Replacement of the Ascending Aorta for Severe Atherosclerosis During Coronary Artery Bypass Surgery (original) (raw)
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Replacing the atherosclerotic ascending aorta is a high-risk procedure
The Annals of Thoracic Surgery, 1998
Background. Improved techniques in cerebral and myocardial protection have made replacement of the chronically aneurysmal ascending thoracic aorta a safe and effective procedure. We hypothesized that patients with severe ascending or aortic arch atherosclerosis were at greater risk for operative complications during ascending aortic replacement because of the diffuse nature of their atherosclerotic process. Methods. We retrospectively analyzed the records of 17 patients who received ascending aortic replacement during elective coronary artery bypass grafting (CABG) because of the intraoperative finding of severe atherosclerosis. All 17 patients underwent tube graft replacement of the ascending aorta under hypothermic circulatory arrest and retrograde cerebral perfusion before coronary artery bypass grafting. The outcomes for these patients were compared with those of a control group of 89 consecutive patients who underwent replacement for ascending thoracic aortic aneurysm. Results. The hospital mortality rate for replacement of the ascending thoracic aorta for severe atherosclerosis was 23.5% (4/17) versus 2.25% (2 of 89) for the control group (p ؍ 0.006). The incidence of cerebrovascular accident in the atherosclerotic group was 17.6% (3/17) and 3.37% (3/89) for the control group (p ؍ 0.051). Nine of 17 atherosclerotic patients (52.9%) had operative morbidity. Only 20.2% (18 of 89) of the control patients had nonfatal postoperative complications. Conclusions. The severely atherosclerotic ascending aorta is a marker of diffuse atherosclerosis. Despite improved techniques of myocardial and cerebral protection, we have been unable to duplicate our success with ascending thoracic aneurysm repair. Preoperative screening of the ascending aorta by chest computed tomography may be appropriate in select high-risk patients to determine operability.
European Journal of Cardio-Thoracic Surgery, 2007
Objective: Severe atherosclerosis of the ascending aorta and arch frequently causes difficulties during heart operations, hindering surgical manoeuvres and potentially leading to systemic embolism. The aim of our study was to assess the safety and effectiveness of replacing the atherosclerotic ascending aorta in this setting. Methods: Aortic atherosclerosis was characterized by epiaortic ultrasonographic scanning in 90.1% of 1927 consecutive adult patients undergoing cardiac operations, and by computed tomographic chest scanning in selected cases. Thirty-six of the 152 patients requiring major derangements from our standard practice due to aortic atherosclerosis underwent replacement of the ascending aorta and constitute the study group. Replacement of the aorta was extended to the arch in 13 cases (36.1%). It was associated with single or multiple valve surgery in 34 patients (94.4%) and with coronary revascularization in 30 (83.3%). Two patients (5.6%) underwent coronary bypass grafting without valve surgery. A cryoablation procedure was associated in three patients with permanent atrial fibrillation. Deep hypothermic circulatory arrest was employed in 34 patients (94.4%), while proximal aortic disease allowed conventional distal crossclamping in 2 cases. The risk of operative mortality was estimated by the logistic EuroSCORE both with and withholding the variable 'surgery of the thoracic aorta'. All survivors were followed-up for 1-41 months (16 AE 12). Results: Two patients died in the hospital (5.6%) and two during follow-up, for a cumulative survival of 91.3% and 85.6% at 1 and 3 years, respectively (hospital deaths included). The hospital death rate compared favourably with the expected estimates of 25.5% ( p < 0.05) and 10.3% ( p = 0.67) obtained by the EuroSCORE full model and without 'aortic surgery', respectively. In-hospital adverse neurologic events occurred in six patients (16.7%), including stroke in one patient (2.8%) and neurocognitive disturbances in five (13.9%), although they were all transient and cleared before discharge. Excess bleeding required re-exploration in four patients (11.1%), and one more patient underwent emergency grafting for acute postoperative coronary occlusion. Ten patients (38.5%) were intubated for longer than 24 h. Conclusion: Despite significant perioperative morbidity, replacement of the severely atherosclerotic aorta is worth consideration to avert expectedly higher death and stroke rates. # a Excluded from the totals, as cases are included in Kouchoukos' series . AVR, aortic valve replacement; DHCA, deep hypothermic circulatory arrest; na, not available.
Early And Long Term Outcomes Of Aortic Valve Surgery Combined Or Not With Cabg Surgery
Objective: The number of patients doing aortic valve surgery with or without CABG (Coronary Artery Bypass Graft) is increasing continuously in our country. The goal of this study is to evaluate the early and long-term results of aortic valve surgery alone or combined with CABG surgery. Methods: This is a retrospective and prospective study. We included the patients underwent aortic valve surgery (replacement or another procedure) with or without CABG from January 2007 to January 2013 . The population of 330 patients is divided into two groups: Group I included 81 patients combined surgery; Group II included 249 patients with isolated aortic valve surgery. In the early results we referred hospital mortality and perioperative complications. The follow-up time is from 2 to 73 months for 303 cases that were discharged from hospital. The long-term results were evaluated in terms of mean survival ,quality of life and prosthetic-related complications. Results: The hospital mortality was 3.6 % in general. The hospital mortality: group I is 4. 9% and group II is 3. 2 %. The difference is not statistically significant. Low cardiac output, conduction disturbances, stroke, pulmonary complications, renal complications, bleeding, atrial fibrillation, wound infections, ventricular arrhythmias are respectively14. 8% vs. 9. 6%, 3. 7% vs. 6. 9%, 3. 7% vs. 0. 4%, 9. 9 % vs. 2. 8%, 3. 7% vs. 1. 2%, 6. 3% vs. 2.0%, 14. 8 % vs. 19.7%, 11. 3% vs. 1. 6 %, 6. 2% vs. 5. 6 % respectively for the group I and II. The differences were statistically significant only for low cardiac output, stroke, pulmonary and wound complications. The long-term outcomes: overall mortality 3. 9%, bleeding 1. 9%, prosthetic endocarditis and thrombosis 1.3%. Endocarditis and thrombosis are more frequent in group I. During the follow-up survival was 93% and 96% respectively for group I and II, with no significant difference between groups. Conclusions: Simultaneous coronary artery by-pass with aortic valve increases slightly the operative mortality and perioperative complications. CABG surgery does not influence long–term results of aortic valve surgery.
Aortic Valve Surgery: Results of Aortic Valve Surgery Combined or not with CABG Surgery
2013
Objective: The number of patients doing aortic valve surgery with or without CABG is increasing continuously in our country. The goal of this study is to evaluate the results of aortic valve surgery alone or combined with CABG surgery in terms of mortality and peri operative complications. Methods: This is a retrospective and prospective study. We included the patients underwent aortic valve surgery (replacement or another procedure) with or without CABG from January 2007 and in April 2012. The population of 243 patients is divided into two groups: Group 1 included 59 patients combined surgery; Group 2 included 184 patients isolated aortic valve surgery. Results: The hospital mortality is 4,5 % in general. The hospital mortality for group 1 is 6,8% and for group 2 is 3,8 %.
The Journal of Thoracic and Cardiovascular Surgery, 2008
Surgical replacement is our standard treatment for descending aortic aneurysm, despite the advent of thoracic endoprostheses. We retrospectively analyzed outcomes of descending aortic replacement performed with partial cardiopulmonary bypass. Methods: Since 1994, a total of 113 patients in our institution (mean age 68 6 12 years, n 5 75 male) have undergone graft replacement of the descending aorta for nondissecting aneurysm. There were 16 emergency cases (14.2%). All operations were performed through left thoracotomy with partial cardiopulmonary bypass with segmental clamping. Since 1998, preoperative magnetic resonance angiography has been performed to detect the Adamkiewicz artery in elective cases. Motor evoked potentials are now measured intraoperatively. Results: Early mortalities were 5.3% overall (6/113), 1.0% (1/97) in elective cases, and 31.3% (5/16) in emergency cases. Rates of spinal cord dysfunction were 2.7% overall (3/113), 1.0% (1/97) in elective cases, and 12.5% (2/16) in emergency cases. Stroke rates were 7.1% overall (8/113), 4.1% (4/97) in elective cases, and 25.0% (4/ 16) in emergency cases. Rates of respiratory failure were 9.7% overall (11/113), 9.2% (9/97) in elective cases, and 12.5% (2/16) in emergency cases. No patient underwent reoperation for the same lesion as a result of repair problems in the follow-up period. Kaplan-Meier overall survival estimates were 92.2% at 3 years, 90.6% at 5 years, and 70.2% at 10 years. Conclusion: Although it is more invasive than stent graft repair, descending aorta replacement performed with partial cardiopulmonary bypass involves a risk comparable to that associated with thoracic endoprosthesis placement.
CABG in pocelain AORTA
A severe aortic calcification (porcelain aorta) carries a high risk of atheroembolism and bleeding during cardiac surgery, with an incidence range of 14% to 29%. Proximal anastomosis of conduits to the ascending aorta in patients undergoing coronary artery bypass grafting may be hazardous or impossible in the presence of complex aortic pathology. Various techniques have been introduced in order to avoid cannulation and clamping of the aorta. Herein, we present a technique in a high-risk group of such patients (Iranian Heart Journal 2014; 15 (1): 29-31)..
Early and Late Results of Ascending Aorta Surgery: Risk Factors for Early and Late Outcome
World Journal of Surgery, 1997
This study was designed to evaluate risk factors for in-hospital mortality and midterm survival in patients undergoing ascending aorta surgery at a single institution during an 11-year period. Between 1984 and 1994 a total of 158 patients underwent an ascending aorta procedure at our institution. Their mean age was 59.6 ± 12.3; 115 (73%) were male, 33 (21%) had a history of congestive heart failure, 61 (39%) had an acute type A dissection, 21 (13%) underwent redo operations, and 55 (35%) were operated on an emergency basis. In-hospital mortality was 9.7% (10/103) for elective procedures and 36.4% (20/55) for emergency operations ( p < 0.0001). Multivariable stepwise logistic regression analysis identified the cardiopulmonary bypass time [odds ratio (OR) = 1.01/min, p = 0.0021], emergency operation (OR = 2.27, p = 0.0022), arch replacement (OR = 2.71, p = 0.0067), and the need of femoral vein cannulation at intervention (OR = 1.89, p = 0.0375) as independent predictors of in-hospital death. When this kind of analysis was performed, evaluating only the variables known before surgery, acute type A dissection (OR = 2.21, p = 0.0009) and preoperative NYHA class (OR = 1.88 per class, p = 0.0290) were independent risk factors for in-hospital death. Follow-up ranged from 10 to 126 months (median 42 months), with Kaplan-Meier survivals of 69 ± 4%, and 60 ± 5% at 5 and 7 years, respectively; survival rates for hospital survivors were 85 ± 4% and 67 ± 7% at 5 and 7 years, respectively. Cox regression analysis has identified arch replacement [relative risk (RR) = 2.48, p < 0.0001], perioperative myocardial infarction (RR = 2.44, p = 0.0003), preoperative NYHA class (RR = 1.97 per class, p = 0.0009), acute type A aortic dissection (RR = 1.44, p = 0.0238), the need of femoral vein cannulation at intervention (RR = 1.55, p = 0.0332), and redo operation (RR = 1.44, p = 0.0851) as independent predictors of reduced survival at follow-up. When this kind of analysis was performed on hospital survivors only, postoperative tracheostomy ( p = 0.0003, RR = 3.42), reexploration for bleeding ( p = 0.0003, RR = 3.77), and the occurrence of postoperative ventricular arrhythmias ( p = 0.0007, RR = 2.45) emerged as risk factors. Multiple factors affect the early and late outcome after ascending aorta surgery; our data suggest that the preoperative clinical status of the patients and the priority of surgery and aortic dissection are the main determinants of the early results; on the other hand, the early postoperative course is the main determinant of the late outcome of hospital survivors.