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Aortic root replacement with a composite graft. Factors influencing immediate and long-term results
J Bachet1, J L Termignon, B Goudot
1Service de Chirurgie Cardio-Vasculaire, Hôpital Foch, Universite Rene Descartes, Suresnes, France.
Insights
Ascending aortic replacement with composite grafts is a safe procedure for aneurysms and dissections. The "button" technique for coronary reimplantation offers superior long-term survival compared to other methods.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Surgery
Background:
- Ascending aortic diseases, including aneurysms and dissections, require complex surgical intervention.
- Composite grafts are frequently used for ascending aortic replacement.
- Coronary reattachment techniques vary and may impact outcomes.
Purpose of the Study:
- To evaluate the safety and long-term efficacy of ascending aortic replacement using composite grafts.
- To compare the outcomes of different coronary reattachment techniques.
- To identify predictors of hospital mortality and long-term survival.
Main Methods:
- Retrospective analysis of 203 patients undergoing ascending aortic replacement with composite grafts between April 1973 and June 1994.
- Categorization of patients by indication: dystrophic aneurysm (AN), chronic dissection (CD), and acute dissection (AD).
- Comparison of outcomes based on coronary reattachment techniques: Bentall, button, Cabrol, and mixed.
Main Results:
- Hospital mortality was 7.3%, with emergency acute dissection and arch replacement being significant predictors of death.
- Long-term survival rates at 1, 5, and 10 years were 89%, 77.9%, and 67.7%, respectively.
- The
- button
- technique demonstrated significantly higher late survival rates compared to the "Cabrol" or "mixed" methods.
Conclusions:
- Ascending aortic replacement with composite grafts is a safe and effective procedure, particularly for elective cases of dystrophic aneurysm or Marfan syndrome.
- Coronary reimplantation technique significantly influences long-term results.
- The "button" technique is recommended for coronary reimplantation, especially in cases with fragile aortic walls, while "Cabrol" is reserved for situations where other methods are not feasible.
Abstract:
From April 73 to June 94, 203 patients (167 men, 36 women) aged from 10 to 74 years (mean: 44.8 +/- 15) underwent ascending aortic replacement with composite graft for: dystrophic aneurysm (AN) (130 cases, 64.5%), chronic dissection (CD) (35 cases, 17.2%), type A acute dissection (AD) (38 cases, 18.7%). Forty-six patients (22.6%) suffered from Marfan syndrome (24 AN, 13 AD, 9 CD). Thirty patients (14.7%) had undergone a previous cardiac or aortic operation. The ascending aortic replacement was extended to the transverse arch in 28 patients (13.7%). A mechanical valve was used in 193 cases (95%). Since 1986, the ascending aorta has been totally resected and a gelatin-or collagen-coated vascular prosthesis used. The technique of coronary reattachment has varied with time and according to the aortic lesions. The classic "Bentall" technique was used in 87 patients (43%), the "button" technique in 74 (36%), the "Cabrol" technique in 26 (13%) and a "mixed" technique in 16 cases (8%). The hospital mortality rate was 7.3% (15/203) (AN: 2.3%, CD: 11.4%, AD: 21%). The only predictors of hospital death were emergency AD (P < 0.03) and arch replacement (P < 0.02). Mean follow-up was 46 +/- 10 months (2-246). The overall long-term survival rate was (Kaplan Meier) 89 +/- 6% at 1 year, 77.9 +/- 9% at 5 years, 67.7 +/- 12% at 10 years and 61.3 +/- 15% at 12 years. The 10-year survival rate is significantly higher in patients with AN (77.8 +/- 11%) than in those with AD (61.6 +/- 17%) (log. rank: P < 0.01). The late survival rate is also significantly higher after the "button" or Bentall reimplantation than after the "Cabrol" or "mixed" methods (90 +/- 5% in the "button" group and 88.7 +/- 6%, 83.8 +/- 9% and 76.6 +/- 12% in the "Bentall" group vs 80 +/- 18%, 63 +/- 21% and 58 +/- 35% in the "Cabrol" group at 1, 5 and 8 years, respectively). In conclusion, ascending aortic replacement with a composite graft is a safe procedure especially when performed electively in patients with dystrophic aneurysm or Marfan syndrome. The technique of coronary reimplantation has a significant influence on the long-term results. The reimplantation of choice is the "button" technique, especially in the presence of a fragile aortic wall (AD). The "Cabrol" technique must be used when the "button" or the "Bentall" reimplantation is not feasible, for instance during redo procedures.