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eoperative Aortic Root Replacement in Patientsith Previous Aortic Surgery
ilson Y. Szeto, MD, Joseph E. Bavaria, MD, Frank W. Bowen, MD,rnar Geirsson, MD, Katherine Cornelius, BSN, RN, W. Clark Hargrove, MD, andlberto Pochettino, MD
ivision of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania Medical Center, Philadelphia,
ennsylvaniahrirway34(t(3
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Background. Reoperative aortic root reconstruction isncreasingly performed and remains a clinical challenge.he aim of this study is to evaluate the outcome ofatients undergoing reoperative aortic root replacementfter previous aortic surgery.Methods. From 1995 to 2006, 156 consecutive patients
nderwent reoperative aortic root replacement after pre-ious aortic valve replacement (group 1, n � 106, 67.8%),roximal aortic reconstruction (group 2, n � 25, 16.1%),nd aortic root replacement (group 3, n � 25, 16.1%).heir records were retrospectively reviewed.Results. The mean age was 58.1 � 14.4 years, and 73.7%
n � 115) were men. Reoperation was performed 98.4onths after previous operation, with 14.7% (n � 23)
aving undergone three or more sternotomies. Indica-ions for reoperations were endocarditis in 55 (35.3%),rosthetic valve dysfunction in 28 (17.9%), paravalvular
eak in 12 (7.7%), aortic aneurysm or pseudoaneurysm in9 (18.5%), aortic dissection in 12 (7.7%), and aortictenosis or insufficiency in 20 (12.9%). Aortic root replace-
ent was performed in all 156 patients, with concomitantpbataatdabneftp
ity of Pennsylvania Medical Center, 3400 Spruce St, 6th Silverstein,hiladelphia, PA 19104; e-mail: [email protected].
2007 by The Society of Thoracic Surgeonsublished by Elsevier Inc
emiarch reconstruction in 62 (39.7%), Cabrol coronaryeconstruction in 5 (3.2%), coronary artery bypass graft-ng (CABG) in 26 (16.6%), and mitral valve repair oreplacement (MVR) in 25 (16.0%). Thirty-day mortalityas 11.5% (n � 18). Actuarial survival was 86.4% � 2.7%
t 1 year, 72.6% � 4.3% at 5 years, and 58.4% � 7.8% at 10ears. Subgroup analysis demonstrated no difference in0-day mortality (group 1, 14.1%; group 2, 8.0%; group 3,.0%; p � 0.31) and late survival between the three groupsp � 0.14). Multivariate analysis demonstrated age olderhan 75 years (p � 0.03) and New York Heart AssociationNYHA) functional class IV (p � 0.05) as risk factors for0-day mortality.Conclusions. Reoperative aortic root reconstruction can
e performed with a low perioperative mortality rate andatisfactory long-term survival. Age older than 75 yearsnd NYHA class IV are risk factors for early mortality.revious aortic root replacement is not a risk factor foreoperative aortic root reconstruction.
(Ann Thorac Surg 2007;84:1592–9)
© 2007 by The Society of Thoracic Surgeonsince first described by Bentall and colleagues in 1968[1], aortic root replacement has become a safe option
or patients with various aortic root pathologies. In anlective setting, aortic root replacement in the current eraan be reproducibly performed with an expected mortal-ty of less than 5% [2–4]. However, as this cohort ofatients continues to increase in number and age, onean expect reoperative aortic root replacement to becomen increasingly common clinical challenge. Furthermore,ecent advances in reparative aortic surgery, includingalve-sparing aortic root reconstruction as well as thencreased use of biologic root prosthesis, have added tohe number of patients who may potentially requiree-replacement of the aortic root in the future.
Historically, reoperative aortic root replacement in
ccepted for publication May 21, 2007.
resented at the Forty-third Annual Meeting of The Society of Thoracicurgeons, San Diego, CA, Jan 29–31, 2007.
ddress correspondence to Dr Szeto, Division of Cardiovascular Surgery,epartment of Surgery, Hospital of University of Pennsylvania, Univer-
atients who have had previous cardiac operations haseen associated with significantly increased morbiditynd mortality. In contrast to first-time root reconstruc-ion, reoperative aortic root replacement in the setting of
previous cardiac operation has been shown to bessociated with increased risk, with a mortality rate of upo 18% in some series [5–8]. Furthermore, recent evi-ence has suggested an increasing incidence of thoracicortic disease in an increasingly aging population [9]. Weelieve the risks of reoperative aortic root reconstructioneed to be further examined. In this study we analyze ourxperience during an 11-year interval to identify riskactors associated with poor outcome in reoperative aor-ic root reconstruction in patients with previous aorticrocedures.
Dr Bavaria discloses that he has financial relationshipswith Carbomedics, Inc; St. Jude Medical, Inc; Vascutek
USA; and CryoLife, Inc.0003-4975/07/$32.00doi:10.1016/j.athoracsur.2007.05.049
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1593Ann Thorac Surg SZETO ET AL2007;84:1592–9 REOPERATIVE AORTIC ROOT RECONSTRUCTION
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aterial and Methods
atientsrom March 1995 to June 2006, 818 consecutive patientsnderwent aortic root replacement at the University ofennsylvania Medical Center. Among those, 156 consec-tive patients underwent reoperative aortic root replace-ent after previous aortic operations. The mean age was
8.1 � 14.4 years (range, 24 to 87 years). There were 11573.7%) men and 41 (26.3%) women. Other patient char-cteristics are listed in Table 1. The Institutional Reviewoard of the University of Pennsylvania approved thetudy and waived the need for patient consent.
revious Cardiac Proceduresll patients underwent reoperative aortic root recon-
truction after a previous aortic operation. The patientsere grouped into three categories according to theirost recent cardiac surgical procedures: group 1, aortic
alve replacement (AVR); group 2, proximal aortic recon-truction; group 3, aortic root replacement. The threeroups and the concomitant procedures performed are
isted in Table 2.A total of 179 previous sternotomies and cardiac pro-
edures were performed in 156 patients. The mean du-
able 3. Indications for Aortic Root Replacement
ndication Group 1a (n � 106)
neurysm/pseudoaneurysm 20ortic dissection 12S/AI 0ndocarditis 37aravalvular leak 12rosthetic valve dysfunction 25
Group 1, aortic valve replacement. b Group 2, proximal aortic recoomograft � 5; Ross � 1.
able 1. Patient Characteristics (n � 156)
ariables N (%) or Mean � SD
ean age, years 58.1 � 14.4 yearsenderMale 115 (73.7)Female 41 (26.3)
AD 32 (20.5)VEF 0.526 � 0.148YHAClass I 37 (23.7)Class II 31 (19.8)Class III 44 (28.3)Class IV 25 (16.0)Unknown 19 (12.2)
enal failure (Cr � 2.0 mg/dL) 19 (12.2)
AD � coronary artery disease; LVEF � left ventricular ejectionraction; NYHA � New York Heart Association; Cr � creatinine.
S/AI � aortic stenosis/aortic insufficiency.
ation from most recent cardiac procedure was 98.4onths. Second-time sternotomy was performed in 133
atients (85.3%). Sternotomy was performed three orore times in 23 patients (14.7%). In these 23 patients,
ternotomy was performed three (n � 18), four (n � 4),nd five (n � 1) times.
ndications for Reoperationhe indications for reoperative aortic root reconstructionre listed in Table 3. For the entire cohort of 156, thendications for surgical intervention were ascending aor-ic aneurysm or pseudoaneurysm, or both, in 29, ascend-ng aortic dissection in 12, aortic stenosis or aortic valvensufficiency, or both, in 20, endocarditis in 55, prostheticalve paravalvular leak in 12, and prosthetic valve dys-unction in 28. The indications were further categorizednto three groups by the most recent cardiac procedures.ndocarditis was the most common indication overall. Inroup 3 (previous aortic root replacement), 13 (52%) of
p 2b (n � 25) Group 3c (n � 25) Total (n � 106)
6 3 290 0 12
14 6d 205 13 550 0 120 3 28
ction. c Group 3, aortic root replacement. d Previous procedures:
able 2. Most Recent Cardiac Surgical Proceduresn � 156)a
rocedure N
roup 1 (AVR) 106AVR 82AVR/CABG 15AVR/MVR 7AVR/MVR/CABG 1AVR/MVR/TVR 1roup 2 (proximal aortic reconstruction) 25Type A aortic dissection/hemiarch/AV resuspension 21Ascending aortic aneurysm/hemiarch 4roup 3 (aortic root) 25Mechanical composite graft 9Aortic homograft 9Bioprosthesisb 6Ross 1
Mean duration from previous procedure 98.4 months. Sternotomy thirdime or greater in 23 patients (14.7%). b Pericardial valve conduit, fullorcine root.
VR � aortic valve replacement; CABG � coronary artery bypassrafting; MVR � mitral valve repair or replacement; TVR � tri-uspid valve repair; VSD � ventricular septal defect.
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1594 SZETO ET AL Ann Thorac SurgREOPERATIVE AORTIC ROOT RECONSTRUCTION 2007;84:1592–9
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he 25 patients underwent reoperative aortic root recon-truction secondary to prosthetic valve endocarditis. Sixatients with a history of previous aortic root homograft
n � 5) and Ross procedure (n � 1) underwent reopera-ive aortic root replacement secondary to aortic valvensufficiency.
perative Techniquell 156 patients underwent reoperative aortic root recon-
truction through a redo sternotomy. After the skinncision and removal of the sternal wires, the sternumas divided using the oscillating saw. If the preoperative
omputed tomography (CT) scan demonstrated minimalpace between the posterior aspect of the sternum andhe aorta or the heart, the femoral artery and vein werexposed before sternotomy. In the event of aortic orardiac injury on entry, peripheral cannulation was per-ormed and cardiopulmonary bypass (CPB) wasnstituted.
In patients with high risk of aortic injury on entry (eg,neurysm/pseudoaneurysm adherent to posterior aspect
able 4. Operative Management
rocedure N (%) or Mean � SD
ortic root replacement 156 (100)oncomitant proceduresHemiarch/arch reconstruction 62 (39.7)Cabrol 5 (3.2)CABG 26 (16.6)MVR 25 (16.0)TVR 3 (1.9)PFO/VSD 6 (3.8)
PB (minutes) 269.3 � 80.5ortic occlusion (minutes) 208.1 � 63.4HCA/RCP (minutes) 30.1 � 16.3
ABG � coronary artery bypass grafting; CPB � cardiopulmonaryypass; DHCA/RCP. deep hypothermic circulatory arrest/retrogradeerebral perfusion; MVR � mitral valve repair or replacement; PFO/SD � patent foramen ovale/ventricular septal defect; SD � standardeviation; TVR � tricuspid valve repair or replacement.
able 5. Hospital Morbidity and Mortality (n � 156)
vent N (%) or Mean � SD
orbidityNeurologic dysfunction and/or
CVA5 (3.2)
Renal failure and/orhemodialysis
16 (10.2)
Infection/sepsis 10 (6.4)Heart block requiring PPM 27 (17.3)Prolonged mechanical ventilation
(�24 hr)30 (19.2)
Bleeding requiring reoperation 12 (7.6)ospital stay (mean days) 13.3 � 12.3ortality 30-day/in-hospital 18 (11.5)
VA � cerebrovascular accident; PPM � pacemaker place-ent; SD � standard deviation.
Cb
f sternum) without significant aortic insufficiency, CPBas instituted by peripheral cannulation and the patientsere cooled to deep hypothermic circulatory arrest
DHCA) before sternotomy. In patients who did notequire CPB and DHCA before sternotomy, the cardiactructures were dissected out upon entry. Arterial can-ulation through the ascending aorta and venous cannu-
ation through the right atrium were used. If arch recon-truction was concomitantly performed, DHCA withdjunct retrograde cerebral perfusion (RCP) through theuperior vena cava (SVC) was used.
All patients were cooled systemically to electroenceph-logram (EEG) silence if intraoperative neuromonitoringas available. Otherwise, systemic cooling of 45 to 50inutes was performed, expecting to achieve EEG si-
ence in 90% to 95% of patients based on our protocol [10,1]. The mean CPB time was 269.3 � 80.5 minutes, andhe mean aortic occlusion time was 208.1 � 63.4 minutes.n the 62 patients (39.7%) who required arch reconstruc-ion, the mean DHCA and RCP time was 30.1 � 16.3
inutes.Coronary reimplantation using the coronary button
echnique was planned in all patients. In 5 patients,owever, Cabrol coronary anastomoses were requiredecondary to difficulty with coronary artery mobilization.ther concomitant procedures are listed in Table 4. The
56 reoperative aortic root replacements were performedith mechanical composite grafts in 88 patients (56.4%),
ortic homografts in 27 (17.3%), and bioprosthesis, in-
able 6. Cause of In-Hospital and 30-Day Mortalityn � 18)
ause N
ardiac 4nfection/sepsis 5oagulopathy/MOSF 7
schemic bowel 1nknown 1
OSF � multiorgan system failure.
able 7. Univariate Analysis of Perioperative Risk Factorsor 30-Day Mortality
erioperative Factors p Valuea
emale sex 0.02ge � 75 years 0.03reoperative renal failure 0.01YHA class IV �0.01PB � 300 minutes 0.02
nfection/sepsis �0.01eoperation for bleeding �0.01rolonged mechanical ventilation (� 24 hr) �0.01ostoperative renal failure/dialysis �0.01
Fisher exact test.
ABG � coronary artery bypass grafting; CPB � cardiopulmonaryypass; NYHA � New York Heart Association.
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1595Ann Thorac Surg SZETO ET AL2007;84:1592–9 REOPERATIVE AORTIC ROOT RECONSTRUCTION
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luding pericardial conduit and full porcine roots, orbioroot” in 41 (26.3%).
ata Collectionospital and outpatient clinical charts were retrospec-
ively reviewed for patient characteristics, preoperativeomorbidities, indications, intraoperative events, andostoperative course. Follow-up data were obtained bylinic visits, retrospective chart review, and the Thoracicortic Surgery clinical database at the University ofennsylvania.
tatistical Analysistatistical analysis was performed using SPSS Base2.0 software (SPSS Inc, Chicago, IL). Continuous vari-bles were expressed as the mean � standard devia-ion (SD) and were compared using one-way analysisf variance with the Bonferroni post hoc correction.ategoric variables expressed as percentage were an-lyzed using �2 test or the Fisher exact test whenppropriate. Univariate analysis using the �2 test waserformed to identify relationships between 30-dayortality and perioperative risk factors. Variables withvalue of p � 0.05 were examined using logistic
egression multivariate analysis to determine theirndependent influence on 30-day mortality. Survivalas analyzed with the Kaplan-Meier method, and
able 8. Patient Subgroup Analysis According to Previous Ca
actors Group 1a (
reoperative factorsMale sex (%) 74.Age (years) 59.5 �
Endocarditis (%) 34.Previous CABG (%) 19.Redo sternotomy, � 3 (%) 11.Interval from previous surgery (mon) 118.4 �
LVEF 0.521 �
NHYA class IV (%) 56.Renal failure (%) 14.perative factorsCPB (min) 261.4 �
Aortic occlusion (min) 204.3 �
Infection/sepsis (%) 6.Neurologic dysfunction/CVA (%) 2.Reoperation for bleeding 7.Mean hospital stay (days) 13.7 �
Prolonged mechanical ventilation � 24 hr (%) 21.Renal failure (%) 9.PPM (%) 16.Mortality, 30-day (%) 14.
Group 1, aortic valve replacement. b Group 2, proximal aortic reconstf variance.
ontinuous data are presented with the standard deviation.
ABG � coronary artery bypass grafting; CPB � cardiopulmonary byraction; NHYA � New York Heart Association; PPM � pacemak
omparison between groups was performed using the
og-rank test. Survival at 1, 5, and 10 years was ex-ressed as a percentage � SD. Multivariate analysisith Cox regression method was used to examine
ndependent risk factors for survival.
esults
ospital Morbidity and Mortalityhe incidence of the postoperative complications is listed
n Table 5. Neurologic events developed in 5 patients. Forpatients, the neurologic dysfunction was temporary
ith full neurologic recovery. All 5 patients were even-ually discharged from the hospital. Acute renal failureccurred in 16 patients, in whom 7 patients subsequentlyequired long-term hemodialysis. Pneumonia, persistentacteremia, or sternal wound infection occurred in 10atients, and 5 atients eventually died secondary to theverwhelming sepsis. Heart block as a result of extensiveébridement and reoperative root reconstruction oc-urred in 27 patients, requiring placement of permanentacemaker during the same hospitalization. Prolongedechanical ventilation, defined as mechanical ventila-
ory support longer than 24 hours, was required in 30atients. Bleeding requiring reoperation for tamponadeccurred in 12 patients. Complications related to coagu-
opathy and bleeding resulted in multisystem organailure and death for 7 of the 12 patients.
Procedure
106) Group 2b (n � 25) Group 3c (n � 25) p Value
60.0 84.0 0.14d
59.0 � 11.9 49.0 � 14.2 0.01c
20.0 52.0 0.06d
20.0 28.0 0.62d
20.0 32.0 �0.01d
70.8 � 58.1 55.3 � 62.4 0.02e
0.532 � 0.109 0.54.2 � 0.107 0.81e
38.0 34.7 0.07d
12.0 4.0 0.37d
279.4 � 69.4 291.8 � 123.0 0.18e
210.3 � 56.0 221.8 � 89.1 0.45e
4.0 8.0 0.83d
8.0 4.0 0.48d
8.0 8.0 0.99d
12.0 � 9.9 12.6 � 8.5 .079e
16.0 12.0 0.49d
20.0 4.0 .015d
16.0 24.0 0.62d
8.0 4.0 0.31d
n. c Group 3, aortic root replacement. d �2 Analysis. e Analysis
CVA � cerebrovascular accident; LVEF � left ventricular ejectioncement.
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1596 SZETO ET AL Ann Thorac SurgREOPERATIVE AORTIC ROOT RECONSTRUCTION 2007;84:1592–9
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1.5% (n � 18). The causes of in-hospital death are listedn Table 6. By univariate analysis (Table 7), risk factors for0-day mortality were female sex, 21.8% (9/41, p � 0.02);ge older than 75 years, 26.0% (6/23, p � 0.03); preoper-tive renal failure, 31.5% (6/19, p � 0.01), New York Heartssociation (NYHA) function class IV, 32.0% (8/25, p �
.01); CPB exceeding 300 minutes, 21.7% (10/46, p � 0.02);epsis, 50.0% (5/10, p � 0.01); reoperation for bleeding,8.3% (7/12, p � 0.01); prolonged mechanical ventilation,0.0% (9/30, p � 0.01); and postoperative renal failure,3.7% (7/16, p � 0.01). Previous coronary artery bypassrafting (CABG), previous aortic root replacement (group), third-time or greater sternotomy, preoperative or
ig 1. Overall actuarial survival using Kaplan-Meier analysis.
ig 2. (A) Kaplan-Meier analysis (log-rank): Comparison of late survolid line), previous proximal aortic reconstruction (group 2, small daine; p � 0.14). (B) Kaplan-Meier analysis (log-rank): Comparison of
to III (solid line) and class IV (dashed line; p � 0.017)ostoperative neurologic dysfunction or cerebrovascularccident (CVA), endocarditis, DHCA, and placement ofacemaker were not significantly associated with in-reased 30-day mortality. Age older than 75 years (p �.03, 95% confidence interval [CI], 0.047 to 0.874), NYHAlass IV (p � 0.05, 95% CI, 0.04 to 1.032), CPB exceeding00 minutes (p � 0.02, 95% CI, 0.050 to 0.794), reoperationor bleeding (p � 0.01, 95% CI, 0.010 to 0.344), andostoperative renal failure (p � 0.01, 95% CI, 0.021 to.490) remained significant by multivariate analysis usingogistic regression.
Subgroup analysis comparing the three groups is re-orted in Table 8. Patients with previous aortic rooteplacement undergoing reoperative aortic root recon-truction (group 3) were significantly younger (49.0 � 14.2ears, p � 0.01). Compared with the other two groups,roup 3 also had the highest incidence of third time orreater sternotomy (32.0%, p � 0.01) and had the shortest
nterval from the previous sternotomy (55.3 � 62.4onths, p � 0.02). Group 3 also demonstrated a trend
owards a lower incidence of NYHA class IV (34.7%, p �.07), with a higher incidence of endocarditis (52%, p �.06) compared with groups 1 and 2. The groups wereimilar in CPB time, aortic occlusion time, incidence ofnfection and sepsis, postoperative stroke, reoperationor bleeding, prolonged mechanical ventilation, postop-rative renal failure, pacemaker placement and meanospital stay. The 30-day mortality rates were 14.1%
15/106), 8.0% (2/25), and 4.0% (1/25) in group 1, group 2,nd group 3, respectively (p � 0.31).
ate Mortalityverall actuarial survival was 86.4% � 2.7% at 1 year,
2.6% � 4.3% at 5 years, and 58.4% � 7.8% at 10 years (Fig
n patients with previous aortic valve replacement (AVR; group 1,line), and previous aortic root replacement (group 3, large dashedsurvival in patients with New York Heart Association (NYHA) class
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1597Ann Thorac Surg SZETO ET AL2007;84:1592–9 REOPERATIVE AORTIC ROOT RECONSTRUCTION
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). Long-term survival was similar among the patientsith previous AVR (group 1), proximal aortic reconstruc-
ion (group 2), and aortic root replacement (group 3; logank, p � 0.14; Fig 2A). Compared with NYHA classes I toII, class IV was associated with a decreased long-termurvival (log rank, p � 0.017; Fig 2B). Multivariate analysissing Cox regression demonstrated age older than 75ears as an independent preoperative predictor of de-rease late survival (p � 0.01, 95% CI, 0.161 to 0.725).revious CABG, previous aortic root replacement (group), third time or greater sternotomy, endocarditis, andYHA class IV were not associated with decreased late
urvival under multivariate analysis.
omment
eoperative aortic root reconstruction is increasinglyerformed and remains a clinical and technical challenge
6–8, 12–15]. Likely factors contributing to the increasingncidence include (1) increasing number of aortic rooteplacements, such as bioprosthesis reconstruction orbioroot,” homografts, and autografts; (2) reparative aor-ic root reconstruction such as valve-sparing aortic rooteplacement; and (3) an aging population with an in-reasing incidence of thoracic aortic pathology.
In 1985 Crawford and colleagues [5] reported a series ofeoperative aortic operations with a mortality of 17%.
ore recent series examining reoperative aortic rooteconstruction in patients with previous cardiac opera-ions have demonstrated early mortality of 3% to 17.9%6–8, 12–15].
The goal of our study was to analyze the outcome ofeoperative aortic root reconstruction in patients withrevious aortic operations and, specifically, previous aor-
ic root reconstruction. Previous studies were often lim-ted in the number of patients and often included aariety of patients with different previous cardiac surgeryanging from previous CABG to ventricular septal defectlosure to pericardiectomy [6, 13]. Re-replacement of theortic root is a technical challenge, and few studies havepecifically examined this cohort of patients.
The overall 30-day mortality in our series was 11.5% inatients with previous aortic surgery undergoing aorticoot reconstruction. However, a subgroup analysis ofatients with previous aortic root replacement undergo-
ng re-replacement of the aortic root (group 3) demon-trated a 30-day mortality of 4.0%. In fact, univariatenalysis of 30-day mortality did not identify previousortic root replacement as a risk factor for 30-dayortality.Although not statistically significant, the differences
n 30-day mortality of 14.1% in group 1, 8.0% in group, and 4.0% in group 3 could be explained by theifferences in the patient population of the threeroups. Patients with previous aortic root replacementgroup 3) were younger, with a mean age, 49 years, andad the lowest incidence of NYHA class IV (34.7%). Inontrast, patients with previous AVR (group 1) werelder, with a mean age of 59.5 years, and 56.9% of these
atients NYHA class IV. Multivariate analysis identi- red both age older than 75 years and NYHA class IV asisk factors for early death.
David and colleagues [12] recently reported their ex-erience of 165 patients with previous cardiac operationsndergoing aortic root replacement. Similarly, the study
dentified increasing age and NYHA class IV as indepen-ent risk factors for death. In a similar study of 147atients, Girardi and colleagues [13] identified age older
han 75 years to be a risk factor for death. Other authorsave also identified age and NYHA class III and IV as risk
actors for death [6, 8].We attempted to identify other preoperative predic-
ors of poor outcome. Endocarditis, the number ofrevious sternotomies, and shorter interval from pre-ious sternotomy were not found to be risk factors foreath by univariate analysis. In fact, patients withrevious aortic root replacement (group 3) demon-trated the highest incidence of endocarditis (52%),ighest incidence of third time or greater sternotomy
32.0%), and shortest interval from previous surgery55.3 months). Although these factors are markers forifficult dissection and technical challenges, the clini-al outcome in this group was the most favorable, with30-day mortality of 4%.Kirsch and colleagues [7] recently reported their expe-
ience of 56 patients undergoing aortic root replacementfter previous surgical intervention on the aortic valve,ortic root, or ascending aorta. In this cohort, 6 patientsad a previous history of aortic root reconstruction. Theverall mortality was 17.9%. Similar to our study, endo-arditis was not identified as a risk factor for earlyortality by univariate analysis.Schepens and colleagues [8] recently reported a series
f 134 patients undergoing reoperation on the aortic rootnd ascending aorta, with 18 patients having had previ-us aortic root replacements. In their review, a preoper-tive creatinine level of more than 200 �mol/L wasdentified as a predictor of hospital death by univariatenalysis. Our study similarly identified preoperative re-al failure as a risk factor for 30-day mortality by univar-
ate analysis; however, it did not remain significant byultivariate analysis.Re-replacement of the aortic root is technically de-anding, and we attempted to identify intraoperative
redictors and postoperative outcomes as risk factors forarly mortality. Kirsch and colleagues [7] identified un-lanned CABG as the sole independent risk factor forospital death. Schepens and colleagues [8] reported
echnical problems necessitating repeat cardioplegic ar-est as a risk factor for hospital mortality. In our series,echnical issues with coronary mobilization required un-lanned Cabrol coronary reconstruction in 5 patients;owever, these patients all survived to hospitalischarge.Others have identified prolonged CPB time as risk
actors for early mortality [6, 13]. We also identified CPBxceeding 300 minutes and reoperation for bleeding asisk factors for 30-day mortality using multivariate anal-sis. In our series, 7 of the 12 patients who underwent
eoperation for bleeding died as a result of complications
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1598 SZETO ET AL Ann Thorac SurgREOPERATIVE AORTIC ROOT RECONSTRUCTION 2007;84:1592–9
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elating to coagulopathy and multiorgan system failure.lthough most of the patients did not have specificleeding sites, issues with the left coronary button anas-
omosis were evident in 2 patients. Others have reportedostoperative renal failure to be associated with poorospital outcome [8, 13]. Similarly in our study, postop-rative renal failure was the only postoperative risk factoro be associated with early mortality under multivariatenalysis.Considering the complexity and technical challengeith “true” reoperative aortic root reconstruction or
e-replacement of the aortic root, our morbidity ratend 30-day mortality rate of 4% are encouraging.lthough the number of patients in this subgroup is
mall (n � 25), our study demonstrates similar experi-nce in this high-risk cohort of patients with theoronto group. Raanani and colleagues [15] reportedn operative mortality of 3% in a series of 31 patients.ctive prosthetic valve endocarditis was the indication
or surgery in 39% of patients, with a mean intervaletween the primary procedure and the reoperation of1 months. The use of interposition graft for coronaryeimplantation was required in 16 patients. The meange at reoperation was 44.7 years. Similar to our study,hey did not find endocarditis to be a significant riskactor for long-term survival.
In conclusion, “true” reoperative aortic root recon-truction, or re-replacement of the aortic root, is techni-ally complex and challenging. Nonetheless, reoperativeortic root reconstruction can be performed with loworbidity and mortality regardless of the presence of
ndocarditis, previous CABG, or multiple sternotomies.ncreasing age and NYHA class IV are risk factors foreath, however.
e would like to acknowledge Seema Sonnad for her statisticalnalysis expertise and Brenton Moore for his databaseanagement.
eferences
1. Bentall H, De Bono A. A technique for complete replacement
of the ascending aorta. Thorax 1968;23:338–9.lder patient, perhaps, we may not be as aggressive.
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2. Gleason TG, David TE, Coselli JS, Hammon JW, Bavaria JE.St. Jude Medical Toronto biologic aortic root prosthesis:early FDA phase II IDE study results. Ann Thorac Surg2004;78:786–93.
3. Zehr KJ, Orszulak TA, Mullany CJ, et al. Surgery for aneu-rysms of the aortic root: a 30-year experience. Circulation2004;110:1364–71.
4. Sioris T, David TE, Ivanov J, Armstrong S, Feindel CM.Clinical outcomes after separate and composite replacementof the aortic valve and ascending aorta. J Thorac CardiovascSurg 2004;128:260–5.
5. Crawford ES, Crawford JL, Safi HJ, Coselli JS. Redo opera-tions for recurrent aneurysmal disease of the ascendingaorta and transverse aortic arch. Ann Thorac Surg 1985;40:439–55.
6. Dougenis D, Daily BB, Kouchoukos NT. Reoperations on theaortic root and ascending aorta. Ann Thorac Surg 1997;64:986–92.
7. Kirsch EW, Radu NC, Mekontso-Dessap A, Hillion ML,Loisance D. Aortic root replacement after previous sur-gical intervention on the aortic valve, aortic root, orascending aorta. J Thorac Cardiovasc Surg 2006;131:601– 8.
8. Schepens MA, Dossche KM, Morshuis WJ. Reoperations onthe ascending aorta and aortic root: pitfalls and results in 134patients. Ann Thorac Surg 1999;68:1676–80.
9. Olsson C, Thelin S, Stahle E, Ekbom A, Granath F.Thoracic aortic aneurysm and dissection: increasingprevalence and improved outcomes reported in a na-tionwide population-based study of more than 14,000cases from 1987 to 2002. Circulation 2006; 114:2611– 8.
0. Stecker MM, Cheung AT, Pochettino A, et al. Deep hypo-thermic circulatory arrest: I. Effects of cooling on electroen-cephalogram and evoked potentials. Ann Thorac Surg 2001;71:14–21.
1. Stecker MM, Cheung AT, Pochettino A, et al. Deep hypo-thermic circulatory arrest: II. Changes in electroencephalo-gram and evoked potentials during rewarming. Ann ThoracSurg 2001;71:22–8.
2. David TE, Feindel CM, Ivanov J, Armstrong S. Aortic rootreplacement in patients with previous heart surgery. J CardSurg 2004;19:325–8.
3. Girardi LN, Krieger KH, Mack CA, Lee LY, Tortolani AJ,Isom OW. Reoperations on the ascending aorta and aorticroot in patients with previous cardiac surgery. Ann ThoracSurg 2006;82:1407–12.
4. Hahn C, Tam SK, Vlahakes GJ, Hilgenberg AD, Akins CW,Buckley MJ. Repeat aortic root replacement. Ann ThoracSurg 1998;66:88–91.
5. Raanani E, David TE, Dellgren G, Armstrong S, Ivanov J,Feindel CM. Redo aortic root replacement: experience with
31 patients. Ann Thorac Surg 2001;71:1460–3.ISCUSSION
R MICHAEL E. JESSEN (Dallas, TX): I think about 39 of youratients were previous aortic valve replacements that now were
argely operated on for aneurysm disease. What is your approach inhe patient who has a small aneurysm and needs just an aortic valveperation? Should we be more aggressive in doing an aortic root
nitially in those patients? Or does the fact that these operations can beone with very good results, suggest that we just treat the aneurysmart independent of a standard aortic valve operation?
R SZETO: We are very comfortable with aortic root replace-ent. We are fairly aggressive with replacing the root if we feel
here is an indication. Much also depends on the patient. An
But, in general, what our practice has been is to replace theortic root and the ascending aorta when the diameter reaches.5 cm if the patient is a bicuspid aortic valve or has a history ofonnective tissue disorder such as Marfan. Also, we will proceedith replacement of the aortic root and ascending aorta if there
s a significant family history of aortic dissection or aneurysm.therwise, we will proceed with replacement of the aortic root
nd ascending aorta when the aorta reaches 5 cm.Now, having said that, we always think about setting up for
he next operation. For a young patient, who really doesn’t havediseased sinus segment (some of those patients in group 2ere in fact Wheat procedures, meaning an AVR and an
scending,) we will perform either an AVR or AVR with ascend-
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ng aorta replacement (Wheat procedures) to set up for aneasier” next operation. By leaving the nondiseased sinus seg-ents in the first operation, the second operation will not be a
true” redo root replacement, perhaps making coronary mobi-ization less of a technical issue.
R BAVARIA: I have two comments on that. The first one is, tomplify these concepts through with his nuance, if we have aoung patient who has opted for a bioroot or tissue value, weill set the case up for a second-time operation and sometimese will do a Wheat procedure (ie, aortic valve replacement,
etention of sinus segment, and ascending aortic replacement athe STS) to make the next operation a little bit easier comparedo a full root redo.
Interestingly, we may change that a little bit here because it isctually the third group, the full-root group, that has the lowestortality, which we were really quite surprised to see. So I think
he take-home message here is that the full root is a goodperation. We have some nuanced concepts regarding patientsho want tissue valves who are less than 60 years of age. In
hese patients, we try to set the operation up for a laterperation. But the 4% reoperative mortality rate for “true”eoperative root procedures was better than we thought we wereoing to get.
R SZETO: Correct. And I think, in addition, the take-homeessage is: A well-performed aortic root replacement is always
etter than a poorly performed AVR. If the clinical situationictates it, you should not shy away from a root replacement.
HOMAS GLEASON (Pittsburgh, PA): Wilson, I’ve got a quickuestion.I am trying to figure out why the AVR group had such a higherortality rate. Is that because more of those patients in that
ubgroup had endocarditis? Why do you think that group haduch a higher mortality?
R SZETO: Correct. I don’t know if we can go back on that slide,ut that was very surprising to me as well when I first saw theata. But group 1 was 10 years older and had a much higher
ncidence (greater than 50% of them) of NYHA class IV heartailure. And so this group is, in general, an older patientopulation with sicker ventricles. And there was not a higher
ncidence of endocarditis in group 1. In fact, endocarditis wasot a risk factor for poor outcome. Indication for surgery in
roup 3 was endocarditis in 52% of patients. In group 1, the wndication for surgery was endocarditis in only 34%. Manyatients in group 1 were in fact, patients who presented withortic dissections. These were patients who have had previousVR and now either have an aortic dissection or a contained
upture or pseudoaneurysm at their aortotomy sites. And inombination with the fact that they are 10 years older and theirV function is worse, I think that would, perhaps, explain why
t’s a 14% mortality in that group as opposed to 4% in group 3.
R GLEASON: So the majority of those were not aneurysms,hey were composed of some other pathology (eg,seudoaneurysms).
R SZETO: Correct. Group 1 were patients with previous AVRho presented for the second operation with aneurysms,seudoaneurysms, or dissections, most likely from a clamp
njury.
R KENNETH K. LIAO (Minneapolis, MN): The most commonalve conduit you used for reoperation is a mechanical valveonduit. Any reason for that, especially in the elderly redoatient?
R SZETO: Yes. As you can see, not an insignificant number ofatients, almost 15% of these patients, were at least a third-timeternotomy. The most common indication for reoperative aorticoot replacement was endocarditis (55 patients). Many of theseatients were basically at the end of their surgical options. For
hese patients, we did not want to go back into the mediastinumthird or fourth or fifth time. Furthermore, this group of
atients, in general, was relatively young, with a mean age of 58ears.
R BAVARIA: Yes, I think the big answer to that question haveeen commented on. It is a little difficult for all of us to startdvocating three-operation lifespans for younger patients. Iave no problem advocating two-operation lifespan strategies,ut not necessarily three. And like the gentleman just said, if theatient is over 60 and needed a redo, we usually put a bioroot in,r even 55 maybe; or we would place a bioroot if the naturalistory of the disease process the patient presented with miti-ates against a 15- to 20-year lifespan.However in the final analysis, I would like to reiterate theisdom of Dr Michael Deeb’s famous line, which is: “There’s theo, there’s the redo, and then there’s the do-do.” And so we may
ant to try to stay away from the third operation if we can.
