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
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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
our experience with proximal aortic reoperations in pa-
tients with composite valve grafts (CVGs) and assess
postoperative survival and morbidity.
Methods. Since 1991, 33 patients with CVGs underwent
reoperation for one or more of the following indications:
aneurysms distal to the CVG (n ⴝ 20, 61%), false aneu-
rysms (n ⴝ 13, 39%) and graft infection (n ⴝ 7, 21%).
Operations included false aneurysm repair (n ⴝ 13, 39%),
graft replacement of distal ascending aortic or transverse
aortic arch aneurysm (n ⴝ 20, 61%) and aortic root
re-replacement with a new CVG (n ⴝ 6, 18%) or ho-
mograft (n ⴝ 4, 12%).
Results. Operative mortality was 15% (n ⴝ 5), includ-
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
these excellent results an increasing number of these
patients are returning with a variety of indications for
reoperation [7–9]. Patients requiring reoperation on the
proximal aorta after previous composite valve graft
(CVG) placement represent a challenging subset [10].
The purpose of this retrospective review was to examine
our experience with proximal aortic reoperations in pa-
tients who have undergone previous CVG placement.
Patients and Methods
Since 1991, 33 patients with previously placed CVGs
presented for reoperation. During the same period, the
senior author (J.S.C.) performed aortic root replacement
with CVGs in 124 patients, only 1 of whom returned for
reoperation; the remaining 32 patients had their original
CVG placed elsewhere. The average age at reoperation
was 46 ⫾ 14 years. Twenty-seven patients (82%) were
men and 6 (18%) were women. Seventeen patients (52%)
had Marfan’s syndrome. The average time interval be-
tween the initial operation and presentation was 81 ⫾ 71
months (range, 3 to 252). In many cases there were
multiple simultaneous indications for reoperation.
Presented at the Aortic Surgery Symposium VIII, May 2–3, 2002, New
York, NY.
Address reprint requests to Dr LeMaire, 6560 Fannin St, Suite 1100,
Houston, TX 77030; e-mail: slemaire@bcm.tmc.edu.
© 2002 by The Society of Thoracic Surgeons
Published by Elsevier Science Inc
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ing 2 of the 7 patients who had infected CVGs (29%). All
4 patients who had infected CVGs replaced with aortic
root homografts survived. Complications included vocal
cord paralysis (n ⴝ 4, 12%), bleeding requiring reopera-
tion (n ⴝ 3, 9%) and stroke (n ⴝ 2, 6%). Actuarial 3-year
survival was 74.4% ⴞ 7.9%.
Conclusions. Reoperations in patients with CVGs re-
main challenging procedures with high associated mor-
bidity and mortality, especially in the setting of graft
infection. The results of homograft aortic root re-
replacement for infected CVGs are encouraging.
(Ann Thorac Surg 2002;74:S1777– 80)
© 2002 by The Society of Thoracic Surgeons
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
patients underwent an emergency operation for rupture.
Two patients had acute dissection and 12 had chronic
dissection. In 19 patients the graft repair extended into
the transverse aortic arch. Graft extension was performed
as the sole operation in 13 patients and combined with
other procedures in 7 patients; 5 of these underwent
concomitant pseudoaneurysm repair and 2 underwent
placement of a new CVG for perivalvular pseudoaneu-
rysm or bioprosthetic aortic valve insufficiency.
Seven patients (21%) presented with infected CVGs,
proven by either preoperative blood culture (n ⫽ 6) or
intraoperative mediastinal fluid culture (n ⫽ 1). One
patient underwent only pseudoaneurysm repair and
omental coverage of the infected graft. Two patients
underwent CVG resection and replacement with a new
CVG; a pedicled omental flap was placed around the new
graft in 1. Since mid-1994 we have used homografts for all
patients with infected CVGs. Four patients underwent
CVG resection and replacement with a homograft aortic
root; omentum was placed around the homograft in 1
patient. One of these patients had also undergone bev-
eled polyester graft replacement of the proximal trans-
verse aortic arch during the initial operation; his reop-
eration included resection of all prosthetic material and
replacement with homograft aortic root and arch.
Pseudoaneurysms were present in 13 patients (39%,
Table 1) and were usually associated with other pathol-
ogy. Only 1 pseudoaneurysm (perivalvular) was related
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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
2002;74:S1777– 80
of 6 years after discharge. The patient who presented
with an infected CVG and beveled hemiarch graft died of
a myocardial infarction 5 months after discharge. Two of
the 13 patients who underwent pseudoaneurysm repair
developed new pseudoaneurysms. One patient had un-
dergone repair of a left main coronary pseudoaneurysm
and presented 4 years later with a new pseudoaneurysm
involving the distal aortic anastomosis; this was repaired
elsewhere by graft extension into the proximal hemiarch.
The other patient had undergone repair of a pseudoan-
eurysm at the distal aortic anastomosis by graft extension
into the proximal hemiarch and concomitant coronary
artery bypass; 5 years later he developed a pseudoaneu-
rysm involving the vein grafts but was lost to follow-up
before treatment.
Comment
The most common indication for reoperation in this
series was aneurysm recurrence just distal to the previ-
ously placed graft [11]. Although more judicious inspec-
tion and aggressive resection of the proximal aorta at the
original operation may reduce the incidence of recur-
rence, we recognize that limiting the initial repair (espe-
cially under emergency circumstances) is often prudent.
When feasible, brief periods of hypothermic circulatory
arrest allow assessment of the aortic arch and may alter
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
clearly identify the need for extended resection in pa-
tients with aortic dissection.
The open button technique of coronary artery reattach-
ment during CVG insertion has decreased the incidence
of coronary artery pseudoaneurysm [3]. Similarly, using
interrupted sutures rather than a continuous suture line
at the annular anastomosis may reduce the risk of peri-
valvular pseudoaneurysm [13]. The variety of the 14
pseudoaneurysms in this series, however, serves as a
reminder that patients with CVGs are at risk for the
development of pseudoaneurysms regardless of the tech-
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AORTIC SURGERY SYMPOSIUM VIII LEMAIRE ET AL S1779
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.
nique used. Lifelong surveillance with echocardiography
and computed tomography scanning is required to as-
sess the integrity of the valve mechanism, the develop-
ment of pseudoaneurysms, and dilatation of the distal
aorta.
As we have reported previously [14], CVG infection
remains a catastrophic complication. Prosthetic endocar-
ditis is the most common complication after CVG place-
ment and carries a mortality that exceeds 50% [2]. Al-
though simply wrapping the infected graft with a
pedicled omental flap and administering long-term in-
travenous antibiotics was successful in 1 patient, replace-
ment of the infected CVG with a homograft aortic root
provided encouraging early and midterm results. After
homograft placement, we recommend a 6-week course of
intravenous antibiotics through a tunneled central ve-
nous catheter. Importantly, the risk of CVG infection
continues long after the initial operation. In our series 4
of the 7 patients (57%) with graft infection presented
more than 3 years after CVG placement. We believe that
this justifies an aggressive approach to antibiotic prophy-
laxis whenever patients with CVGs require invasive
procedures that produce bacteremia such as bronchos-
copy, colonoscopy, and dental procedures; regardless of
the length of time since CVG placement, we recommend
periprocedural administration of intravenous broad-
spectrum antibiotics.
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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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