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J Thorac Cardiovasc Surg 2007;133:414-418
© 2007 The American Association for Thoracic Surgery
Surgery for Acquired Cardiovascular Disease |
Peter Munk Cardiac Centre at the University Health Network and University of Toronto, Toronto, Ontario, Canada.
Received for publication July 18, 2006; revisions received September 17, 2006; accepted for publication September 29, 2006. * Address for reprints: Tirone E. David, MD, 200 Elizabeth St, 4N-457, Toronto, Ontario M5G 2C4, Canada. (Email: tirone.david{at}uhn.on.ca).
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Abstract |
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 Top Abstract IntroductionPatients and MethodsResultsDiscussionReferences |
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METHODS: Replacement of the ascending aorta with reduction of the diameter of the sinotubular junction to correct aortic insufficiency was performed in 103 consecutive patients. Twenty-nine also needed repair of cusp prolapse. The patients’ mean age was 65 ± 12 years and all had ascending aortic aneurysm; 63 also had arch aneurysm and 21 had aneurysm of the entire aorta. The aortic insufficiency was graded as moderate in 54 patients and severe in 49. Patients were followed up prospectively and had echocardiographic studies annually. The mean follow-up was 5.7 ± 3.4 years.
RESULTS: There were 2 operative and 30 late deaths. Cardiovascular events were the cause of death in 19 patients. Arch aneurysm and age were the only predictors of late death. Overall survival at 10 years was 54% ± 7%. Seven patients had moderate and 1 had severe aortic insufficiency. The freedom from moderate or severe aortic insufficiency at 10 years was 80% ± 7% and from severe aortic insufficiency, 98% ± 1%. Two patients required aortic valve replacement, 1 because of severe aortic insufficiency and 1 for endocarditis. The freedom from aortic valve replacement at 10 years was 97% ± 1%. At the latest follow-up, 98% of the patients were in functional class I or II.
CONCLUSIONS: Reduction in the diameter of the sinotubular junction restores aortic valve competence in patients with ascending aortic aneurysm and aortic insufficiency with normal aortic cusps. Late survival of these patients is suboptimal because they often have extensive aneurysmal disease.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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Aortic valve–sparing operations to treat aortic root aneurysms are complex procedures because most anatomic components of the aortic root need surgical correction.3 This is not the case in patients who have an ascending aortic aneurysm and normal or minimally dilated aortic root because the AI is usually caused by dilation of the STJ.4 Simple reduction of its diameter restores valve competence if the cusps are normal.4 This study examines the clinical and echocardiographic results of replacement of the ascending aorta with reduction of the diameter of the STJ to correct AI in patients with ascending aortic aneurysms and normal or minimally dilated aortic sinuses. |
Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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Twenty-nine patients had prolapse of one or two cusps and the free margin was shortened by plication along the nodule of Arantii. In 11 patients one cusp had stress fenestration near the commissure and its free margin was reinforced with a double layer of 6-0 polytetrafluoroethylene suture (W. L. Gore & Associates, Inc, Flagstaff, Ariz).5 Nine patients had bicuspid aortic valve with dilation of the STJ in all 9 and prolapse of the anterior cusp in 4. Two of them required replacement of the posterior sinus.
Twenty-one patients had aneurysm of the entire thoracic or abdominal aorta or both. The arch was replaced by the elephant trunk technique in 17 patients,6 and the entire thoracic aorta was replaced in 4. In addition, 42 patients had the aortic arch replaced down to the level of the left subclavian artery (11 total and 31 hemiarch replacement). Table 2
shows the operative data.
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Statistical Analysis
All data analyses were performed with SAS 8.1 software (SAS Institute, Inc, Cary, NC). Categorical variables are reported as frequencies and all continuous variables are reported as mean ± SD. The Kaplan-Meier method was used to calculate estimates for long-term survival, freedom from recurrent AI, reoperation, and thromboembolic events. All preoperative variables with a univariate P value of less than .25 or those with known biologic significance but failing to meet this critical 
level were submitted to the multivariable model for Cox regression analysis to determine the independent multivariable predictors of late death. Variables retention criteria in the model were set at a P value of .05.
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Results |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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Late Mortality
Thirty patients died during the follow-up. The causes of death were cardiovascular in 19 patients, noncardiovascular in 9, and unknown in 2. Cardiovascular causes were myocardial infarction in 4 patients, sudden death in 3, stroke in 3, type B dissection in 3, ruptured thoracoabdominal aneurysm in 3, surgery for thoracoabdominal aneurysm in 2, and thrombosed mitral valve prosthesis in 1. There was no valve-related death. Patients’ survival was 54% ± 7% at 10 years (Figure 1). Independent predictors of late death were age by increment of 5 years (hazard ratio 1.04, 95% confidence limit 1.01–1.09) and aortic arch aneurysm (hazard ratio 2.9, 95% confidence limit 1.6–7.3).
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Thromboembolism and Hemorrhage
Eight patients had a thromboembolic event: 3 strokes and 5 transient ischemic attacks. The freedom from thromboembolic complications at 10 years was 86% ± 5%. Nine patients were receiving warfarin sodium for atrial fibrillation or a previous thromboembolic event. There was no major anticoagulant-related hemorrhage.
Infective Endocarditis
One patient with a bicuspid aortic valve had infective endocarditis 2 years postoperatively and underwent successful aortic valve replacement.
Event-free Survival and Late Functional Class
Seventy patients had no cardiovascular complications or death during the follow-up. At the latest follow-up contact, 51 patients were in New York Heart Association functional class I, 18 in class II, and 1 in class III.
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Discussion |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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Frater7 first described this operation in 1986. Corrigan8 described this mechanism of AI in a paper titled "Permanent Patency of the Mouth of the Aorta" in 1832. Dilation of the STJ pulls the commissures away from each other and prevents the cusps from coapting centrally. This mechanical alteration of the aortic root increases the stress on the cusps, and they may become elongated or develop fenestrations in the commissural areas, or both. However, if the cusp tissue is still strong, the elongation of the free margin can be satisfactorily corrected by plication along the nodule of Arantii, and in cases of large fenestrations, the free margin of the cusp can be reinforced with a double layer 6-0 polytetrafluoroethylene suture.5 These types of cusp procedures do not seem to increase the risk of late AI, and they expand the indications for aortic valve repair.3 Although it is possible to select patients for this procedure by reviewing the preoperative echocardiogram, the decision on the type of aortic valve–sparing operation is more often made intraoperatively. These patients are usually in their sixth and seventh decades, and the ascending aortic aneurysm ends a couple of centimeters above the aortic valve. The echocardiogram often shows a large ascending aortic aneurysm with ill-defined STJ and normal or minimally dilated aortic sinuses. The AI is central and caused by lack of coaptation of the cusps. Cusp prolapse is only evident in patients with bicuspid aortic valve because the dilation of the STJ masks the elongated cusp. Intraoperatively, the aortic cusps are relatively small, the annulus is also small or normal, and the STJ is not easily identifiable, particularly along the noncoronary sinus. After the graft has been sutured to the aortic root, cusp prolapse, if present, becomes evident and it should be corrected. Once all this is done, cardioplegic solution is injected into the graft under pressure and the left ventricle is observed for distention. If no distention occurs, the repair is usually satisfactory because even mild AI causes left ventricular distention when cardioplegic solution is injected into the aortic root under pressure.
The diameter of the graft was selected after transecting the ascending aorta immediately above the commissures of the aortic valve and pulling the three commissures upward and approximating to each other until the cusps touch each other centrally.9 The diameter of the imaginary circle that included all three commissures was the estimated diameter of the STJ. If the diameter was less than 24 mm, a graft of this size or larger, depending on the size of the patient, was selected and the end to be anastomosed to the aortic root to correct the diameter of the STJ was reduced to the desired size by plicating the graft. This was done to avoid small grafts in large patients, which may increase left ventricular afterload, particularly when long segments of the thoracic aorta are replaced.
Patients with ascending aorta aneurysm and AI are usually older than patients with aortic root aneurysm3 and have more extensive aneurysmal disease with frequent involvement of the transverse arch and remaining thoracic and sometimes the abdominal aorta. These patients are good candidates for aortic valve–sparing operations such as the remodeling of the aortic root because the aortic annulus is not dilated.4 However, we do not believe that the aortic sinuses need to be replaced because their thickness is normal and the dilation is limited to the area of the STJ, which is corrected once the STJ is sutured around the Dacron graft used for replacement of the ascending aorta. The noncoronary sinus is sometimes dilated or involved by dissection, but if the other two are normal, we replace only the dilated sinus by tailoring the Dacron graft accordingly.4
The function of the aortic valve after this relatively simple procedure was excellent. Only 1 patient had severe AI, and it was likely due to a technical error. When we first began repairing elongated aortic cusps, we used to perform a triangular resection in its central portion. We have learned that dehiscence of that suture line is a potential complication of the technique, particularly in patients with a bicuspid aortic valve.10 We have since abandoned triangular resection in favor of simple plication of the cusp along the nodule of Arantii. Seven patients had moderate AI, but in none was it hemodynamically significant because they did not have symptoms or echocardiographic evidence of left ventricular volume overload.
Although the operative mortality was very low, the long-term survival was suboptimal at 54% ± 7% at 10 years. There were no valve-related deaths in this series. There were, however, a high number of cardiovascular deaths resulting from the extensiveness of the arterial disease of these patients. Two-thirds of them had transverse arch aneurysm and 20% had aneurysm of the entire thoracic aorta. Recently, LeMaire, Carter, and Coselli11 reported the outcomes of 148 patients who had the elephant trunk technique to treat extensive thoracic aneurysms. The aortic valve was normal in 71 patients, repaired in 35, and replaced in 42. The 10-year survival was only 31% ± 5%. This poor survival is a reflection of the extensiveness of the aneurysmal disease in these patients. Because of the high mortality owing to rupture and/or dissection of the remaining thoracic aorta in these patients, Kouchoukos and associates12 believe that the entire thoracic aorta should be replaced during the initial procedure by approaching the chest through a clamshell incision. However, most surgeons treat these patients with a two-stage procedure.11,13
In conclusion, aortic valve sparing to treat patients with ascending aortic aneurysm with AI resulting from dilation of the STJ is a relatively simple and durable procedure. The only difficult part of the operation is the recognition of the pathologic condition. Experienced surgeons and echocardiographers can identify these patients preoperatively by echocardiography. Aortic valve function remains stable for many years and valve-related events are rare. The long-term survival is adversely affected by the extensiveness of the aneurysmal disease that these patients frequently have.
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References |
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