Dealing with dilated ascending aorta during aortic valve replacement: advantages of conservative surgical approach

Abstract

Five to fifteen percent of patients undergoing aortic valve replacement (AVR) will have an ascending aortic aneurysm requiring a concomitant surgical procedure. On the other hand, a dilated ascending aorta is known to be a potential source of complications after AVR. From 1972 to 1988, 2278 AVR, either isolated or combined with a second cardiac procedure, were performed in our institution. In the same time interval, a dilated ascending aorta was treated in additional 291 consecutive patients during AVR. Three different surgical options were employed: aortic remodelling and external wall support in 164 patients (56.4%), composite graft replacement in 81 patients (27.8%) and a supracoronary graft in 46 patients (15.8%). Early mortality was 4.8%. Aortic remodelling plus external wall support had the lowest early mortality (1.8%) and the best 8-year survival (89.6%). Supracoronary grafting had a higher early mortality (6.4%) and lower 8-year survival (73.2%). The results of the composite graft were least favourable: early mortality was 9.8% and 8-year survival 76.5%. The results point out the necessity for instituting the appropriate surgical procedure for a dilated ascending aorta during AVR. They show that conservative aortic surgery with preservation of endothelial lining gives excellent early and late results.

Diretrizes para a cirurgia das doenças da aorta

“…-idade e expectativa de vida em indivíduos muito idosos, ou de alto risco cirúrgico, a substituição valvar e a redução do calibre da aorta por uma sutura longitudinal com suporte pode ser uma boa alternativa 134 ; igualmente, a troca valvar seguida do implante de enxerto reto de dacron, separadamente, pode ser apropriada a pacientes com limitada expectativa de vida 135 ;…”

Mid term follow up in patients with reduction ascending aortoplasty

“…In our study, the most relevant valvular heart disease was aortic valve replacement associated with relevant stenosis (63%) while Bauer et al [13] reported a percentage of 47%. Muller et al [18] also reports that all re-dilatations occurred in patients with Marfan syndrome, while other authors classified Marfan syndrome as an absolute contraindication for RAA [19][20][21]. We determined an absence of redilatation of 94% over a period of 10 years.…”

Alternative Surgical Management of Ascending Aorta Aneurysm

“…The hemodynamic stress can be associated with an aortic valve disease. In these patients, a dilatation of the ascending aorta of various entities has been observed regardless of the presence of degenerative disease (Carrel et al, 1991). Patients with a mild or moderate dilatation of the ascending aorta in association with an aortic valve disease often undergo only aortic valve replacement (Prenger et al, 1994;Natsuaki et al, 1998), believing it is not necessary to replace the ascending aorta.…”

“…The efficacy of this technique is still under question since complications and redilatation may occur at follow up. These controversial results may be related to the extreme heterogeneity of the enrolled patients in the literature reports; some had aneurysms of the www.intechopen.com ascending aorta without aortic valve disease, others ascending aorta dissection or Marfan disease Carrel et al, 1991;Natsuaki et al, 1998;Barnett et al, 1995). These last clinical conditions are usually associated with a high frequency of redilatation (Kouchoukos et al, 1986;Carrel et al, 1993;Lawrie et al, 1993).…”

“…The results reported in the literature, both for the simple aortoplasty and for the aortic wrapping, are heterogeneous. However, most report advantages in using a conservative approach rather than radical surgery in selected cases (Carrel et al, 1991;Barnett et al, 1995). The aortic cross clamp time and the extracorporeal circulation time are usually shorter, and this may represent an important factor in older patients requiring additional cardiac surgical procedures Mueller et al, 1997;Baumgartner et al, 1998).…”