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ORIGINAL ARTICLE |
Department for Surgery of the Aorta and Its Branches National Research Center of Surgery Moscow, Russia
Dmitri D Savichev, MD, Tel: +7 499 2481015;, Fax: +7 4992468988;, Email: 7332326{at}mail.ru, Department for Surgery of the Aorta and Its Branches, 2 Abrikosovsky per., Moscow, 119992, Russia.
ABSTRACT
We present early results and long-term follow-up after reduction aortoplasty with external wrapping of the ascending aorta. From December 1993 to February 2008, 32 consecutive patients who had reduction aortoplasty were compared with 47 consecutive patients who underwent prosthetic graft replacement of the ascending aorta. The groups were similar in baseline characteristics. Patients in the reduction aortoplasty group had significantly shorter aortic crossclamp times (18.78 ± 1.91 vs. 34.04 ± 3.25 min) and cardiopulmonary bypass times (30.16 ± 2.36 vs. 60.83 ± 2.05 min), and they received fewer transfusions. There was no significant enlargement of the aortic diameter at the level of the sinus of Valsalva in the reduction aortoplasty group during the follow-up period (from 38.84 ± 3.10 to 39.48 ± 2.72 mm). Reduction aortoplasty with external wrapping of the ascending aorta is a simple and promising surgical method. Our experience shows that this technique is the procedure of choice in patients without aortic dissection and with an appropriately sized sinus of Valsalva.
Key Words: Aorta • Thoracic • Aortic Aneurysm • Thoracic • Aortic Diseases • Sinus of Valsalva
INTRODUCTION
Recent advances in the surgical technique of resection and grafting for ascending aortic aneurysm have significantly improved the early and late results.1,2 Replacement of the ascending aorta is well-established for the treatment of ascending aorta aneurysm, and the most frequently performed procedure for thoracic aortic pathology.3 However, this operation is still associated with substantial perioperative mortality and morbidity.4,5 It has long cardiopulmonary bypass (CPB) times and high blood transfusion requirements. A procedure with a shorter CPB time and less operative injury may overcome this problem. Reduction aortoplasty with external wrapping of the ascending aorta was proposed by Robicsek6 in 1982 to treat fusiform aneurysm associated with aortic valve disease, as an alternative to radical resection and prosthetic graft replacement. This procedure is generally advocated for combined aortic valve and ascending aorta pathology.2,7–9 Aortic wrapping, with or without partial resection, also became an alternative to graft replacement for aneurysms of the ascending aorta <6 cm in diameter, especially in elderly or high-risk patients.6,7,9,10 The purpose of this study was to compare the early results and late outcome after aortic graft replacement with those after reduction aortoplasty and external wrapping of the ascending aorta in patients with ascending aortic aneurysm and an appropriately sized sinus of Valsalva, without aortic dissection or aortic insufficiency.
PATIENTS AND METHODS
From December 1993 to February 2008, 198 patients with moderately sized ascending aortic aneurysms without dissection were surgically treated. Among them, concomitant operations on the aortic valve and coronary arteries were performed in 119 patients; they were excluded from analysis. A review of the medical records and outpatient notes of all 79 patients undergoing ascending aortic reduction aortoplasty or prosthetic aortic graft replacement, without concomitant cardiac procedures, was undertaken. The total number of operations on aneurysms of the ascending aorta, including reduction aortoplasties, prosthetic replacements, and Bentall procedures, with or without concomitant cardiac procedures, was 374 during this period. Patients with aortic arch involvement were not considered. We used 
5-cm diameter as the indication for repair of an ascending aortic aneurysm. On admission, all patients signed a consent form allowing collection and use of their medical records. The institutional ethical review board approved the study in January 2008.
We compared immediate and long-term results after reduction aortoplasty with external wrapping of the ascending aorta in 32 patients (study group) and after radical aortic aneurysm resection with prosthetic graft replacement in 47 patients (control group). The study group comprised 8.6% of all ascending aortic aneurysm operations. Follow-up was conducted from May to June 2008. Patients were contacted by telephone, and a systemic questionnaire was completed. Outpatient transthoracic echocardiography examinations were performed in district clinics, and the results were sent to us. Complete follow-up was available in 31 (96.9%) patients in the study group and 42 (89.4%) in the control group. The endpoints of this study were late diameter of the aorta at the level of the sinus of Valsalva, and late aortic valve function.
Preoperative patient characteristics and comorbid conditions are shown in Table 1
. The groups were similar in age and aortic diameters. Preoperative data were obtained by obligatory echocardiography and contrast-enhanced spiral computed tomography. The diameter of the aorta was evaluated according to departmental protocol: diameter of the fibrous ring of the aortic valve, maximal diameter at the level of the sinus of Valsalva, diameter at the level of the sinotubular junction, maximal diameter of the tubular part of ascending aorta, and aortic diameter at the level of the innominate artery origin. The width of removal of an elliptical section of the ascending aorta (X in Figure 1A) was calculated before the operation according to computed tomography, using the formula: X = 
(D1 – D2), where D1 is the maximal aneurysm diameter, and D2 is the aortic diameter at the level of the origin of the innominate artery.
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). The aortotomy was closed using continuous polypropylene suture (Figure 1C). Before placing the last few sutures, the patient was placed in a head-down position, and the aortic crossclamp was released to remove air and prevent embolization to the head. The suture line was inspected for significant leaks. Additional hemostatic sutures were placed if necessary. A graft was chosen with a diameter approximating that of the reduced aorta. The graft was incised longitudinally and inserted beneath the ascending aorta. The reduced aorta was tightly wrapped by the graft to prevent future aortic enlargement. The prosthesis was directly sutured with sewing margins of 5 mm at both sides (Figure 1D), and after the first few stitches, the prosthesis was fixed to ascending aorta proximally by 2 U-type adventitial sutures, to avoid even minor displacement. Thus the whole ascending aorta was covered by the prosthesis. Thereafter, the prosthesis was fixed to the aortic wall distally. The operation was completed in the standard manner. Packed red blood cell transfusions were given after CPB at a packed cell volume <30% and/or arterial hemoglobin <80 g L–1, with the aim of a packed cell volume of 35% or more. Postoperatively, patients with major ongoing hemorrhage received transfusions of packed red blood cells, platelets, and plasma. The data are reported as mean ± standard deviation with the range, or as numbers and percentages. Statistical analysis was performed using a statistical software program (SPSS, Inc., Chicago, IL, USA). Differences were considered significant at p less than 0.05.
RESULTS
Perioperative data are summarized in Table 2. The overall hospital mortality was2.53% (2 patients). There was no hospital mortality in the study group. In the control group, 2 (4.26%) patients died early postoperatively (after 7 and 8 days) from multiple organ failure. Both of these patients had long cardiopulmonary bypass times (65 and 67 min) and each received 6 units of the packed red blood cells due to ongoing postoperative bleeding. In one of them, reexploration for bleeding was performed. There were 3 (6.38%) reoperations for bleeding without source, all in the control group. Patients in the reduction aortoplasty group had significantly shorter aortic crossclamp and CPB times. Intensive care unit stay was shorter in the study group. There was no need for reexploration for bleeding in the study group. Transfusion requirements in this group were significantly less than in the control group. Hospital stay was similar in both groups. Follow-up data are shown in Table 3. One late death in the study group and 3 in the control group occurred due to noncardiac reasons. There were no late reoperations in either group. Late aortic valve function was similar in both groups. There was no significant enlargement of the aortic diameter at the level of the sinus of Valsalva in the study group during the follow-up period (38.84 ± 3.10 preoperatively to 39.48 ± 2.72 postoperatively; p = 0.39).
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The anatomy of ascending aortic aneurysms is very variable, which has led to a number of different repair techniques. A more physiological technique that is safe, effective, and causes less injury is an attractive option. The indications for reduction aortoplasty with wrapping of ascending aorta, risks of the procedure, and long-term durability are pertinent to the debate regarding this surgical approach.11 There is general agreement that patients with ascending aortic aneurysms with a diameter exceeding 6 cm should not undergo aortic wrapping.8,12 In our opinion, the main criterion for performing reduction aortoplasty with external wrapping of the ascending aorta is the diameter at the level of the sinus of Valsalva only, rather than the maximal diameter of the tubular ascending aorta. We considered a sinus of Valsalva diameter <4.5 cm as conditionally appropriate for the reduction aortoplasty. On the other hand, substantial enlargement of the tubular ascending aorta usually leads to aortic root dilatation; reduction aortoplasty with external wrapping may be impossible in these circumstances. In our experience, the maximal tubular ascending aorta diameter with an appropriately sized sinus of Valsalva and normal aortic valve function was 81 mm. In patients with greater aneurysm size, aortic root dilatation with severe impairment of valve function was observed.
Encouraged by recent reports of good mid- and long-term results, reduction aortoplasty has become more widely used, despite continued suspicion about the efficacy of this strategy.11,12 No evidence of a significant increase in sinus of Valsalva diameter, dissection, or rupture was observed in this study. External wrapping of the reduced aorta by prosthetic graft from the outside was performed in all of our patients to avoid re-dilatation of the aorta in the future. Moreover, we suggest that external wrapping may prevent sudden bleeding due to disruption of the suture line. We consider that aortoplasty with external wrapping of the ascending aorta has an advantage over graft replacement in surgical invasiveness. Nevertheless, this procedure is applicable only to selected patients with an appropriate sinus of Valsalva diameter and an aortic aneurysm without dissection.
ACKNOWLEDGMENTS
We would like to express our gratitude to Dr Alexandr N Bletkin for improving this manuscript by reading and correcting the text and giving valuable criticism.
REFERENCES
Asian Cardiovasc Thorac Ann 2009;
17:162-166
© 2009 by SAGE Publications
DOI: 10.1177/0218492309103302
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