Elsevier

Heart, Lung and Circulation

Volume 25, Issue 12, December 2016, Pages 1245-1251
Heart, Lung and Circulation

Original Article
The Aortic Root Replacement Procedure: 12-year Experience from the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Database

https://doi.org/10.1016/j.hlc.2016.04.014Get rights and content

Background

The aortic root replacement procedure (ARR), is often considered the gold standard in the management of aortic root and ascending aorta aneurysms. Our aim was to review the Australian experience with this procedure to ascertain early and late outcomes of mortality and morbidity.

Methods

We reviewed the Australian and New Zealand Society of Cardiac and Thoracic Surgeons’ (ANZSCTS) database for patients undergoing ARR. Preoperative, intraoperative and postoperative variables were analysed. Multiple regression was performed to determine independent predictors of 30-day mortality and permanent stroke, and predictors of late death. Survival estimates were obtained by cross-linking the ANZSCTS database with the Australian Institute of Health and Welfare's National Death Index database.

Results

Between January 2001 and December 2011, 954 patients underwent ARR with a mean age of 56 ± 15.2 years. The overall 30-day mortality was 5.9% (n = 56) with a permanent stroke rate of 2.3% (n = 21). The elective surgery mortality was 3.6%. Long-term survival was estimated as 84.4% and 68.7% at 5 and 10 years, respectively.

Conclusions

Aortic root replacement surgery reveals acceptable early mortality, low postoperative stroke rates, and acceptable long-term survival.

Introduction

Approximately 4.5 per 100,000 people develop a thoracic aortic aneurysm, of which 60% predominantly affects the supravalvular aorta (aortic root and/or ascending thoracic aorta) [1]. The patient with a large aortic aneurysm faces disease progression and an increased risk of dissection or rupture [2], and early surgical intervention is recommended.

In 1968 Bentall and de Bono developed the composite aortic valve and root replacement with reimplantation of the coronary arteries to tackle thoracic aortic aneurysms [3]. Since then there have been several modifications made to this procedure, the notable one being the creation of aortic tissue buttons around the coronary ostia and extensive mobilisation of the proximal ends of the coronary arteries [4]. Although originally designed for supravalvular aortic aneurysms, the indications for the aortic root replacement procedure (ARR) have expanded [5], [6], [7].

The type of replacement valve, mechanical or biological, depends on surgeon and patient preference. Younger patients (<50 years old) are more likely to receive a mechanical valve due to the increased rate of deterioration of biological valves in this age group, requiring a reoperation. Patients over the age of 70 years are likely to benefit most from a biological valve, which has a low probability of rapid structural deterioration in older patients and a lower rate of thromboembolism, haemorrhage and endocarditis [8], [9]. However, patients between 50 and 70 years old are often offered a choice between a mechanical valve and a biological valve depending on their surgical risk, presence of comorbidities and desired quality of life [10].

Valve-sparing aortic reconstruction surgeries (VSARR) such as the David ‘reimplantation’ procedure and the Yacoub ‘remodelling’ procedure have been developed over the last two decades to overcome the shortcomings of prosthetic aortic valves [11]. These procedures have the added benefit of retaining the superior functionality and haemodynamics of the native aortic valve, and as such are usually only performed if the aortic valve is competent or with minimal deformity [10]. However, ARR is still the surgery of choice in any condition where the integrity of the aortic valve is compromised [12].

We present here the Australian experience with ARR from the Australian and New Zealand Society of Cardiac and Thoracic Surgeons [13] database.

Section snippets

Methods

Ethics approval for this study was granted by the Human Research Ethics Committee, Royal Prince Alfred Hospital Zone.

Results

The mean age of the patients was 56.0 ± 15.2 years (range 17-101) with 3% (n = 29) aged 80 years and above. Other preoperative and intraoperative characteristics are summarised in Table 1. The replacement valve distribution data are shown in Table 2, while the different aortic pathologies are tabulated in Table 3.

The overall 30-day mortality was 5.9% (Table 3). Mortality in elective surgeries was 3.6% compared to 12.7% in non-elective surgeries. Among the different aortic pathologies, the mortality

Discussion

The ARR procedure is well-recognised as the surgical treatment for aortic aneurysmal disease, especially with aortic valve disease. Depending on the aortopathy and extent of aortic involvement, the composite valve graft (CVG) is designed to include the aortic root, ascending aorta and the proximal arch. Over the years this procedure has evolved continuously and has been subjected to various modifications with increasing understanding of different aortic root pathologies [4], [5], [6], [7]. To

Limitations

This is an analysis of prospectively collected data in the ANZSCTS database and thus has limitations applicable to registry studies. All database studies have an inherent treatment bias. There is no established standard selection criteria for the patients that undergo the ARR procedure in Australia and patient selection is based on surgeon preference. The ANZSCTS database, like all large databases, is subject to sampling error and missing data. The database has been developing since 2001 with

Conclusion

Aortic root replacement in the Australian population can be performed with acceptable 30-day mortality and morbidity as well as long-term survival. Acute type A aortic dissection, cardiogenic shock, concomitant CABG and atrial arrhythma proved to be significant risk factors for early mortality.

Acknowledgements

The Australian and New Zealand Society of Cardiac and Thoracic Surgeons [13] National Cardiac Surgery Database Program is funded by the Department of Health, Victoria, and the Health Administration Corporation (GMCT) and the Clinical Excellence Commission (CEC), NSW, and funding from individual Units.

The following investigators, data managers, and institutions participated in the ANZSCTS Database: Alfred Hospital: Pick A, Duncan J; Austin Hospital: Seevanayagam S, Shaw M; Cabrini Health:

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