Reoperative Aortic Root Replacement in Patients Aortic Root Replacement in Patients With Previous Aortic Surgery Wilson Y. Szeto, MD, Joseph E. Bavaria, MD, Frank W. Bowen, MD, Arnar Geirsson, MD, Katherine Cornelius, BSN, RN, W. Clark Hargrove, MD, andPublished in: The Annals of Thoracic Surgery 2007Authors: Wilson Y Szeto Joseph E Bavaria Frank W Bowen Arnar GeirssonAffiliation: University of PennsylvaniaAbout: Thorax Root Surgery Therapy
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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,
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 concomitant
ity of Pennsylvania Medical Center, 3400 Spruce St, 6th Silverstein,hiladelphia, PA 19104; e-mail: email@example.com.
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;84:15929)
2007 by The Society of Thoracic Surgeons
ince first described by Bentall and colleagues in 1968, 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% . 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 2931, 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 . Furthermore, recent evi-ence has suggested an increasing incidence of thoracicortic disease in an increasingly aging population . 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.
1593Ann Thorac Surg SZETO ET AL2007;84:15929 REOPERATIVE AORTIC ROOT RECONSTRUCTION
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
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.
1594 SZETO ET AL Ann Thorac SurgREOPERATIVE AORTIC ROOT RECONSTRUCTION 2007;84:15929
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
Renal failure and/orhemodialysis
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.
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)
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.
C pass;f er pla
1595Ann Thorac Surg SZETO ET AL2007;84:15929 REOPERATIVE AORTIC ROOT RECONSTRUCTION
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 stand...