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Proximal aortic reoperations in patients with composite valve grafts

Scott A. LeMaire, Daniel J. DiBardino, Cüneyt Köksoy and Joseph S. Coselli


Ann Thorac Surg 2002;74:1777-1780

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The Annals of Thoracic Surgery is the official journal of The Society of Thoracic Surgeons and the
Southern Thoracic Surgical Association. Copyright © 2002 by The Society of Thoracic Surgeons.
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Proximal Aortic Reoperations in Patients With
Composite Valve Grafts
Scott A. LeMaire, MD, Daniel J. DiBardino, MD, Cüneyt Köksoy, MD, and
Joseph S. Coselli, MD
The Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, and the
Methodist DeBakey Heart Center, Houston, Texas

Background. The purpose of this study was to examine ing 2 of the 7 patients who had infected CVGs (29%). All
our experience with proximal aortic reoperations in pa- 4 patients who had infected CVGs replaced with aortic
tients with composite valve grafts (CVGs) and assess root homografts survived. Complications included vocal
postoperative survival and morbidity. cord paralysis (n ⴝ 4, 12%), bleeding requiring reopera-
Methods. Since 1991, 33 patients with CVGs underwent tion (n ⴝ 3, 9%) and stroke (n ⴝ 2, 6%). Actuarial 3-year
reoperation for one or more of the following indications: survival was 74.4% ⴞ 7.9%.
aneurysms distal to the CVG (n ⴝ 20, 61%), false aneu- Conclusions. Reoperations in patients with CVGs re-
rysms (n ⴝ 13, 39%) and graft infection (n ⴝ 7, 21%). main challenging procedures with high associated mor-
Operations included false aneurysm repair (n ⴝ 13, 39%), bidity and mortality, especially in the setting of graft
graft replacement of distal ascending aortic or transverse infection. The results of homograft aortic root re-
aortic arch aneurysm (n ⴝ 20, 61%) and aortic root replacement for infected CVGs are encouraging.
re-replacement with a new CVG (n ⴝ 6, 18%) or ho-
mograft (n ⴝ 4, 12%). (Ann Thorac Surg 2002;74:S1777– 80)
Results. Operative mortality was 15% (n ⴝ 5), includ- © 2002 by The Society of Thoracic Surgeons

D ata from several centers have established that pri-


mary aortic root replacement can be performed
with low morbidity and mortality [1– 6]. In the wake of
Twenty patients (61%) presented with a recurrent an-
eurysm distal to the previously placed CVG; this was the
most common indication for reoperation. One of these
these excellent results an increasing number of these patients underwent an emergency operation for rupture.
patients are returning with a variety of indications for Two patients had acute dissection and 12 had chronic
reoperation [7–9]. Patients requiring reoperation on the dissection. In 19 patients the graft repair extended into
proximal aorta after previous composite valve graft the transverse aortic arch. Graft extension was performed
(CVG) placement represent a challenging subset [10]. as the sole operation in 13 patients and combined with
The purpose of this retrospective review was to examine other procedures in 7 patients; 5 of these underwent
our experience with proximal aortic reoperations in pa- concomitant pseudoaneurysm repair and 2 underwent
tients who have undergone previous CVG placement. placement of a new CVG for perivalvular pseudoaneu-
rysm or bioprosthetic aortic valve insufficiency.
Seven patients (21%) presented with infected CVGs,
Patients and Methods
proven by either preoperative blood culture (n ⫽ 6) or
Since 1991, 33 patients with previously placed CVGs intraoperative mediastinal fluid culture (n ⫽ 1). One
presented for reoperation. During the same period, the patient underwent only pseudoaneurysm repair and
senior author (J.S.C.) performed aortic root replacement omental coverage of the infected graft. Two patients
with CVGs in 124 patients, only 1 of whom returned for underwent CVG resection and replacement with a new
reoperation; the remaining 32 patients had their original CVG; a pedicled omental flap was placed around the new
CVG placed elsewhere. The average age at reoperation graft in 1. Since mid-1994 we have used homografts for all
was 46 ⫾ 14 years. Twenty-seven patients (82%) were patients with infected CVGs. Four patients underwent
men and 6 (18%) were women. Seventeen patients (52%) CVG resection and replacement with a homograft aortic
had Marfan’s syndrome. The average time interval be- root; omentum was placed around the homograft in 1
tween the initial operation and presentation was 81 ⫾ 71 patient. One of these patients had also undergone bev-
months (range, 3 to 252). In many cases there were eled polyester graft replacement of the proximal trans-
multiple simultaneous indications for reoperation. verse aortic arch during the initial operation; his reop-
eration included resection of all prosthetic material and
Presented at the Aortic Surgery Symposium VIII, May 2–3, 2002, New replacement with homograft aortic root and arch.
York, NY. Pseudoaneurysms were present in 13 patients (39%,
Address reprint requests to Dr LeMaire, 6560 Fannin St, Suite 1100, Table 1) and were usually associated with other pathol-
Houston, TX 77030; e-mail: slemaire@bcm.tmc.edu. ogy. Only 1 pseudoaneurysm (perivalvular) was related

© 2002 by The Society of Thoracic Surgeons 0003-4975/02/$22.00


Published by Elsevier Science Inc PII S0003-4975(02)04152-8

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S1778 AORTIC SURGERY SYMPOSIUM VIII LEMAIRE ET AL Ann Thorac Surg
PROXIMAL AORTIC REOPERATIONS 2002;74:S1777– 80

Table 1. Location and Type of Repair of 14 Pseudoaneurysms was placed to the left main coronary artery ostium.
in 13 Patients With Composite Valve Grafts Nine patients not requiring re-replacement of the aortic
Pseudoaneurysm No. of
root also underwent coronary artery procedures includ-
Location Type of Repair Patients ing pseudoaneurysm repair (Table 1) and coronary
revascularization.
Perivalvular Replacement with new CVG 4 Mean cardiopulmonary bypass and aortic clamp times
Primary repair 2* were 147 ⫾ 63 minutes and 108 ⫾ 49 minutes, respec-
Distal aortic Extended graft repair of aorta 3* tively. Hypothermic circulatory arrest was used in 25
anastomosis
patients (76%) to enable either aortic arch repair or safe
RCA attachment site Dacron interposition graft to 2
RCA (10 mm) sternal reentry. The mean circulatory arrest time was 49
Patch closure and SVG to 1 ⫾ 29 minutes. Seven patients received retrograde cere-
RCA bral perfusion during circulatory arrest. Operative trans-
LMCA attachment Dacron interposition graft to 2 fusion requirements were 10 ⫾ 6 U packed red blood
site LMCA (8 and 10 mm) cells, 31 ⫾ 22 U platelets, 16 ⫾ 17 U fresh frozen plasma,
and 27 ⫾ 18 U cryoprecipitate.
* One patient had simultaneous repair of perivalvular and distal aortic
anastomotic pseudoaneurysms.
CVG ⫽ composite valve graft; LMCA ⫽ left main coronary artery; Results
RCA ⫽ right coronary artery; SVG ⫽ saphenous vein graft.
There were no intraoperative deaths. There were 5 oper-
ative deaths (15%). All deaths occurred during the initial
hospitalization and 3 occurred within 30 days. The indi-
to graft infection. One patient with a perivalvular pseu- cations for operation in these 5 patients were CVG
doaneurysm and prosthetic aortic valve insufficiency infection (n ⫽ 2), recurrent aneurysm of the ascending
underwent placement of a new CVG. One patient had a aorta and aortic arch (2, including 1 rupture) and false
perivalvular pseudoaneurysm-to-right atrial fistula that aneurysm (n ⫽ 1). Both patients who had an infected
was closed at the time of pseudoaneurysm repair. CVG removed and replaced with a new CVG died.
Pseudoaneurysms were the sole indication for reopera- Causes of death included multiple organ failure (n ⫽ 2),
tion in only 4 patients (12%); 3 underwent repair alone stroke (n ⫽ 1), heart failure (n ⫽ 1), and pulmonary
and 1 underwent placement of a new CVG. embolism (n ⫽ 1).
A variety of coronary artery procedures were per- There were no postoperative complications in 42% of
formed depending on the presence of previously placed patients (n ⫽ 14). Two patients had strokes (6%), one of
coronary grafts, the presence of coronary occlusive dis- which was fatal. Both strokes occurred in patients who
ease, and the procedure chosen for aortic reconstruction. required hypothermic circulatory arrest. Nine patients
Overall, 58% of patients (n ⫽ 19) required at least one (27%) required more than 48 hours of ventilatory sup-
coronary artery intervention. Of 10 patients who under- port. Two patients required a tracheostomy; both were
went aortic root re-replacement (Table 2), 8 required successfully weaned from the ventilator and discharged
either a Cabrol interposition graft or saphenous vein home. Left vocal cord paralysis occurred in 4 patients
grafts to maintain coronary circulation. Cabrol grafts (12%). Three of these patients had undergone graft re-
were used when adequate coronary mobilization was placement of the transverse aortic arch during reopera-
not possible, ie, when there was extensive fibrosis or a tion and 1 had an infected CVG with a perivalvular
large coronary pseudoaneurysm. One patient required a pseudoaneurysm. Three patients (9%) required reopera-
Cabrol reattachment of the left coronary artery (hemi- tion for postoperative bleeding. Wound infection oc-
Cabrol) and a vein bypass graft to the right coronary curred in 3 patients (9%) and required a subsequent
artery. In 1 patient with a preexisting saphenous vein operation for wound debridement in 2 cases; only 1 of
bypass to the right coronary, the right coronary ostium these patients had initially presented with an infected
was oversewn and an interposition saphenous vein graft CVG. One patient developed atrioventricular block, but
did not require pacemaker placement.
Of 28 patients surviving to discharge, long-term fol-
Table 2. Coronary Artery Procedures in 10 Patients low-up was available for 24 patients (86%) and included
Requiring Redo Aortic Root Replacement data up to 9 years postoperatively (mean follow-up, 4.7 ⫾
2.5 years). There were 5 late deaths yielding a 79%
Method of Root No. of
Re-replacement Coronary Artery Procedure Patients survival rate among these 24 patients. Actuarial 3-year
survival was 74.4% ⫾ 7.9% (Fig 1). The patient who
Composite valve graft Open button anastomoses 1 underwent a pedicled omental wrap of the existing
Saphenous vein grafts 2* infected CVG was discharged on oral antibiotics and
Cabrol graft 4* remains active and healthy 8 years after discharge. Three
Homograft aortic root Open button anastomoses 1 patients who received homografts were discharged with
Saphenous vein grafts 3 intravenous antibiotics and tunneled central venous
* One patient underwent “hemi-Cabrol” reattachment of the left main lines. Three of the 4 patients with homografts remain
coronary artery and saphenous vein bypass to the right coronary artery. alive and well with no further complications an average

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Ann Thorac Surg AORTIC SURGERY SYMPOSIUM VIII LEMAIRE ET AL S1779
2002;74:S1777– 80 PROXIMAL AORTIC REOPERATIONS

Fig 1. Kaplan-Meier curve demonstrating


actuarial survival after proximal aortic re-
operation in 33 patients with composite
valve grafts. Values are reported with stan-
dard deviations.

of 6 years after discharge. The patient who presented nique used. Lifelong surveillance with echocardiography
with an infected CVG and beveled hemiarch graft died of and computed tomography scanning is required to as-
a myocardial infarction 5 months after discharge. Two of sess the integrity of the valve mechanism, the develop-
the 13 patients who underwent pseudoaneurysm repair ment of pseudoaneurysms, and dilatation of the distal
developed new pseudoaneurysms. One patient had un- aorta.
dergone repair of a left main coronary pseudoaneurysm As we have reported previously [14], CVG infection
and presented 4 years later with a new pseudoaneurysm remains a catastrophic complication. Prosthetic endocar-
involving the distal aortic anastomosis; this was repaired ditis is the most common complication after CVG place-
elsewhere by graft extension into the proximal hemiarch. ment and carries a mortality that exceeds 50% [2]. Al-
The other patient had undergone repair of a pseudoan- though simply wrapping the infected graft with a
eurysm at the distal aortic anastomosis by graft extension pedicled omental flap and administering long-term in-
into the proximal hemiarch and concomitant coronary travenous antibiotics was successful in 1 patient, replace-
artery bypass; 5 years later he developed a pseudoaneu- ment of the infected CVG with a homograft aortic root
rysm involving the vein grafts but was lost to follow-up provided encouraging early and midterm results. After
before treatment. homograft placement, we recommend a 6-week course of
intravenous antibiotics through a tunneled central ve-
nous catheter. Importantly, the risk of CVG infection
Comment
continues long after the initial operation. In our series 4
The most common indication for reoperation in this of the 7 patients (57%) with graft infection presented
series was aneurysm recurrence just distal to the previ- more than 3 years after CVG placement. We believe that
ously placed graft [11]. Although more judicious inspec- this justifies an aggressive approach to antibiotic prophy-
tion and aggressive resection of the proximal aorta at the laxis whenever patients with CVGs require invasive
original operation may reduce the incidence of recur- procedures that produce bacteremia such as bronchos-
rence, we recognize that limiting the initial repair (espe- copy, colonoscopy, and dental procedures; regardless of
cially under emergency circumstances) is often prudent. the length of time since CVG placement, we recommend
When feasible, brief periods of hypothermic circulatory periprocedural administration of intravenous broad-
arrest allow assessment of the aortic arch and may alter spectrum antibiotics.
the extent of reconstruction. Cooley and Livesay [12]
have referred to this as the open distal anastomosis
technique and have long recommended its use to more References
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Proximal aortic reoperations in patients with composite valve grafts
Scott A. LeMaire, Daniel J. DiBardino, Cüneyt Köksoy and Joseph S. Coselli
Ann Thorac Surg 2002;74:1777-1780

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