mismatches, 3 valve prosthesis deteriorations (1 structural and 2 none-structural) and 1 paravalvular leak. Indication for aortic root replacement was true or false aneurysm, porcelain aorta and intraoperative aortic wall injury in 17, 6 and 6 patients, respectively. RESULTS: The composite graft for complete aortic root replacement was assembled using a mechanical (26) or biological (3) valve prosthesis placed inside a vascular graft with a median size of 24 (range 22-26) mm. The margin of the tube beneath the valve was anastomosed to the aortic annulus, and coronary ostia were implanted in the usual manner. The mean transvalvular gradient at discharge was 10.8 ± 3.9 mmHg and remained virtually unchanged at the follow-up completed for all patients. Early mortality was 0. During the mean follow-up of 95.8 ± 43.7 months, 2 patients died (54 and 146 months after surgery) due to pulmonary embolism and myocardial infarction, respectively. CONCLUSIONS: In patients with a small aortic annulus who need complete aortic root replacement, an oversizing of the valve can be easily achieved using modified, self-assembled composite grafts. Offering excellent haemodynamic characteristics, these grafts lead to prevention of prosthesis-patient mismatch and result in very good and durable functional and clinical results.

Valve-sparing aortic root repair in acute type A dissection: how many sinuses have to be repaired for curative surgery?

OBJECTIVES: The aim of the study was to evaluate operative and long-term results of valve-sparing aortic root surgery in acute type A dissection. The repair consisted of selective replacement of all dissected and pathological sinuses. METHODS: Forty-six patients (mean age 62 ± 14; range 29-88 years, 3 with Marfan syndrome), operated on between August 2001 and July 2011 due to acute type A aortic dissection, underwent valve-sparing root repair, resulting in a valve preservation rate of 56% in acute aortic dissection surgery involving the aortic root. Insufficiency grades of 0/1+, 2+, 3+ and 4+ were presented in 16, 17, 12 and 1 patients, respectively. Root repair with resection of the whole of the pathological aortic wall without the use of any glue was performed in all patients. Replacement of 1, 2 or 3 sinuses of Valsalva was performed in 29, 12 and 5 patients, respectively. Concomitant cusp repair was necessary in 7 patients. All perioperative data were collected prospectively and an intention-to-treat analysis was performed. RESULTS: A total of 6 patients (median age 76, range 63-81 years) died, on average 10 months (range 0.9-44) after surgery resulting in an overall survival of 87% at the mean follow-up of 54 ± 37, range 0.9-132 months. The linearized death rate was 2.9%/year, and the actuarial survival rate at 8 years was 85.5 ± 5.6%. No death was related to the aortic valve or aortic root. There were no valve-related events and no patient required reoperation on the proximal aorta/aortic valve during the follow-up. At the last echocardiography (47.8 ± 35.6 months after surgery), 33 patients showed no and 13 patients slight (1+) aortic insufficiency. CONCLUSIONS: Curative repair with replacement of all pathological sinuses of Valsalva leads to an excellent long-term outcome. Selected sinus repair is a simple and effective method of curative, valve-sparing root repair in acute aortic dissection because replacement of all sinuses is seldom necessary.