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(Chest. 2003;124:984-988.)
© 2003 American College of Chest Physicians

Long-term Results of Bentall Composite Aortic Root Replacement for Ascending Aortic Aneurysms and Dissections*

Sandro Gelsomino, MD; Giorgio Morocutti, MD; Romeo Frassani, MD; Gianluca Masullo, MD; Paolo Da Col, MD; Leonardo Spedicato, MD and Ugolino Livi, MD

* From the Department of Cardiovascular Sciences, General Hospital "S. Maria Della Misericordia," Udine, Italy.

Correspondence to: Sandro Gelsomino, MD, Cardiothoracic Surgery, Department of Cardiovascular Sciences, Azienda Ospedaliera S. Maria della Misericordia, Piazzale S. Maria Della Misericordia 11, 33100 Udine, Italy; e-mail: sandrogelsomino{at}virgilio.it


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusions
 References
 
Study objectives: The aim of this study was to evaluate the early and long-term outcomes in patients undergoing aortic root replacement (ARR) with the Bentall procedure.

Design: Retrospective study.

Setting: Cardiothoracic surgery unit.

Patients and methods: Between January 1986 and January 2002, 72 patients (mean age 58.3 ± 12.4 years, 81.9% males) underwent ARR by means of a Bentall operation. Annuloaortic ectasia was the most frequent cause of aortic disease in this series of patients (31 patients; 43.1%), followed by type A dissection (19 patients; 26.3%), atherosclerotic aneurysm (18 patients; 25.1%), and poststenotic dilatation (4 patients; 5.5%). Nine patients (12.5%) had Marfan syndrome, and 10 patients (13.8%) underwent a concomitant replacement of the aortic arch. Follow-up ranged from 2 to 192 months (mean [± SD], 86.6 ± 23.8 months).

Results: The mean 30-day mortality rate was 5.5 ± 2%. The mean early mortality rate was 21 ± 4% and 0% (p < 0.001), respectively, in patients with and without dissecting aortic aneurysms. There were two late deaths that were due to a pulmonary neoplasm and a cerebrovascular accident. The mean 16-year survival rate was 91.7 ± 3.2%. The mean hazard of freedom from death was constant beyond 3 years (8.5 ± 3.5%). No patient required reoperation. Furthermore, the long-term clinical follow-up was marked by a complete absence of endocarditis, anticoagulant-related hemorrhage, valve thrombosis, and prosthesis failure. Finally, patients showed a significant improvement in mean New York Heart Association functional status (1.3 ± 0.1; p < 0.001 [postoperatively vs preoperatively]).

Conclusions: In our experience, the late results of the Bentall operation were satisfactory. Our findings confirm that this technique still represents the procedure of choice for ARR with coronary reimplantation.

Key Words: aortic aneurysm • aortic root replacement • Bentall technique • composite graft • dissecting aneurysm


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusions
 References
 
Since its introduction, the Bentall operation has been considered to be the "gold standard" in the surgical treatment of combined valve and ascending aorta pathology.1

In the present study, we reviewed our own series of patients who underwent composite aortic root replacement (ARR) with coronary artery reimplantation employing the Bentall procedure for ascending aortic aneurysms and dissections.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusions
 References
 
We reviewed the records of all the patients with chronic aortic aneurysms who had undergone composite ARR and valve replacement with a Bentall operation between January 1986 and January 2002. Forty-eight percent of the procedures were performed in the first decade of the study (ie, from 1986 to 1996), and 52% were carried out in the last 5 years. Altogether, between 1986 and 1996, the Bentall operation was used in 31.1% of the patients undergoing a composite ascending aorta and aortic valve replacement in our institution. In contrast, during the last 5 years, the Bentall operation represented 49.3% of the procedures for ascending aorta replacement with aortic valve reimplantation (p = 0.02). In all, 72 consecutive patients were eligible for the study. The preoperative characteristics are summarized in Table 1 . Annuloaortic ectasia was the most frequent cause of aortic disease in this series (31 patients; 43.1%), followed by type A dissection (19 patients; 26.3%), atherosclerotic aneurysm (18 patients; 25.1%), and poststenotic dilatation (bicuspid valve) [4 patients; 5.5%]. Nine patients (12.5%) had Marfan syndrome with typical ocular and skeletal manifestations. The operative data are shown in Table 2 . Standard moderate hypothermic (28°C) cardiopulmonary bypass was generally used. Ten patients (13.8%) had extensive aortic disease involving the aortic arch that required concomitant partial or total aortic arch replacement. In these patients, circulatory arrest with profound hypothermic circulatory arrest (18°C to 22°C), retrograde cerebral perfusion, or selective antegrade cerebral perfusion through a direct cannulation of both the innominate branch and left carotid artery, or using the technique first proposed by Kazui et al,2 were employed. Myocardial protection consisted of antegrade infusion of crystalloid cardioplegia and topical hypothermia.


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  		Table 1.. Preoperative Patient Characteristics*

 

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  		Table 2.. Operative Data*

 
All the procedures were performed as previously described, employing the inclusion technique and, more recently, the end-to-side reimplantation of the coronary ostia using the "button" technique.1 3 4

A Cabrol fistula5 between the periprosthetic space and the right atrium was created in 25 patients (34.7%) who underwent ARR with the inclusion technique, in order to decompress the perigraft space, thus reducing tension at the suture lines, which may be responsible for pseudoaneurysm formation.

In case of a repeat procedure with a difficult mobilization of the coronary ostia or in case of complex repairs, a Cabrol technique3 was preferred for composite ARR. Furthermore, since 1997, a "valve-sparing" operation (ie, the Tirone David I "reimplantation" technique)6 was preferred in case the valve cusps were macroscopically normal, with valve insufficiency secondary to root dilatation.

From the first postoperative day, all patients with mechanical prostheses started a regimen of lifelong treatment with warfarin sodium (Coumadin; Du Pont Pharmaceuticals; Wilmington, DE). The target international normalized ratio was 2.5 to 3.0. Antiplatelet therapy was continued in patients who had undergone concomitant coronary artery bypass surgery.

All clinical data were obtained by a retrospective review of medical records, and postoperative follow-up information was obtained by written and/or telephone communication. The duration of follow-up ranged from 2 to 192 months (mean [± SD] duration, 86.6 ± 23.8 months). Infectious, thromboembolic, and bleeding complications were recorded, as required by American Association of Thoracic Surgery/Society of Thoracic Surgeons/European Association for Cardio-Thoracic Surgery guidelines.7 Patients underwent transthoracic Doppler echocardiography at hospital discharge and at a mean time of 86.6 ± 23.8 months postoperatively (range, 2 to 192 months). ECGs were performed (Sonos 1000/2500/5500 systems; Hewlett Packard; Andover, MA) with 2.5-MHz and 5.0-MHz ultrasound transducers (Hewlett Packard) and were recorded on VHS videotape for subsequent review. Measurements and calculations were carried out in accordance with published criteria.8 The degree of aortic regurgitation was evaluated following standard echocardiographic criteria.9 All data were analyzed with a statistical software package (SPSS for Windows, version 8.0; SPSS, Inc; Chicago, IL). Continuous data were presented as the mean ± SD, and discrete variables were presented as percentages. Discrete variables were analyzed by the {chi}2 test or the Fisher exact test, and continuous variables were analyzed by one-way analysis of variance. Actuarial freedom from deaths/events were calculated by the Kaplan-Meier method and were reported with 95% confidence intervals. A p value of < 0.05 was judged to be statistically significant.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusions
 References
 
Mortality and Morbidity
The 30-day mortality rate was 5.5% (4 of 72 patients). The rate was 0% for patients with a nondissecting aortic aneurysms and 21% for those with dissections (p < 0.001). The causes of death were as follows: low-output syndrome (two patients); multiorgan failure (one patient); and sepsis (one patient). Early nonfatal events included bleeding requiring surgical reexploration (eight patients;11.1%), myocardial infarction (five patients; 6.9%), acute renal insufficiency (five patients; 6.9%), pulmonary insufficiency (five patients; 6.9%), low- output syndrome (four patients; 5.5%), and stroke (three patients; 4.1%).

During the follow-up period there were two late deaths, 18 and 34 months postoperatively, that were due to pulmonary neoplasm and cerebrovascular accident, respectively. The mean actuarial survival rates at 1, 10, and 16 years, were 94.5 ± 2.6%, 91.7 ± 3.2%, and 91.7 ± 3.2%, respectively (Fig 1 ). The hazard of death at 16 years was 8.5 ± 3.5%, and it became constant beyond 3 years. The mean 5-year survival rates for patients operated on before and after 1996 were 89.5 ± 4% and 91.5 ± 2%, respectively (log-rank, 1.16; p = 0.28).



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  		Figure 1.. Actuarial survival after ARR and valve replacement with the Bentall procedure.

 
The mean 16-year survival rate did not differ significantly between patients with nondissecting aneurysms or dissections (94.3 ± 3.4% vs 90.1 ± 4.5%; log-rank, 2.1; p = 0.132).

Valve-Related Complications and Symptomatic Status
No patient required reoperation. Furthermore, clinical follow-up was marked by a complete absence of endocarditis, anticoagulant-related hemorrhage, valve thrombosis, and prosthetic failure. Thus, freedom from these events was 100%. At follow-up, there was an improvement in symptomatic status, as assessed by mean New York Heart Association (NYHA) class (1.3 ± 0.1; p < 0.001 [postoperatively vs preoperatively]), with 69.7% of patients in NYHA functional class I and 30.3% in NYHA II. No patients were in NYHA class III or higher.

Echocardiographic Measurements
ECG control subjects showed a postoperative reduction in mean end-systolic dimensions (at hospital discharge, 38.5 ± 1.9 mm; at last follow-up, 34.6 ± 1.1 mm; vs preoperatively, 46.2 ± 3.1 mm; p = 0.02 and p = 0.01, respectively) and end-diastolic dimensions (at hospital discharge, 56.2 ± 4.4 mm; at last follow-up, 53.9 ± 3.1 mm; vs preoperatively, 62.3 ± 5.5 mm; p = 0.03 and p = 0.02, respectively). Changes in mean septum thickness (at hospital discharge, 1.33 ± 0.1 cm; at follow-up, 1.30 ± 0.1 cm; vs preoperatively, 1.34 ± 0.1 cm; difference not significant), mean posterior wall thickness (at hospital discharge, 1.22 ± 0.1 cm; at follow-up, 1.21 ± 0.1 cm; vs preoperatively, 1.28 ± 0.1; difference not significant), and mean fractional shortening (at hospital discharge, 41 ± 7%; at follow-up, 46.4 ± 9%; vs preoperatively, 41.3 ± 8%; differences not significant) did not reach statistical significance. Early postoperatively peak and mean transvalvular gradients gradient were 25 ± 3 mm Hg and 12 ± 6 mm Hg, respectively. At the last follow-up, those values were 16 ± 3 mm Hg and 9 ± 1 mm Hg, respectively (difference not significant). The mean aortic root diameter was 3.1 cm at hospital discharge and 3.2 cm at follow-up control (difference not significant). At hospital discharge, aortic insufficiency was judged to be absent or trivial in 55 patients (80.9%), mild in 11 patients (16.1%), and moderate in 2 patients (3%). At follow-up, aortic insufficiency was absent or trivial in 62 patients (94%) and mild in 4 patients (6%). No patient had an insufficiency that was graded moderate or higher.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusions
 References
 
Since Cooley et al10 and Cooley and De Bakey11 in 1956 first described the resection of an aneurysm of the ascending aorta with the use of cardiopulmonary bypass and proposed the employment of hypothermia in the treatment of aortic aneurysms, many surgical techniques have been reported for the treatment of annuloaortic ectasia and other disorders of the ascending aorta that are associated with aortic regurgitation. In 1964, Wheat and coworkers12 first performed a successful replacement of the aortic valve in continuity by separate graft valve repair. In the same period, Groves and coworkers13 proposed the supracoronary method, and, later, Creech14 introduced the inclusion technique for the repair of aortic aneurysms. In 1968, Bentall and De Bono1 described the total replacement of the ascending aorta and aortic valve with a composite tubular graft containing a prosthetic valve with side-to-end reimplantation of the coronary artery ostia to the graft. This technique reduced the risk of recurrent proximal aortic aneurysm,15 16 and it quickly became the treatment of choice for patients with annuloaortic ectasia, ascending aortic dissection, and other disorders of the ascending aorta and aortic valve. Nonetheless, concerns have been raised about the traction on the aortic wall at the level of the reimplanted ostia when a classic Bentall operation is performed because it may lead to hemorrhage, which is difficult to control because of the inaccessibility of the anastomosis sites.17 18 In addition, pseudoaneurysms of the coronary ostia or distal aortic suture have been reported to occur frequently.19

For these reasons, many modifications to the original technique have been proposed, the most common of which is the coronary button (Carrel patch) technique6 20 and the Cabrol technique.2 The theoretical advantages of the coronary button technique include a better exposure of the anatomic structures, an improved surgical access for the control of hemostasis, and a more anatomic reconstruction.21 Potential disadvantages of the open technique include the time necessary to mobilize the coronary ostia, the risk of damaging these vessels, the possibility of occlusion caused by tension, and its nonfeasibility in case of aortic dissection.20 22 With the Cabrol technique, all bleeding sites can be easily visualized and the formation of pseudoaneurysms at the coronary ostia is avoided. However, the technique may carry the potential risk of various late complications such as kinking of the limbs of the coronary Dacron graft and occlusion of the limb of the right coronary artery.18 Since 1986, we have used primarily the Bentall composite ARR with coronary artery reimplantation for the treatment of chronic ascending aorta aneurysms and dissection. This technique was performed in 49.3% of the ascending aorta and valve replacement procedures carried out in our institution in the past 5 years. In our study, the early mortality rate was 5.5% (4 of 72 patients), and no patient undergoing a Bentall procedure for a nondissecting aneurysm died within 30 days. There were two late deaths due to pulmonary neoplasm and cerebrovascular accident, and the long-term (ie, at 16 years) survival rate was satisfactory (91.7 ± 3.2%), with the risk of death becoming constant beyond 3 years (8.5 ± 3.5% at 16 years). No patient in this series required reoperation, and long-term clinical follow-up was marked by a complete absence of endocarditis, anticoagulant-related hemorrhage, valve thrombosis, and prosthetic failure.

Finally, patients showed a significant improvement in NYHA functional status (p < 0.001 vs preoperative values). The inclusion technique, as originally described by Bentall and De Bono,1 was in the past our method of choice for the composite replacement of the ascending aorta and aortic valve. In our experience, this technique reduced the risk of recurrent proximal aortic aneurysm by removing the entire diseased aortic wall. A Cabrol operation was used only in the following specific situations: patients undergoing repeat procedures; in the presence of an extensive calcification of the aneurysmal aorta; or when the coronary ostia were quite low (ie, < 1.5 cm above the annulus) and the direct reimplantation was difficult; or when using the technique might lead to an excessive tension on ostial anastomoses. In our current policy, the open technique, including direct implantation of coronary buttons and a distal anastomosis to the completely divided ascending aorta, is the preferred method of ARR. This technique allows an increased length of artery with a reduced gap between the aneurysm wall and the graft with minimal tension on the anastomoses. The employment of the "button" technique further reduced, in our practice, the indications for the Cabrol operation, which actually is rarely used and is only used when the excision of the coronary ostial buttons is really difficult or not feasible (ie, in some repeat procedures or complex repairs).

Limitations of the Study
Our investigation has some strong limitations that have to be pointed out, as follows: the retrospective nature of this clinical study; the small number of patients remaining at risk beyond 10 years; and the small number of events, which reduced the strength of the statistical analysis.


   Conclusions
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusions
References
 
The late results of the Bentall operation were satisfactory. In our opinion, this technique still should be considered to be the procedure of choice for ARR with coronary reimplantation.


   Acknowledgements
 
We acknowledge the help of Dr. Orlando Parise for statistical analysis. We thank Viviana Giavedoni, Cristina Ceccotti, and Devi Papais for their assistance in the manuscript preparation, and Dr. Laura Pilotto for the English revision of the article.


   Footnotes
 
Abbreviations: ARR = aortic root replacement; NYHA = New York Heart Association

Received for publication August 12, 2002. Accepted for publication January 9, 2003.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusions
 References
 

  1. Bentall, H, De Bono, A (1968) A technique for complete replacement of the ascending aorta. Thorax 23,338-339[ISI][Medline]
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  3. Edwards, W, Kerr, AR A safer technique for replacement of the entire ascending aorta and aortic valve. J Thorac Cardiovasc Surg 1970;59,837-839[ISI][Medline]
  4. Kouchoukos, NT, Wreing, TH, Murphy, SF, et al Sixteen-year experience with aortic root replacement. Ann Surg 1991;214,308-320[ISI][Medline]
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  6. David, TE, Feindel, M An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992;103,617-622[Abstract]
  7. Edmunds, LH, Clark, RE, Cohn, LH, et al Guidelines for reporting morbidity and mortality after valvular cardiac operations. Ann Thorac Surg 1996;62,932-935[Abstract/Free Full Text]
  8. Otto, CM Aortic stenosis: echocardiographic evaluation of disease severity, disease progression and role of echocardiography in clinical decision-making. Otto, CM eds. Clinical echocardiography 1997,405-432 Saunders. Philadelphia, PA:
  9. Perry, GJ, Helmcke, F, Nanda, NC, et al Evaluation of aortic insufficiency by Doppler color flow mapping. J Am Coll Cardiol 1987;9,952-959[Abstract]
  10. Cooley, DA, De Bakey, ME, Creek, O, Jr Surgical treatment of aortic aneurysm. Am Surg 1956;22,1043-1051[Medline]
  11. Cooley, DA, De Bakey, ME Hypothermia in the surgical treatment of aortic aneurysms. Bull Soc Int Chir 1956;3,1-10
  12. Wheat, MW, Jr, Wilson, JR, Bartley, TD Successful replacement of the entire ascending aorta and aortic valve. JAMA 1964;188,717-719[ISI][Medline]
  13. Groves, LK, Effler, DB, Hawk, WA, et al Aortic insufficiency secondary to aneurysmal changes in the ascending aorta: surgical management. J Thorac Cardiovasc Surg 1964;48,362-379[ISI][Medline]
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  15. Symbas, PN, Raizner, AE, Tyras, DH, et al Aneurysms of all sinuses of Valsalva in patients with Marfan’s syndrome: an unusual late complication following replacement of aortic valve and ascending aorta for aortic regurgitation and fusiform aneurysm of ascending aorta. Ann Surg 1971;174,902-907[ISI][Medline]
  16. McCready, RA, Pluth, JR Surgical treatment of ascending aortic aneurysms associated with aortic valve insufficiency. Ann Thorac Surg 1979;28,307-316[Abstract]
  17. Asano, KI, Ando, T, Hanada, S, et al Control of bleeding during the Bentall operation. J Cardiovasc Surg 1983;24,13-14[Medline]
  18. Svensson, LG, Crawford, ES, Hess, KR, et al Composite valve graft replacement of the proximal aorta: comparison of techniques in 348 patients. Ann Thorac Surg 1992;54,427-439[Abstract]
  19. Cabrol, C, Pavie, A, Mesnildrey, P, et al Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries. J Thorac Cardiovasc Surg 1986;91,17-25[Abstract]
  20. Aoyagi, S, Kosuga, K, Akashi, H, et al Aortic root replacement with a composite graft: results of 69 operations in 66 patients. Ann Thorac Surg 1994;58,1469-1475[Abstract]
  21. Niederhauser, U, Rudiger, H, Kunzli, A, et al Surgery for acute type a aortic dissection: comparison of techniques. Eur J Cardiothorac Surg 2000;18,307-312[Abstract/Free Full Text]
  22. Hahn, C, Tam, SK, Vlahakes, GJ, et al Repeat aortic root replacement. Ann Thorac Surg 1998;66,88-91[Abstract/Free Full Text]



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