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Cir Ciruj 2010;78:43-49

Bentall procedure in ascending aortic aneurysm: hospital mortality

Matilde Myriam Galicia-Tornell,* Bertha Marín-Solís,** Clotilde Fuentes-Orozco,*** Manuel Martínez-Martínez,* Esteban Villalpando-Mendoza,* and Fermín Ramírez-Orozco*

abstract

Background: Ascending aortic aneurysm disease (AAAD) shows a low frequency, heterogeneous behavior, high risk of rupture, dissection and mortality, making elective surgery necessary. Several procedures have been developed, and the Bentall technique is considered as the reference standard. The objective was to describe the hospital mortality of AAAD surgically treated using the Bentall procedure. methods: We carried out a descriptive study. Included were 23 patients with AAAD who were operated on between March 1, 2005 and September 30, 2008 at our hospital. Data were obtained from clinical files, and descriptive statistics were selected for analysis. results: The study population was comprised of 23 patients with an average age of 46 years; 83% were males. Etiology was nonspecific degeneration of the middle layer with valve implication in 43%, bivalve aorta in 22%, Marfan syndrome, Turner's syndrome and poststenotic aneurysms each represented 9%, and Takayasu disease and ankylosing spondylitis 4% each. Associated heart disease was reported in six (26%) patients as follows: aortic coarctation (2), ischemic cardiopathy (1), atrial septal defect (1), severe mitral insufficiency (1) and subaortic membrane (1). Procedures carried out were Bentall surgery in 20 (87%) patients and aortoplasty with valve prosthesis in three (13%) patients. Complications reported were abnormal bleeding with mediastinal exploration (17%), nosocomial pneumonia (13%), arrhythmia (13%), and septic shock (9%). Mortality was reported in three (13%) patients due to septic shock and ventricular fibrillation. Conclusions: Surgical mortality with the Bentall procedure is similar to published results by other specialized centers. Events related to the basic aortic pathology, surgical technique, aortic valve prosthesis and left ventricular dysfunction encourage longterm studies with follow-up. Key words: Bentall procedure, ascending aortic aneurysm.

introduction

Ascending aorta aneurysm disease (AAAD) is characterized by its low frequency, heterogeneity and risk of rupture and dissection, complications that determine the high mortality of 94 to 100%. These are clear indications for the need for urgent surgery.1-6 The determining factors of these complications are the diameter of the aorta and the underlying disease; therefore, the indication of elective surgery is essential.1,3-5,7 It is documented that an aortic diameter >5 cm has a risk of rupture and dissection up to 45% per person/year.1-10 However, independent of the pathogenic

mechanism of AAAD, the natural tendency of aneurysms is to progressively increase, with the average rate recorded as 0.42 cm/year (range: 0.1-0.52 cm/year).1-7 The decision for surgical treatment is multifactorial and is established by the anatomic features of the aorta, underlying disease, risk of anticoagulation, age of the patient and presence of active infection, among others.7,8 Various surgical techniques have been developed that reflect the evolution in the management of AAAD, each with advantages, limitations and specific risks.3,7 Root replacement and ascending aorta with a tubular valved graft called the Bentall procedure is considered as an option for treatment of AAAD accompanied by

* Departamento de Cirugía Cardiotorácica ** Departamento de Cardiología *** Unidad de Investigación en Epidemiología Clínica, Sección Cirugía, Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco Correspondence and reprint requests to Matilde Myriam Galicia-Tornell. Valle de Mezquital 135, Col. Valle de Aragón Primera Sección, 57100 Estado de México, México Tels.: (55) 5780 1123; 5796 8573. E-mail: [email protected] Received for publication: 4-17-2009 Accepted for publication: 10-21-2009

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annuloectasia.3,9 This technique has shown low morbidity and mortality (1.7 to 17%) and a 5-year survival rate of 73 to 92%, being 60 to 73% at 10 years.1,3-5,7,10 However, surgical mortality can vary dramatically according to hospital experience, medical equipment, disposable resources and heterogeneity of patients.5 At the Hospital de Especialidades, Centro Medico Nacional de Occidente, IMSS, Guadalajara, Jalisco, the Bentall procedure is the technique used for the reconstruction of the ascending aorta; however, information is unavailable documenting hospital mortality. Therefore, the objective of this study was to determine the frequency of hospital mortality of AAAD surgically treated using the Bentall procedure in our hospital.

materials and methods

We performed a descriptive study that included 23 patients with AAAD who were surgically treated with the Bentall procedure in the referred hospital between March 1, 2005 and September 30, 2008. Clinical information was obtained from medical records. Studied variables were hospital mortality, which corresponded to deaths occurring within the first 30 days postoperatively. Hospital mortality associated with surgical technique was determined from the following reasons: postoperative bleeding, dehiscence or perianastomotic leak at the level of the coronary ostia and distal and proximal anastomosis of the tubular graft to the aorta, pseudoaneurysm formation and acute coronary event. Hospital mortality unrelated to surgical technique was determined by cerebral vascular event, systemic inflammatory response, postoperative heart failure, pulmonary failure, nosocomial pneumonia, and postoperative renal failure. Indications for emergency surgery were acute aortic dissection, hematoma of the aortic wall, NYHA functional class III, acute and severe aortic insufficiency, myocardial or distant organ infarction, and acute endocarditis. Indications for elective surgery were an aortic root diameter >5.5 cm or growth rate of 0.5 cm/year or more, diameter of 5 cm in Marfan syndrome or bicuspid aortic valve, insufficiency or severe aortic stenosis and symptomatic regardless of aneurysm size, with ejection fraction <50% and significant dilatation of left ventricular: telediastolic diameter >75 mm or telesystolic >55 mm. The Bentall procedure was performed in all patients through a median sternotomy with cardiopulmonary bypass (CPB) through the cannulation in the ascending aorta or in the femoral artery when aortic dissection and right atrial cannulation were presented (Figure 1). With moderate systemic hypothermia (30-32ºC), the ascending aorta was clamped and cardiac arrest was carried out with cold hyperkalemic crystalloid cardioplegia and local hypother-

figure 1. Aneurysm associated with aortic dissection and annuloectasia.

figure 2. Longitudinal aortotomy with extension to non-coronary sinus of Valsalva

mia. Aneurysm identification was done with longitudinal aortotomy and resection of the native aortic valve (Figure 2). Anastomosis of the valved tubular graft (Carbomedics, Austin, TX) with the aortic valve ring was performed with 2-0 continuous polypropylene suture (Figure 3). Cauterization was managed with two holes over the graft and through

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these the coronary ostia were implanted with 5-0 polypropylene suture (Figure 4). If the aneurysm was confined to the ascending aorta and was not associated with dissection, the graft was measured and the distal anastomosis to the aortic clamp was completed. In the presence of dissection, modification of the technique consisted of placing Teflon material to plicate the aortic wall and the graft in order to obliterate the false lumen and reinforce the anastomosis (Figure 5). The warm-up was begun, aortic and left chambers were purged through the aortic root and right upper pulmonary vein. After completing the distal and proximal anastomosis, the residual aortic wall was sutured around the tubular graft (Figure 6). Cabrol fistula was performed with a polytetrafluoroethylene (PTFE) graft of 8 mm or with the plicature of the right atrial appendage towards the remaining aortic tissue, with the object of avoiding a hematoma in the periprosthetic space. The procedure was completed conventionally. Descriptive statistics were used and analysis was performed using the SPSS (Statistical Package for Social Sciences) v.8.0 program for Windows.

results

There were a total of 1862 cases of cardiac surgery carried out from March 1, 2005 to September 30, 2008 at the Hospital de Especialidades. The procedures on the ascending aorta corresponded to 1.2% (23 cases). Average age of presentation of the AAAD was 46 years (range: 16-74 years). Males were more affected in 19/23 cases (83%) (M:F ratio 4.7:1). The most frequent etiology was nonspecific degeneration of the middle layer associated with valvular disease in 10 cases (43%), principally represented by cystic necrosis of the middle layer in 39% (nine cases) and 4% (one case) by atherosclerosis. The bivalve aorta represented 22% (five cases), genetic diseases of Marfan and Turner syndrome types and poststenotic aneurysms were 9% (two cases each), Takayasu disease and ankylosing spondylitis with 4% (one case for each) (Table 1). Heart disease coexistent with AAAD occurred in six patients (26%) and consisted of aortic coarctation in two cases (9%), ischemic heart disease, interatrial communication, severe mitral insufficiency and subaortic membrane, one case of each (4%) (Table 2). The indication for emergency surgery occurred in six cases (26%), manifested by aortic dissection and hematoma in 22% (5 cases) and NYHA functional class III in 4% (1 case). Elective surgery was performed in 17 cases (76%), aneurysmal size being the main indication for 15 cases, with average diameter of 63 mm at the time of the diagnosis and growth of 1.5 cm/year for poststenotic aneurysms

figure 3. After resection of the native valve, proximal anastomosis is performed of the tubular valve graft of the aortic ring.

figure 4. Coronary ostia are anastomosed to the tubular Dacron graft with 5-0 polypropylene continuous suture.

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table 1. Etiology of AAAD n = 23 % Nonspecific degenerative aneurysms · Cystic degeneration of the middle layer · Atherosclerosis Bivalve aortic valve Marfan syndrome Turner syndrome Poststenotic aneurysms Takayasu disease Ankylosing spondylitis

AAAD, ascending aortic aneurysm disease.

10 9 1 5 2 2 2 1 1

43 39 4 22 9 9 9 4 4

figure 5. In cases of type A aortic dissection, Teflon material was placed to obliterate the false lumen and reinforce the anastomosis.

The procedures for the treatment of AAAD were Bentall surgery in 20 cases (87%), of which four cases (20%) were supplemented with Cabrol fistula and aortoplasty with prosthetic valve implant in three patients (13%). Concomitant procedures were performed in four cases (17%), which consisted of myocardial revascularization, closure of interatrial communication, mitral valve implant and resection of subaortic membrane (Table 3). Hospital complications occurred in eight cases (35%): abnormal bleeding with mediastinal exploration in four cases (17%), nosocomial pneumonia in three cases (13%), isolated as the causative bacteria Candida albicans and Staphylococcus haemolyticus, disturbances in the conduction and pace in three cases (13%) and septic shock in two cases (9%) (Table 4). Mortality accounted for three cases (13%): septic shock secondary to nosocomial pneumonia in two cases and one case due to ventricular fibrillation (Table 5).

discussion

We found that hospital mortality when using the Bentall procedure for the treatment of AAAS was 13% caused by septic shock and ventricular fibrillation, results that cointable 2. Cardiac diseases associated with AAAD (n = 23)

figure 6. After completing the distal and proximal anastomosis, the residual aortic wall was sutured around the tubular graft (inclusion technique).

n Associated cardiac disease · Aortic coarctation · Interatrial communication · Ischemic cardiopathy · Severe mitral insufficiency · Subaortic root

AAAD, ascending aortic aneurysm disease.

% 26 9 4 4 4 4

(two cases). Valvular affection was predominantly valvular aortic insufficiency of moderate to severe level in 65% (15 cases), decrease of left ventricular ejection fraction (<50%) in five cases (22%) and severe dilatation of the left ventricular in six cases (26%).

6 2 1 1 1 1

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cide with the literature. Since its introduction in 1968, the Bentall procedure has been considered the procedure of choice for the treatment of AAAD that is combined with aortic valve disease. Refinement of the surgical technique and continuous advances in anesthetic procedures have achieved mortality rates of 1.7 to 17.1% for elective surgery and 23 to 59% for emergency surgery,6,10-15 with a 5-year survival rate of 73 to 92% and 60 to 73% at 10 years postsurgery.1,3-5,7,10,16-25 The results of two national studies from the Centro Medico Nacional XXI Century, IMSS and Centro Médico 20 de Noviembre (ISSSTE) indicate an operative mortality of 6.6 to 7.7% for thoracic aneurysms, referring to causes of death such as postoperative bleeding, myocardial infarction, ventricular failure, acute dissection and shock.26,27 However, these reports included aneurysms of different location and etiology and therefore with different surgical approaches, suggesting the need for national prospective studies to identify factors associated with mortality as well as the impact of surgical treatment on the survival of patients with AAAD. Regarding the causes of mortality, the most common was aortic rupture, which is often rapidly fatal, followed by low output syndrome, multi-organ failure and sepsis.5,14,19-20 Statistically significant factors associated with early mortality are age >65 years, functional class III-IV NYHA preoperative, aortic dissection, emergency surgery, duration of extracorporeal circulation >140 min, severe mitral insufficiency, concomitant procedures and postoperative complications such as abnormal bleeding, neurological deficits and disorders of cardiac rhythm and conduction. Emergency surgery is associated with a mortality rate seven times higher compared to elective procedure.5,19-20,25 table 3. Type of surgery carried out in AAAD and other cardiopathies (n = 23) n Bentall procedure · With Cabrol fistula · With close of interatrial communication · With myocardial revascularization (3 HD) · With prosthesis mechanical mitral implant · With resection of subaortic root Aortoplasty with prosthetic valvular implant · Valvular mechanical prosthesis · Valvular biological prosthesis

AAAD, ascending aortic aneurysm disease; HD, hemiduct

table 4. Hospital morbidity with the Bentall procedure n = 23 n Complications · Abnormal postoperative bleeding (>100 ml/h) · Nosocomial pneumonia · Alterations in rhythm conduction · Encephalopathy · Right pneumothorax · Septic shock · Hepatic insufficiency · Renal insufficiency 8 4 3 3 1 1 2 1 1 % 35 17 13 13 4 4 9 4 4

% 87 20 5 5 5 5 13 67 33

20 4 1 1 1 1 3 2 1

In our study, factors for mortality were Stanford type A dissection, indications for emergency surgery, concomitant procedures represented by resection of subaortic membrane and mitral mechanical prosthetic valvular implant secondary to severe mitral insufficiency, time of extracorporeal circulation and abnormal postoperative bleeding. In addition, there was another factor observed that has not been mentioned in other studies, ventricular dysfunction defined by reduced ejection fraction and left ventricular dilation, which coincided with the evolution time of the AAAD. Ventricular dysfunction has not been identified as a survival-reducing factor in previous studies probably because aneurysm size and valvular insufficiency are indicative of surgery before the establishment of heart failure. However, it has become clear that there is postoperative improvement in functional class and ventricular restoration.19 This suggests the need for statistical analysis to identify risk factors prevalent in our population. We followed the technique described by Bentall with direct reimplantation of the coronary arteries, using the inclusion technique whenever possible. We have recently added to our routine the construction of a Cabrol fistula. However, the Bentall technique has been associated with postoperative bleeding and pseudoaneurysm formation at suture lines, explaining the rationale for modifications to the original concept: 1) coronary implantation technique with a tubular graft (Cabrol modification), 2) the mobilization of the coronary button and the direct reimplantation over the valved graft (Kouchoukos' exclusion technique), and 3) inclusion technique with Carrel patch.20-22,28 Despite modifications, 97.3% of patients who received a Bentall surgical procedure reported to be free of late aortic complications vs. 68% of patients who underwent surgery using other techniques 10 years previously.7 The advantages offered by aortic root replacement are removal of diseased

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table 5. Hospital mortality with Bentall procedure (n = 23) n % Death · Septic shock (nosocomial pneumonia) · Ventricular fibrillation 3 13 2 23 1 4

aortic tissue, decreased postoperative bleeding and incidence of pseudoaneurysm around the coronary implantation with the use of the inclusion technique. This may be done with short times of ischemia and CPB with good shortterm results, keeping in mind that the selection of type of procedure is a multifactorial decision that includes life expectancy, base pathology of the aorta and individual risk of complications in the natural course (rupture, dissection) vs. risk of surgical correction in the hands of a particular surgical group. However, acute coronary event, pseudoaneurysms, bleeding, and dehiscence of the coronary anastomosis persist as the most important complications.21-22,28 In such situations, the problems to be resolved are the ideal coronary implantation technique, type of material to be used and conservation of the functions of the aortic ring.18 This study identified that the average aneurysm diameter at the time of diagnosis was >6.3 cm, a figure greater than that indicated by Trainini and Concha who document an average aneurysm size at the time of diagnosis of 5.2 cm (range: 3.5-10 cm), with an average growth rate of 0.12 cm/year, which varies proportionately to the diameter of the aneurysm and the presence of dissection.1,7 With regard to aneurysm size, initially an elective procedure was recommended for those with diameters close to 6 cm, but a high percentage of these patients present dissection or rupture before reaching that diameter. It has been documented that a diameter of 5.5 cm causes a rupture risk of 50 to 74% per year, so the goal of therapy for AAAD is to prevent complications that involve high mortality: rupture or aortic dissection. 1-3,5,15,19 Current protocols advise that elective surgery be performed before reaching these diameters, taking into consideration the pathological basis of the aortic wall. Aortic diameters >55 mm (or 50 mm in Marfan syndrome) or a growth of 5 mm/year are generally considered as the parameters for surgical indication (class I, level C).8-12 In our clinical practice, the presence of aneurysms with an average diameter >6 cm at the time of diagnosis is attributed to limited access to studies such as an ultrasound, computed tomography and magnetic resonance imaging, either due to their high cost or their limited availability, which determines the delay in specific diagnosis and timely treatment of the AAAD. Nevertheless, therapeutic

treatments (beta blockers, sutures, low porosity prostheses, core protection) and the most experienced surgical team have improved the survival rate. In conclusion, hospital mortality for the Bentall procedure in the treatment of ascending aortic aneurysmal disease with aortic valve involvement in our hospital was 13%, being within the range reported in the literature. Causes and risk factors for mortality correspond to that recorded by other highly specialized centers. Our findings confirm that despite being a surgical procedure of low frequency and high complexity, the classic Bentall technique for management of the increasing AAAD can be safely performed, with acceptable short-term morbidity and mortality at our medical center. Complications related to hospital mortality, nosocomial pneumonia and postoperative bleeding demonstrate the practical importance for being potentially preventable. Left ventricular dysfunction was presented as another risk factor not reported in the literature and which was associated with hospital mortality and expresses the advanced stage of disease when patients seek treatment at our medical facility, suggesting the need for development of strategies for early diagnosis. Development of related events with the basic aortic pathology, surgical technique, aortic valve prosthesis and left ventricular dysfunction require individualized monitoring and further study to meet the same results on a long-term basis. references

1. 2. 3. 4. 5. 6. Trainini J. Consenso de patología de la aorta. Rev Argentina de Cardiol 2004;72:387-400. De la Garza. Los aneurismas en el tiempo. Cir Gen 2000;22:264271. Martínez H. Los aneurismas de la aorta torácica y su enfoque terapeútico. Arch Cardiol Mex 2006;76(S2):124-133. Juvonen T, Ergin MA, Galla JD, Lansman SL, Nguyen KH, McCullough JN, et al. Prospective study of the natural history of thoracic aortic aneurysms. Ann Thorac Surg 1997;63:1533-1545. Gutiérrez J, Camblor S, Llaneza C, Menéndez P, Menéndez H, Carreño M, et al. Historia natural de los aneurismas de la aorta torácica. Angiología 2006;58(suppl 1):S3-S14. Olsson C, Thelin S, Stahle E, Ekbom A, Granath F. Thoracic aortic aneurysm and dissection. Increasing prevalence and improved outcomes reported in a nationwide population-based study of more than 14,000 cases from 1987 to 2002. Circulation 2006;114:26112618. Concha M. Tratamiento quirúrgico de la raíz de la aorta. Cir Cardiovasc 2007;14:305-310. Ergin A, Spielvogel D, Apaydin A. Surgical treatment of the dilated ascending aorta: when and how? Ann Thorac Surg 1999;67:18341839. Zehr K, Orszulak T, Mullany C, Matloobi A, Danielson R, Schaff H. Surgery for aneurysm of the aortic root: a 30-year experience.

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Circulation 2004;110:1364-1371. 10. Darrin WD, Hallett J, Schaff H, Gayari M, Ilstrup D, Melton L III. Improved prognosis of thoracic aortic aneurysms. JAMA 1998;280:1926-1929. 11. Elefteriades J. Natural history of thoracic aortic aneurysm: indications for surgery, and surgical versus nonsurgical risks. Ann Thorac Surg 2002;74:S1877-1880. 12. Masuda Y, Takanashi K, Takasu J, Morooka K, Inagaki Y. Expansion rate of thoracic aortic aneurysms and influencing factors. Chest 1992;102:461-467. 13. Davies R, Gallo A, Coady M, Tellires G, Botta D, Burke B, et al. Novel measurement of relative aortic size predicts rupture of thoracic aortic aneurysms. Ann Thorac Surg 2006;81:169-177. 14. Achneck H, Rizzo J, Elefteriades J, Tranquilli M. Safety of thoracic aortic surgery in the present era. Ann Thorac Surg 2007;84:11801185. 15. Tirone D. El rol de la enfermedad de la raíz aórtica: implicancias en el tratamiento de la estenosis e insuficiencia aórtica. Valv Heart Dis 2005;9:1-3. 16. Patel N, Weiss K, Alejo L, Williams J, Dietz H, Nwakanma L, et al. Aortic root operations for Marfan syndrome: a comparison of the Bentall and valve-sparing procedures. Ann Thorac Surg 2008;85:2003-2011. 17. DiBartolomeo R, Martín S. Thoracic aorta surgery today. Leadership Med 2006;4:1-09. 18. Kirali K, Mansuroglu D, Nail S, Yakut C. Five-year experience in aortic root replacement with the flanged composite graft. Ann Thorac Surg 2002;73:1130-1137. 19. Lewis C, Cooley D, Murphy M. Aortic root aneurysms. Ann Thorac

Surg 1992;53:38-46. 20. Gelsomino S, Morocutti G, Frassani R, Masullo G, DaCol P, Spedicato L, et al. Long-term results of Bentall composite aortic root replacement for ascending aortic aneurysms and dissections. Chest 2003;124:984-988. 21. Bhan A, Choudhary SK, Saikia M, Sharma R, Venugopal P. Surgical experience with dissecting and nondissecting aneurysms of the ascending aorta. Indian Heart J 2001;53:319-322. 22. Hirasawa Y, Aomi S, Saito S, Kihara S, Tomioka H, Kurosawa H. Long-term results of modified Bentall procedure using flanged composite aortic prosthesis and separately interposed coronary graft technique. Interact CardioVasc Thorac Surg 2006;5:574-577. 23. Apaydin A, Posacioglu H, Islamoglu F, Calkavur T, Yagdi T, Buket S, et al. Analysis of perioperative risk factors in mortality and morbidity after modified Bental operation. Jpn Heart J 2002;43:151-157. 24. Yakut C. A new modified Bentall procedure: the flanged technique. Ann Thorac Surg 2001;71:2050-2052. 25. Shapira OZ, Aldea G, Cutter S, Fitzgerald C, Lazar H, Shemin R. Improved clinical outcomes after operation of the proximal aorta: a 10-year experience. Ann Thorac Surg 1999;67:1030-1037. 26. Ramírez A, Careaga G, Téllez S, Argüero R. Tratamiento quirúrgico de los aneurismas de la aorta torácica. Rev Mex Cardiol 2003;14:118127. 27. Díaz G, Archundia A, Vázquez J, Aceves J. Manejo quirúrgico de aneurisma en aorta ascendente. Presentación de un caso. Rev Esp Med Quir 2003;8:52-55. 28. Kawazoe K, Eishi K, Kawashima Y. New modified Bentall procedure: Carrel patch and inclusion technique. Ann Thorac Surg 1993;55:1578-1579.

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