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Late Results of Operation for Acute Aortic Dissection Producing Aortic Insufficiency
Late Results of Operation for Acute Aortic Dissection Producing Aortic Insufficiency J. Kenneth Koster, Jr., M.D., Lawrence H. Cohn, M.D., Roger B. B. Mee, M.D., and John J. Collins, Jr., M.D. patients for acute ascending aortic dissections producing aortic insufficiency. There were 7 men and 1 woman who ranged in age from 40 to 57 years (mean, 50 years). During the same period, 3 other patients underwent operation in which the aortic valve was prosthetically replaced rather than resuspended because of either marked dilatation of the aortic annulus or intrinsic leaflet deformity. Six patients had initial complaints of either chest or back pain. Of the remaining 2, 1 complained of a cold, pulseless upper extremity and the other had dense hemiparesis. Only 1 patient had typical signs of Marfan’s syndrome. However, some form of medial degeneration was present in 5 of the 6 patients in whom a full-thickness portion of the aortic wall was resected to allow microscopic examination. Three patients had a history of hypertension. Of the 7 patients undergoing preoperative aortography, 6 demonstrated moderate to Acute dissections of the ascending aorta with marked aortic insufficiency. In the instance in major aortic valve insufficiency are best treated which the aortogram showed no valvular inby immediate operative repair. Satisfactory re- competence, both the right and the noncorosults may be obtained in this situation by aortic nary cusp were found at operation to be seresection with insertion of a graft and aortic verely prolapsed because of intimal dehiscence. valve replacement. However, in some patients a In 1 case, aortography was not performed. This simpler operation with repair of the aorta and patient had a loud murmur of aortic insuffiresuspension of the valve may be accom- ciency and was taken directly to operation beplished. This report documents our experience cause of severe hypotension that developed with a relatively simple technique for recon- after echocardiographic demonstration of a struction of the aorta and valve using interposi- double ascending aortic wall. At operation in each instance, there was an tion of a prosthetic media to prevent late aortic identifiable intimal tear within the ascending root dilatation. aorta with dissection and prolapse of one or more aortic valve leaflets. The dissecting Clinical Material From July, 1970, through April, 1975, prosthetic hematoma extended beyond the ascending media reconstruction has been performed in 8 aorta in 6 cases (DeBakey type I) and was confined to the ascending aorta in 2 instances (DeFrom the Department of Surgery, Harvard Medical School Bakey type 11). ABSTRACT Since July, 1970, 8 patients with acute dissecting aneurysms of the ascending aorta producing aortic insufficiency have undergone immediate operation employing a technique in which the origin of the dissection is resected, the dissected base of the aorta is lined with nondistensible prosthetic cloth for support, and the native aortic valve is resuspended. Aortic continuity is then reestablished with end-to-end anastomosis or use of a short segment of woven graft (not necessarily circumferential). There were no operative deaths. Mean follow-up has been 60 months (range, 25 to 82 months). One late death has occurred (cerebral hemorrage at 48 months); of the remaining 7 patients, 2 have faint murmurs of aortic insufficiency, but all are in New York Heart Association Functional Class I. This technique of aortic reconstruction in acute ascending dissections allows preservation of the native aortic valve while preventing late aortic root dilatation or major valve insufficiency.
and Peter Bent Brigham Hospital, Boston, MA. Presented at the Fourteenth Annual Meeting of The Society of Thoracic Surgeons, Jan 23-25, 1978, Orlando FL. Address reprint requests to Dr. Collins, Department of Surgery, Peter Bent Brigham Hospital, Boston MA 02115.
Operative Technique Median sternotomy is employed. Cardiopulmonary bypass is instituted with femoral artery
461 0003-4975/78/0026-0511$01.25@ 1978 by J. Kenneth Koster, Jr.
462 The Annals of Thoracic Surgery Vol 26 No 5 November 1978
&~ AORTA \\
INTIMAL 01si T A l
ME
PROXIMAL F E L T MEDIA
Fig 2 . Lining the proximal and distal dissection zuitlz the prosthetic media. (RCA = right coronary artery.) Fig I . Dissected aorta showing bulging adventitia and normal-caliber intima. (RCA = right coronary artery.)
trimmed so that the edges of the two layers match for oversewing. Since the dissection perfusion and venous drainage through a single usually proceeds along the greater curvature, right atrial cannula. In the course of systemic some portion of the posterior wall is often intact cooling to 28"C, the heart is electrically fibril- and need not be resected. The aortic valve is inspected. If the incompelated and the left ventricle apically vented. The aorta is cross-clamped immediately proximal to tence appears to be the result of commissural the origin of the innominate artery. Myocardial detachment and the valve leaflets are not intrinprotection during the ischemic period is pro- sically deformed and can be made to coapt vided by a continuous infusion of iced Ringer's normally, valve resuspension is undertaken solution into the pericardium and intermittent after the aortic root has been reconstructed with prosthetic media. This is accomplished by linendocardia1 lavage. The bulging adventitia is incised transversely ing the space between the intima and advenapproximately 3 cm superior to the origin of the titia with a tailored sheet of Teflon felt so that right coronary artery. After the adventitia has the cloth extends into the most proximal been opened, it will usually be observed that reaches of the dissection (Fig 2). If necessary, the dissection has separated the intima from the the Teflon cloth is cut in a bat-wing configuradistended adventitia anteriorly and that the tion to allow it to extend around and deep to the tubular intima is of relatively normal caliber right coronary artery so as to line the aortic sinus. The cloth is then trimmed to conform (Fig 1). The intima is incised and resected only to the with the cut intimal and adventitial edges, and extent required to include the origin of the the three layers are oversewn together (Fig 3). The aortic valve is then resuspended with dissection, if possible, and the adventitia is
463
Koster et al: Operation for Acute Aortic Dissection Producing Aortic Insufficiency
FELT
Fig 4 . Restoration of aortic continuity with either primary anastomosis (B) or an anterior woven gusset (C). (RCA = right coronary artery.) Fig 3. Oversewing of the adventitia-media-intima and resuspension of the aortic valve.
felt-buttressed sutures placed at the commissures. These sutures are brought out through all layers of the reconstructed aortic wall and tied over a second felt pledget. A second piece of Teflon cloth is used to line the distal dissection, no farther than the crossclamp if the dissection extends into the distal .OTH aorta. The cut edge of the intima-cloth-adventitia is then oversewn as was done for the proximal edge. If the proximal and distal edges of oversewn aorta can be brought together easily, direct suture anastomosis is accomplished (Fig 4A, B). If tension would result from direct anastomosis, a wedge-shaped woven graft may be interposed as an anterolateral gusset (Fig 4C). In the few instances in which resection of the posterior wall of the aorta is required, a woven tube graft is inserted with circumferential anastomoses Fig 5. Restoration of aortic continuity with interposirtion of a tubular woven graft. (Fig 5).
464
The Annals of Thoracic Surgery Vol 26 No 5 November 1978
eration of the origin of the false lumen, restoration of aortic continuity, and reinstitution of valve competence. Various surgical techniques have been employed to achieve these goals, with a current trend favoring graft replacement of the ascending aorta over reconstructive approaches [3, 51. The reconstruction technique we have utilized has proved satisfactory in late follow-up and offers several technical advantages [2]. First, it is simple to perform and the operative time is brief. The entire repair was accomplished in the patients reported here with a mean aortic clamping time of 70 minutes. Second, limiting resection of the aortic wall to the region of the intimal tear usually allows aortic continuity to be restored without the interposition of a tubular graft. This avoids circumferential anastomoses and potentially troublesome posterior suture line bleeding. Furthermore, lining the proximal depths of the dissected aortic root with a tailored sheet of Teflon felt provides a nondistensible buttress against late dilatation of the proximal aorta and annular region, while still allowing preservation of the native aortic valve. When graft replacement of the aorta is employed, the supracoronary anastomosis leaves the area immediately above the valve unsupported, with the potential for late dilatation [6]. Provision of support to this area with a graft requires proximal anchoring of a composite graft and valve prosthesis to the aortic "annulus," which involves sacrifice of the native valve and reimplantation of the coronary artery into the graft. Finally, this reconstructive approach makes consistent preservation of the native aortic valve possible even when the dissection has extended into the sinuses of Valsalva, producing extensive commissural detachment and severe leaflet prolapse. An otherwise normal aortic valve is too good to waste, especially when one Comment considers the spectrum of potential problems The therapy for acute ascending aortic dis- encountered with most prosthetic valves in sections producing aortic insufficiency has terms of wear, thromboembolism, and longevolved so that there is now little argument that term anticoagulation. In a majority of acute disimmediate surgical treatment provides the most sections, aortic annular ectasia is minimal when satisfactory results [l, 41. the valve leaflets are normal, which makes reOperation in this setting is directed at oblit- suspension simple and practical. The absence
Results In all patients, the aortic base was reconstructed and the aortic valve resuspended using the technique described. Aortic continuity was reestablished with the interposition of a woven tubular graft in 2 patients. An anterior noncircumferential woven graft gusset was used in 3. In the 3 remaining patients, primary anastomosis of the reconstructed aortic wall without grafting was utilized. Mean aortic cross-clamp time was 70 minutes (range, 42 to 89 minutes). Two patients underwent reoperation for continued postoperative bleeding. In 1, no specific source was found, while in the other, one suture was required for a small bleeding point on the right ventricular wall. Postoperatively, 2 patients developed atrial fibrillation that necessitated additional digitalis, and 1 developed atrial flutter for which electrical cardioversion was required. The mean postoperative hospital stay, excluding that of the patient who sustained a preoperative stroke and required extended physical therapy, was 15 days (range, 10 to 26). There were no operative deaths. Mean follow-up has been 60 months (range, 25 to 82 months). There has been 1late death, at 48 months, from a cerebral hemorrhage that was confirmed postmortem. In this case, postmortem examination of the reconstructed aorta showed no dilatation of the aortic root, and the aortic valve was competent. Three patients have undergone repeat aortography, which has shown no aortic root dilatation or valve insufficiency. One has a large, asymptomatic dissection of the transverse and descending aorta. All 7 patients who are alive are in New York Heart Association Functional Class I. Two have faint murmurs of aortic insufficiency, but all have normal-sized hearts, and no patient has developed signs of aortic root dilatation or progressive aortic insufficiency.
465 Koster et al: Operation for Acute Aortic Dissection Producing Aortic Insufficiency
of major insufficiency on late follow-up in this series suggests that such repairs are also durable. Reconstruction of the aortic root with aortic valve resuspension h a s been feasible in a majority (8 of 11) of the acute ascending aortic dissections with associated aortic valve insufficiency treated during the period included in this report. The operation h a s been quite satisfactory i n terms of technical simplicity, low early morbidity, lack of operative mortality, a n d absence of late deterioration.
References 1. Appelbaum A, Karp RB, Kirklin JW: Ascending versus descending aortic dissections. Ann Surg 183:296, 1976 2. Collins JJ, Cohn LH: Reconstruction of the aortic valve: correcting valve incompetence due to acute dissecting aneurysm. Arch Surg 106:35, 1973 3. Daily PO, Trueblood HW, Stinson EB, et al: Management of acute aortic dissections. Ann Thorac Surg 10237, 1970 4. Dalen JA, Alpert JS, Cohn LH, et al: Dissection of the thoracic aorta: medical or surgical therapy. Am J Cardiol 34303, 1974 5. Kidd JN, Reul GJ, Cooley DA, et al: Surgical treatment of aneurysms of the ascending aorta. Circulation 54:Suppl 3:118, 1976 6. Kouchoukos NT, Karp RB, Lell WA: Replacement of the ascending aorta and aortic valve with a composite graft. Results in 25 patients. Ann Thorac Surg 24:140, 1977
Discussion DR. MYRON w. WHEAT (St. Petersburg, FL): The authors are to be complimented for providing a new and imaginative approach to a very difficult and extremely lethal problem: the patient with acute aortic dissection with aortic valve insufficiency. There certainly should be no question that the proper treatment for this lesion is surgical repair. As is apparent in their patients, the lesion tends to occur in younger persons in the spectrum of acute dissecting aneurysms, the mean age in this group being 50 years. The approach described is simple and direct-so simple that it amazes me none of us has used it before. The basic problem is the weakened and dissected media. What the authors have done is to reinforce or replace that media with a felt one, and the results from two to almost seven years after repair are good. There were no operative deaths, and only 2 patients had to be reoperated upon for bleeding. This approach (1)preserves the usually normal aortic valve, which is particularly important in the younger patient; (2) preserves the normal intimal lin-
ing in most patients and decreases the size of the graft replacement in the others; and (3), perhaps most important, by virtue of the felt media, appears to prevent the late development of an aneurysm of the aortic root, with its more difficult surgical problems. I hope the authors will keep us informed about further follow-up on these patients and that other cardiac surgeons will utilize this approach. If, indeed, this repair holds up and further deterioration of the aortic root, aortic valve, and descending aorta is prevented or even greatly delayed, this operation will have been a truly major contribution. I believe it is. Finally, I would like to remind you that medial degeneration is a systemic problem. These patients still need to have their blood pressure and cardiac impulse controlled with drugs throughout their life span. In 1 of the cases reported in this series, even though the aortic root was repaired, the patient has current dissections of the transverse and descending thoracic aorta. (Philadelphia, PA): I enjoyed Dr. Koster’s presentation very much and agree with him that restoring aortic valve competence with the use of a nondistensible and nonyielding prosthetic material is an excellent technique. His results have proved this. I wish to describe what I believe is a much simpler and safer operation. At the Medical College of Pennsylvania Hospital in Philadelphia, we use a ringed intraluminal shunt in the repair of dissecting aneurysms of the descending and ascending thoracic aorta. We have devised an improvisational model consisting of a woven tubular Dacron graft that is inserted through the ring, folded over, and sutured back on the graft. A model has also been made for US by a commercial firm for investigational use. The technique consists of doing a very limited dissection in the area where the ligatures are passed proximal and distal to the aneurysm. Under total cardiopulmonary bypass, the aorta is cross-clamped proximal to the innominate artery and the whole prosthesis is inserted. It is anchored at both ends with mattress sutures buttressed outside the aortic wall with Dacron felt, after which the aorta is circumferentially ligated against the grooves of the ring. Then the aortotomy is tightly closed. We have performed this operation in a 69-year-old normotensive man with acute dissection of the ascending aorta and associated aortic regurgitation. At operation we found a transverse intimal tear, circumferential dissection of the ascending aorta, and a flail aortic valve. The graft was inserted and ligated, and the aorta was ligated against the groove of the rings proximal and distal to the dissection. The aortotomy was then tightly closed. One year later the rings were in place and the valve was competent. DR. SARIEL G . ABLAZA
466 The Annals of Thoracic Surgery Vol 26 No 5 November 1978
You are probably wondering-as we did before we embarked on this operation-what happens to the aorta in the area of the circumferential ligature, the idea being that there might be pressure necrosis. We used this technique in 1976 in a patient with a chronic arteriosclerotic aneurysm of the descending aorta extending from just beyond the left subclavian artery down to the diaphragm. There has been no necrosis at the ligature lines. The secret of the technique is that the surgical dissection is very limited. You don't do anything with the intercostal arteries, the mediastinal pleura, or the adventitia. All you do is pass the ligatures around the normal aorta proximal and distal to the aneurysm, cross-clamp the aorta, do a longitudinal aortotomy, and insert the intraluminal shunt and ligate it.
IL): Six years ago I had the privilege of presenting before this society a nearly identical series of patients who were operated on for acute aortic insufficiency secondary to aortic dissection, with the principal objective of emphasizing that aortic valve replacement is not necessary under these circumstances. The excellent results reported by the authors and the sad truth that there are still many who excise these normal valves and replace them with prostheses stimulated me to take a second look at our experience and share it with you this morning. During the past ten years, we have actively participated in the care of 16 patients with acute aortic dissection causing aortic incompetence. Incidentally, I wish to ask the authors whether they had other patients with aortic insufficiency secondary to aortic dissection during the same period who were not operated on. I ask this because occasionally, refraining from operating may actually constitute a partial surgical failure or a partial surgical success, depending on the patient's course. This was illustrated to us by the fact that of these 16 patients, 2 died before operation, 1 during radiological studies and the second before a repeat aortogram could be obtained after the first study failed to show the origin of the dissection; this second patient died of pericardial tamponade after his aorta ruptured. Two further patients had massive neurological deficit, hemiplegia or paraplegia, and were not operated on. Therefore we ended up operating upon 12 patients. In 2 of these, the dissection began posteriorly immediately distal to the subclavian artery and came around the arch; it resulted in aortic incompetence. This unfortunate situation was discovered at operation, and in neither of these patients were we successful. Of the 10 patients who actually had anterior dissection and were operated on, there are 9 longterm survivors. Four of these patients had primary repair; the valve was not replaced, nor was any kind of prosthetic material used to reconstruct the disDR. HASSAN NAJAFI (Chicago,
sected ascending aorta. In 5 patients a tube graft was used to restore continuity of the ascending aorta. (Houston, Tx):Since the early days of open-heart surgery, acute dissecting aneurysm of the ascending aorta has been a technical challenge to surgeons. Indeed, a decade ago some surgeons became so discouraged by their poor results that they recommended the lesion be treated medically. We have consistently shared the opinion of the authors that this lesion basically is a surgical problem. The experience at the Texas Heart Institute with surgical treatment of acute and chronic aneurysms of the ascending aorta caused by cystic medial necrosis includes 263 cases with an overall surgical mortality of 17%. Acute dissection was present in 54 patients whose ages ranged between 21 and 74 years. Operative mortality in this group was 18%. In only 3 patients was end-to-end anastomosis performed, and the remainder received a Dacron tube graft (48 patients) or patch graft (3 patients). The aortic valve was replaced in 19 patients, resuspended in 9, and left intact in 24. Attempts to resuspend the valve leaflets have not been uniformly successful, although we have not used the exact technique described by the authors. Some of our patients have undergone subsequent replacement of the aortic valve, and a few were handicapped by aortic regurgitation. I believe repair of the aortic annulus should be used only in selected instances in which dissection of the commissural attachment is minimal and no dilatation of the annulus is present. Aortic valve replacement with excision of the ascending aorta and graft replacement is our procedure of choice in most patients with this lesion. I would like to know from the authors if these were consecutive patients seen with an acute aneurysm complicated by aortic regurgitation or if they were selected patients in their series. According to the authors, none of the patients had major aortic regurgitation after operation. I would like to hear their definition of this term. DR. DENTON A. COOLEY
I thank the discussants for an excellent discussion and for their very kind remarks. This operation, although we call it new, was actually envisioned by Dr. Aldo Castaneda several years before we used it for the first time. Dr. Castaneda, to my knowledge, was the first person to suggest placing cloth in the area formerly occupied by the media of the aorta. However, he also suggested that the aortic valve be replaced. We are the first, I think, to combine prosthetic media replacement with resuspension of the valve, using the prosthetic media to bolster the aortic root against dilatation. We agree with Dr. Wheat that control of blood pressure and reduction of systolic stress on the aortic
DR. COLLINS:
467
Koster et al: Operation for Acute Aortic Dissection Producing Aortic Insufficiency
wall are important in the continuing management of these patients. Relative to Dr. Ablaza’s interesting description of his operative technique, I would point out that in my opinion, such an operation is overdue. I think his operation will work. I am somewhat surprised that he has not made use of the Hufnagel multiple-point fixation ring rather than a simple suture for graft fixation. Dr. Ablaza is to be congratulated for actually doing an operation which others perhaps have simply envisioned. Dr. Najafi’s series is one that is familiar to me, and his results are excellent. In answer to his question whether some of our patients died prior to operation, the answer is yes. I can recall only 2 patients in whom
no attempt was made to operate, but we have had several who were probably not capable of recovery because of profound shock before operation. In answer to Dr. Cooley’s question, this is not a consecutive series. There were 3 patients with acute dissection in a normal-sized aortic root in whom we replaced the valve because we were unable to achieve satisfactory repair. In most cases, when the aortic root is not chronically dilated, this operation can be utilized. If the aortic root is dilated, the valve should be replaced and a cloth graft reconstruction used. The patients with mild aortic insufficiency have a soft murmur but no cardiac enlargement, widened pulse pressure, or other sign of hemodynamic compromise.
and Peter Bent Brigham Hospital, Boston, MA. Presented at the Fourteenth Annual Meeting of The Society of Thoracic Surgeons, Jan 23-25, 1978, Orlando FL. Address reprint requests to Dr. Collins, Department of Surgery, Peter Bent Brigham Hospital, Boston MA 02115.
Operative Technique Median sternotomy is employed. Cardiopulmonary bypass is instituted with femoral artery
461 0003-4975/78/0026-0511$01.25@ 1978 by J. Kenneth Koster, Jr.
462 The Annals of Thoracic Surgery Vol 26 No 5 November 1978
&~ AORTA \\
INTIMAL 01si T A l
ME
PROXIMAL F E L T MEDIA
Fig 2 . Lining the proximal and distal dissection zuitlz the prosthetic media. (RCA = right coronary artery.) Fig I . Dissected aorta showing bulging adventitia and normal-caliber intima. (RCA = right coronary artery.)
trimmed so that the edges of the two layers match for oversewing. Since the dissection perfusion and venous drainage through a single usually proceeds along the greater curvature, right atrial cannula. In the course of systemic some portion of the posterior wall is often intact cooling to 28"C, the heart is electrically fibril- and need not be resected. The aortic valve is inspected. If the incompelated and the left ventricle apically vented. The aorta is cross-clamped immediately proximal to tence appears to be the result of commissural the origin of the innominate artery. Myocardial detachment and the valve leaflets are not intrinprotection during the ischemic period is pro- sically deformed and can be made to coapt vided by a continuous infusion of iced Ringer's normally, valve resuspension is undertaken solution into the pericardium and intermittent after the aortic root has been reconstructed with prosthetic media. This is accomplished by linendocardia1 lavage. The bulging adventitia is incised transversely ing the space between the intima and advenapproximately 3 cm superior to the origin of the titia with a tailored sheet of Teflon felt so that right coronary artery. After the adventitia has the cloth extends into the most proximal been opened, it will usually be observed that reaches of the dissection (Fig 2). If necessary, the dissection has separated the intima from the the Teflon cloth is cut in a bat-wing configuradistended adventitia anteriorly and that the tion to allow it to extend around and deep to the tubular intima is of relatively normal caliber right coronary artery so as to line the aortic sinus. The cloth is then trimmed to conform (Fig 1). The intima is incised and resected only to the with the cut intimal and adventitial edges, and extent required to include the origin of the the three layers are oversewn together (Fig 3). The aortic valve is then resuspended with dissection, if possible, and the adventitia is
463
Koster et al: Operation for Acute Aortic Dissection Producing Aortic Insufficiency
FELT
Fig 4 . Restoration of aortic continuity with either primary anastomosis (B) or an anterior woven gusset (C). (RCA = right coronary artery.) Fig 3. Oversewing of the adventitia-media-intima and resuspension of the aortic valve.
felt-buttressed sutures placed at the commissures. These sutures are brought out through all layers of the reconstructed aortic wall and tied over a second felt pledget. A second piece of Teflon cloth is used to line the distal dissection, no farther than the crossclamp if the dissection extends into the distal .OTH aorta. The cut edge of the intima-cloth-adventitia is then oversewn as was done for the proximal edge. If the proximal and distal edges of oversewn aorta can be brought together easily, direct suture anastomosis is accomplished (Fig 4A, B). If tension would result from direct anastomosis, a wedge-shaped woven graft may be interposed as an anterolateral gusset (Fig 4C). In the few instances in which resection of the posterior wall of the aorta is required, a woven tube graft is inserted with circumferential anastomoses Fig 5. Restoration of aortic continuity with interposirtion of a tubular woven graft. (Fig 5).
464
The Annals of Thoracic Surgery Vol 26 No 5 November 1978
eration of the origin of the false lumen, restoration of aortic continuity, and reinstitution of valve competence. Various surgical techniques have been employed to achieve these goals, with a current trend favoring graft replacement of the ascending aorta over reconstructive approaches [3, 51. The reconstruction technique we have utilized has proved satisfactory in late follow-up and offers several technical advantages [2]. First, it is simple to perform and the operative time is brief. The entire repair was accomplished in the patients reported here with a mean aortic clamping time of 70 minutes. Second, limiting resection of the aortic wall to the region of the intimal tear usually allows aortic continuity to be restored without the interposition of a tubular graft. This avoids circumferential anastomoses and potentially troublesome posterior suture line bleeding. Furthermore, lining the proximal depths of the dissected aortic root with a tailored sheet of Teflon felt provides a nondistensible buttress against late dilatation of the proximal aorta and annular region, while still allowing preservation of the native aortic valve. When graft replacement of the aorta is employed, the supracoronary anastomosis leaves the area immediately above the valve unsupported, with the potential for late dilatation [6]. Provision of support to this area with a graft requires proximal anchoring of a composite graft and valve prosthesis to the aortic "annulus," which involves sacrifice of the native valve and reimplantation of the coronary artery into the graft. Finally, this reconstructive approach makes consistent preservation of the native aortic valve possible even when the dissection has extended into the sinuses of Valsalva, producing extensive commissural detachment and severe leaflet prolapse. An otherwise normal aortic valve is too good to waste, especially when one Comment considers the spectrum of potential problems The therapy for acute ascending aortic dis- encountered with most prosthetic valves in sections producing aortic insufficiency has terms of wear, thromboembolism, and longevolved so that there is now little argument that term anticoagulation. In a majority of acute disimmediate surgical treatment provides the most sections, aortic annular ectasia is minimal when satisfactory results [l, 41. the valve leaflets are normal, which makes reOperation in this setting is directed at oblit- suspension simple and practical. The absence
Results In all patients, the aortic base was reconstructed and the aortic valve resuspended using the technique described. Aortic continuity was reestablished with the interposition of a woven tubular graft in 2 patients. An anterior noncircumferential woven graft gusset was used in 3. In the 3 remaining patients, primary anastomosis of the reconstructed aortic wall without grafting was utilized. Mean aortic cross-clamp time was 70 minutes (range, 42 to 89 minutes). Two patients underwent reoperation for continued postoperative bleeding. In 1, no specific source was found, while in the other, one suture was required for a small bleeding point on the right ventricular wall. Postoperatively, 2 patients developed atrial fibrillation that necessitated additional digitalis, and 1 developed atrial flutter for which electrical cardioversion was required. The mean postoperative hospital stay, excluding that of the patient who sustained a preoperative stroke and required extended physical therapy, was 15 days (range, 10 to 26). There were no operative deaths. Mean follow-up has been 60 months (range, 25 to 82 months). There has been 1late death, at 48 months, from a cerebral hemorrhage that was confirmed postmortem. In this case, postmortem examination of the reconstructed aorta showed no dilatation of the aortic root, and the aortic valve was competent. Three patients have undergone repeat aortography, which has shown no aortic root dilatation or valve insufficiency. One has a large, asymptomatic dissection of the transverse and descending aorta. All 7 patients who are alive are in New York Heart Association Functional Class I. Two have faint murmurs of aortic insufficiency, but all have normal-sized hearts, and no patient has developed signs of aortic root dilatation or progressive aortic insufficiency.
465 Koster et al: Operation for Acute Aortic Dissection Producing Aortic Insufficiency
of major insufficiency on late follow-up in this series suggests that such repairs are also durable. Reconstruction of the aortic root with aortic valve resuspension h a s been feasible in a majority (8 of 11) of the acute ascending aortic dissections with associated aortic valve insufficiency treated during the period included in this report. The operation h a s been quite satisfactory i n terms of technical simplicity, low early morbidity, lack of operative mortality, a n d absence of late deterioration.
References 1. Appelbaum A, Karp RB, Kirklin JW: Ascending versus descending aortic dissections. Ann Surg 183:296, 1976 2. Collins JJ, Cohn LH: Reconstruction of the aortic valve: correcting valve incompetence due to acute dissecting aneurysm. Arch Surg 106:35, 1973 3. Daily PO, Trueblood HW, Stinson EB, et al: Management of acute aortic dissections. Ann Thorac Surg 10237, 1970 4. Dalen JA, Alpert JS, Cohn LH, et al: Dissection of the thoracic aorta: medical or surgical therapy. Am J Cardiol 34303, 1974 5. Kidd JN, Reul GJ, Cooley DA, et al: Surgical treatment of aneurysms of the ascending aorta. Circulation 54:Suppl 3:118, 1976 6. Kouchoukos NT, Karp RB, Lell WA: Replacement of the ascending aorta and aortic valve with a composite graft. Results in 25 patients. Ann Thorac Surg 24:140, 1977
Discussion DR. MYRON w. WHEAT (St. Petersburg, FL): The authors are to be complimented for providing a new and imaginative approach to a very difficult and extremely lethal problem: the patient with acute aortic dissection with aortic valve insufficiency. There certainly should be no question that the proper treatment for this lesion is surgical repair. As is apparent in their patients, the lesion tends to occur in younger persons in the spectrum of acute dissecting aneurysms, the mean age in this group being 50 years. The approach described is simple and direct-so simple that it amazes me none of us has used it before. The basic problem is the weakened and dissected media. What the authors have done is to reinforce or replace that media with a felt one, and the results from two to almost seven years after repair are good. There were no operative deaths, and only 2 patients had to be reoperated upon for bleeding. This approach (1)preserves the usually normal aortic valve, which is particularly important in the younger patient; (2) preserves the normal intimal lin-
ing in most patients and decreases the size of the graft replacement in the others; and (3), perhaps most important, by virtue of the felt media, appears to prevent the late development of an aneurysm of the aortic root, with its more difficult surgical problems. I hope the authors will keep us informed about further follow-up on these patients and that other cardiac surgeons will utilize this approach. If, indeed, this repair holds up and further deterioration of the aortic root, aortic valve, and descending aorta is prevented or even greatly delayed, this operation will have been a truly major contribution. I believe it is. Finally, I would like to remind you that medial degeneration is a systemic problem. These patients still need to have their blood pressure and cardiac impulse controlled with drugs throughout their life span. In 1 of the cases reported in this series, even though the aortic root was repaired, the patient has current dissections of the transverse and descending thoracic aorta. (Philadelphia, PA): I enjoyed Dr. Koster’s presentation very much and agree with him that restoring aortic valve competence with the use of a nondistensible and nonyielding prosthetic material is an excellent technique. His results have proved this. I wish to describe what I believe is a much simpler and safer operation. At the Medical College of Pennsylvania Hospital in Philadelphia, we use a ringed intraluminal shunt in the repair of dissecting aneurysms of the descending and ascending thoracic aorta. We have devised an improvisational model consisting of a woven tubular Dacron graft that is inserted through the ring, folded over, and sutured back on the graft. A model has also been made for US by a commercial firm for investigational use. The technique consists of doing a very limited dissection in the area where the ligatures are passed proximal and distal to the aneurysm. Under total cardiopulmonary bypass, the aorta is cross-clamped proximal to the innominate artery and the whole prosthesis is inserted. It is anchored at both ends with mattress sutures buttressed outside the aortic wall with Dacron felt, after which the aorta is circumferentially ligated against the grooves of the ring. Then the aortotomy is tightly closed. We have performed this operation in a 69-year-old normotensive man with acute dissection of the ascending aorta and associated aortic regurgitation. At operation we found a transverse intimal tear, circumferential dissection of the ascending aorta, and a flail aortic valve. The graft was inserted and ligated, and the aorta was ligated against the groove of the rings proximal and distal to the dissection. The aortotomy was then tightly closed. One year later the rings were in place and the valve was competent. DR. SARIEL G . ABLAZA
466 The Annals of Thoracic Surgery Vol 26 No 5 November 1978
You are probably wondering-as we did before we embarked on this operation-what happens to the aorta in the area of the circumferential ligature, the idea being that there might be pressure necrosis. We used this technique in 1976 in a patient with a chronic arteriosclerotic aneurysm of the descending aorta extending from just beyond the left subclavian artery down to the diaphragm. There has been no necrosis at the ligature lines. The secret of the technique is that the surgical dissection is very limited. You don't do anything with the intercostal arteries, the mediastinal pleura, or the adventitia. All you do is pass the ligatures around the normal aorta proximal and distal to the aneurysm, cross-clamp the aorta, do a longitudinal aortotomy, and insert the intraluminal shunt and ligate it.
IL): Six years ago I had the privilege of presenting before this society a nearly identical series of patients who were operated on for acute aortic insufficiency secondary to aortic dissection, with the principal objective of emphasizing that aortic valve replacement is not necessary under these circumstances. The excellent results reported by the authors and the sad truth that there are still many who excise these normal valves and replace them with prostheses stimulated me to take a second look at our experience and share it with you this morning. During the past ten years, we have actively participated in the care of 16 patients with acute aortic dissection causing aortic incompetence. Incidentally, I wish to ask the authors whether they had other patients with aortic insufficiency secondary to aortic dissection during the same period who were not operated on. I ask this because occasionally, refraining from operating may actually constitute a partial surgical failure or a partial surgical success, depending on the patient's course. This was illustrated to us by the fact that of these 16 patients, 2 died before operation, 1 during radiological studies and the second before a repeat aortogram could be obtained after the first study failed to show the origin of the dissection; this second patient died of pericardial tamponade after his aorta ruptured. Two further patients had massive neurological deficit, hemiplegia or paraplegia, and were not operated on. Therefore we ended up operating upon 12 patients. In 2 of these, the dissection began posteriorly immediately distal to the subclavian artery and came around the arch; it resulted in aortic incompetence. This unfortunate situation was discovered at operation, and in neither of these patients were we successful. Of the 10 patients who actually had anterior dissection and were operated on, there are 9 longterm survivors. Four of these patients had primary repair; the valve was not replaced, nor was any kind of prosthetic material used to reconstruct the disDR. HASSAN NAJAFI (Chicago,
sected ascending aorta. In 5 patients a tube graft was used to restore continuity of the ascending aorta. (Houston, Tx):Since the early days of open-heart surgery, acute dissecting aneurysm of the ascending aorta has been a technical challenge to surgeons. Indeed, a decade ago some surgeons became so discouraged by their poor results that they recommended the lesion be treated medically. We have consistently shared the opinion of the authors that this lesion basically is a surgical problem. The experience at the Texas Heart Institute with surgical treatment of acute and chronic aneurysms of the ascending aorta caused by cystic medial necrosis includes 263 cases with an overall surgical mortality of 17%. Acute dissection was present in 54 patients whose ages ranged between 21 and 74 years. Operative mortality in this group was 18%. In only 3 patients was end-to-end anastomosis performed, and the remainder received a Dacron tube graft (48 patients) or patch graft (3 patients). The aortic valve was replaced in 19 patients, resuspended in 9, and left intact in 24. Attempts to resuspend the valve leaflets have not been uniformly successful, although we have not used the exact technique described by the authors. Some of our patients have undergone subsequent replacement of the aortic valve, and a few were handicapped by aortic regurgitation. I believe repair of the aortic annulus should be used only in selected instances in which dissection of the commissural attachment is minimal and no dilatation of the annulus is present. Aortic valve replacement with excision of the ascending aorta and graft replacement is our procedure of choice in most patients with this lesion. I would like to know from the authors if these were consecutive patients seen with an acute aneurysm complicated by aortic regurgitation or if they were selected patients in their series. According to the authors, none of the patients had major aortic regurgitation after operation. I would like to hear their definition of this term. DR. DENTON A. COOLEY
I thank the discussants for an excellent discussion and for their very kind remarks. This operation, although we call it new, was actually envisioned by Dr. Aldo Castaneda several years before we used it for the first time. Dr. Castaneda, to my knowledge, was the first person to suggest placing cloth in the area formerly occupied by the media of the aorta. However, he also suggested that the aortic valve be replaced. We are the first, I think, to combine prosthetic media replacement with resuspension of the valve, using the prosthetic media to bolster the aortic root against dilatation. We agree with Dr. Wheat that control of blood pressure and reduction of systolic stress on the aortic
DR. COLLINS:
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Koster et al: Operation for Acute Aortic Dissection Producing Aortic Insufficiency
wall are important in the continuing management of these patients. Relative to Dr. Ablaza’s interesting description of his operative technique, I would point out that in my opinion, such an operation is overdue. I think his operation will work. I am somewhat surprised that he has not made use of the Hufnagel multiple-point fixation ring rather than a simple suture for graft fixation. Dr. Ablaza is to be congratulated for actually doing an operation which others perhaps have simply envisioned. Dr. Najafi’s series is one that is familiar to me, and his results are excellent. In answer to his question whether some of our patients died prior to operation, the answer is yes. I can recall only 2 patients in whom
no attempt was made to operate, but we have had several who were probably not capable of recovery because of profound shock before operation. In answer to Dr. Cooley’s question, this is not a consecutive series. There were 3 patients with acute dissection in a normal-sized aortic root in whom we replaced the valve because we were unable to achieve satisfactory repair. In most cases, when the aortic root is not chronically dilated, this operation can be utilized. If the aortic root is dilated, the valve should be replaced and a cloth graft reconstruction used. The patients with mild aortic insufficiency have a soft murmur but no cardiac enlargement, widened pulse pressure, or other sign of hemodynamic compromise.