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aortic annular dilatation, graft size should be decided very carefully. There are several methods to measure the graft size
in the presence of annular dilatation. The main idea is to reduce and reshape the native aortic annulus and at the same time
to create neo-pseudosinuses. The radius of the proximal graft should be approximately two-thirds of the average height of
the cusps while adding approximately 6 mm because the graft is placed on the outside of the aortic annulus: dg [=2 × 2/3
hc (=rg)] + 6 mm [63]. The similar, but simpler calculation, is offered because the height of the cusps is fixed for patient: dg
(=2hc) + 1–2 mm [64]. A Hegar dilator can also be used to measure the annulus and it is available as a 19-mm dilator for
body surface area of about 1.5 m2, 21 mm for 2 m2 [2], and 23 mm for 2.5 m2 [65]. Another option is to use seizers of stentless bioprostheses as Hegar dilator to measure the true diameter of the aortic annulus and use the same graft size [66]. We
prefer to use intra- or supraannular seizers for stented bioprosthetic valves for the measurement of the proximal graft size
[67]. The main point of these approaches is to get the true native aortic annular outside diameter and to add 1–2 mm to find
the appropriate graft size (one bigger size than true annular outside diameter). If an intra-annular seizer is used, the seizer
is pushed into the aortic annulus tightly. The appropriate graft size must be its outside diameter of the seizer + 1–2 mm,
whereas the outside diameter of this seizer is equal to “the number of seizer (=inner diameter) + 4 mm”: dg = (the number
of the intra-annular seizer) + 5–6 mm. If a supra-annular seizer is used, the seizer is placed onto the aortic annulus and the
base of three trigons should be visible through the supra-annular seizer. The appropriate graft size must be “the number of
seizer (=inner diameter) + 1–2 mm”: dg = (the number of the supra-annular seizer) + 1–2 mm. When Valsalva graft is used
for reimplantation technique, the graft size must be equal to the height of the NCC-LCC commissure, which is equal to the
external diameter of the STJ [68].
After sizing the appropriate graft, one of three suturing options can be used to place multiple sutures below the nadir
of the aortic valve without causing any distortion on the valve: to support all sutures with pledgets, to prefer some sutures
with and without pledgets sequentially, or to use pledgeted sutures only on the muscular portion of the aortic annulus and
simple sutures on the fibrous part. All 2-0 polyester mattress sutures are passed from inside of the left ventricle to outside
just below the aortic valve and then through the base of the graft and tied. This helps in achieving annular reduction in
patients with annular dilatation.
The other important step is creating the correct position and height of commissures within the graft according to aortic
annulus and native commissures, which is the main mechanism to prevent leaflet prolapses or torsion and to secure competence of the aortic valve. After three placement sutures are tied, the aortic wall in each sinus is sutured continuously with
three separate 5-0 polypropylene sutures. Each suture is started at the middle of each sinus and continued upward bilaterally
and tied at the tabs of three commissures. The next step is to control the competence of the aortic valve, and if there is any
prolapse of one or two leaflets, aortic valve repair techniques can be performed. The coronary artery reimplantations are
performed in the same manner as described for the total ARR.
The second smaller graft is anastomosed to the first graft with a continuous 4-0 polypropylene suture. The main goal of
this approach is to build a neo-STJ that manages aortic valve coaptation during diastole. The diameter difference between
both grafts helps to achieve this goal and the suturing technique realizes the crown-shaped aortic annulus at the tab, where
the neo-STJ is built. The key point during the anastomosis of both grafts together is to take the equal distance from both
grafts for each bite at the commissural levels and longer from the proximal graft between commissures. This maneuver
narrows intercommissural distance, which has been created by the larger proximal graft, to create an equal ring as reduced
annular ring. Distal anastomosis between the second graft and distal ascending aorta is performed with a continuous 4-0
polypropylene suture (Fig. 26.8).
Subtotal Aortic Root Replacement Procedures
These techniques are subtypes of the standard remodeling technique and popularized to avoid either a total composite or
aortic valve–sparing root replacement procedure because these techniques reduce operative complexity. The aortic root
seems more or less intact and may distort aortic valve functions. Subtotal aortic root remodeling techniques can be preferred if all three sinuses are not involved without an aortic annular dilatation. Significant aortic annular dilatation requiring annular fixation is a contraindication for these approaches. Another indication is supravalvular stenosis, which can be
congenital or acquired, and the repair option of this pathology depends on its involvement: single [69], double [70], or triple
[71] sinus replacement.
One-Sinus Replacement Technique
Isolated sinus involvement usually affects NCS, especially in the bicuspid aortic valve. Aortic root enlargement is not diffuse, and both coronary sinuses seem normal. The other rare pathology is restricted aortic dissection with/without involving
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FIGURE 26.8 David V reimplantation technique.
the ascending aorta, and chronic healing surrounds the dissection tear, but the dissection can spread into the coronary
artery if LCS or RCS is affected. The most commonly observed pathology is involvement of one or more sinuses from the
ascending aorta aneurysm or dissection, especially NCS. The affected sinus can be replaced with a patch or with prosthetic
tubular graft having a tongue-shape extension (Fig. 26.9A). If ascending aorta replacement is not necessary, a Dacron patch
is tailored as a new sinus and sutured to the annulus of the resected sinus of Valsalva [72]. The shape of the patch should be
appropriate to the sinus, but the width should be <10 mm more than the diameter between two commissures and the height
<10 mm more than the diameter form the annulus to the STJ. If ascending aorta replacement is necessary, a neo-sinus can be
created by tailoring the graft as having a tongue that is sutured to the resected annulus. The height and width of the tongue
should be 3–4 mm more than the diameter of the graft.
FIGURE 26.9 Isolated sinus replacement techniques: (A) one sinus; (B) double sinuses.
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Two-Sinus Replacement Technique
Two-sinus replacement is not a preferred option, but it must be chosen to avoid total ARR when the third sinus of Valsalva
is healthy. Subtotal root remodeling on the two sinuses can be chosen for acute aortic dissection without left coronary ostial
involvement if aortic root dilatation is not greater than 35 mm, which can prevent the reimplantation of the left coronary
ostium. In contrast, if both coronary sinuses are involved or the presence of aortic annular dilatation requires aortic annular
stabilization, any total ARR is more meaningful. Two-sinus aortic root remodeling is carried out using a tube graft trimmed
as a twin-“U” shape (Fig. 26.9B). A tubular graft is prepared with two tongues, and the operation is carried out with the
similar technique described above. Two-sinus repair with Y-shaped patch is more popular in surgical repair of supravalvular
aortic stenosis, where a pantaloon patch is used to replace NCC and RCC [73].
Sinus of Valsalva Aneurysm Repair Techniques
The RCS is most frequently affected, followed by the NCS. The aneurysm can rupture into any of low-pressure cardiac
chambers, especially into the right-sided ones, to form an aorticocardiac fistula. Surgical closure is the gold standard treatment, but percutaneous closure can be chosen in very sick patients [74]. After standard initial steps, aortotomy is performed
to check pathologies of the aneurysm, the aortic valve, and the associated cardiac anomaly. Different surgical approaches
can be used: transaortic, double-chamber, or involved chamber. Transaortic approach is used for isolated SVA with/without
aortic regurgitation, especially in unruptured cases. The double-chamber approach is chosen mostly in ruptured aneurysms
because of closing defect from both sides or presence of any intracardiac pathology [75]. The last approach is used very
seldom because of possible bacterial colonization or thrombus formation inside the aneurysm or recurrent fistula formation
or rupture of aneurysmal sac. The goals of repair are removing the aneurysmal sac, closing the primary defect with a patch
or with valve replacement, and repairing any associated defects [18]. Primary closure with/without pledgeted mattress
sutures can be sufficient and routinely used for small cases, but it has potential disadvantages such as deformation of the
aortic sinus resulting aortic incompetence or suture line stress causing recurrence of fistula formation. Patch (pericardial or
synthetic) closure at the aortic end is the most preferred technique, which minimizes aortic leaflet distortion, with/without
a concomitant surgery for aortic valve repair. If aortic regurgitation is severe and not repairable, AVR is the restorative
approach.
Extensive Aortic Root Replacement Technique
Aortic root abscess continues to challenge cardiovascular surgeons because uncontrolled aortic root abscess can manifest
itself as a burrowing pathology destroying the whole aortic annulus and extending proximally into the LVOT, a cardiac
fistula or a rupture into a cardiac chamber, a pseudoaneurysm, or an arrhythmia leading to hemodynamic instability. Early
and extensive surgical intervention of aortic root abscesses is essential, and the complexity of the surgical treatment ranges
from partial resection of the aortic annulus and surrounding tissues to radical removal of the base of the heart—including
the entire aortic root, the intervalvular fibrous body, and part of the interventricular septum. After resection of the abscess
with all infected and necrotic surrounding tissue, extraction of prosthetic materials, and debridement of abscess cavity with
the extensive annular destruction, the LVOT can be reconstructed with standard (using biologic conduits: freestyle valve
[76], allograft [77], or xenograft [78]) or extensive ARR. Several techniques are also described to reconstruct the mitro-
aortic continuity during double-valve replacement [79,80].
Extensive ARR technique is the only option to rebuild the LVOT because of the reconstruction of the neo-aortoventricular continuity. The flanged technique with the elongated tubular graft below the prosthetic valve is the best option
for solving this life-threatening sequel and reconstructing the aortic root (Fig. 26.10) [19]. A larger (3 cm) segment of
the proximal end of the flanged conduit is implanted in a circular manner with 2-0 interrupted sutures supported by large
Teflon pledgets placed subannularly on healthy tissue at the native LVOT (on the membranous septum at the right fibrous
trigone, on the mitral annulus, or on the base of the anterior leaflet, deep on the myocardium). Both ends of the sutures
are passed through the proximal free end of the flanged portion of the conduit to use that part as a strip between knots
and the myocardial aortic wall. The coronary button anastomoses and distal anastomosis are carried out in the same
manner as described above. If any iatrogenic defect at the LVOT (mitral anterior leaflet or ventricular septal defect) is
observed, it can be closed with a tonguelike elongation of this flanged graft. In a similar alternative method, the tubular
graft is first implanted into the LVOT, and the prosthetic valve is subsequently implanted into the graft at the level of the
native annulus [81].
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FIGURE 26.10 Extensive aortic root replacement technique.
OUTCOMES
Bentall Procedures
It has been almost 50 years since the initial report of Bentall and DeBono, and the current operative survival for ARR is
excellent compared with initial reports. In a metaanalysis, a total of 46 studies were reviewed with a total number of 7629
patients operated between 1968 and 2012 with 49,175 patient-years of follow-up [82]. The most observed indications were
connective tissue disease (22.6%), bicuspid aortic valve (25%), acute type A dissection (15.3%), and reoperation (16.2%).
A mechanical (93.2%) or biologic (6.8%) valve was used to perform the composite graft. Early mortality was 5.6% and
the main risk factors were low cardiac output, perioperative bleeding, multiorgan failure, and cardiac arrhythmias. Late
mortality was 12.3% during the mean 6.4-year follow-up, and the established risk factors were low cardiac output, distal
aortic dissection or rupture, hemorrhage, stroke, and endocarditis. Important prosthesis-related complications were root
reoperation (2.2%), valve reoperation (1.2%), thromboembolism (4%), hemorrhage (2.4%), and endocarditis (1.7%) during
the postoperative period. Using bioprostheses to build composite graft for Bentall procedures cannot change early and late
morbidity and mortality [83] and also postoperative quality of life [40]. Despite the excellent durability of prosthetic valves,
thromboembolic and bleeding complications cannot be eliminated totally [84]. Because endocarditis and anticoagulationrelated complications following prosthetic Bentall procedures are still a major problem, xeno- or allografts can be used for
biologic Bentall with better long-term survival and freedom from recurrent infective complications [85].
Cabrol or modifications can be performed with similar results as modified Bentall procedures. The early mortality rate
ranges between 2.8% and 8.5%, whereas late mortality rate can reach 20% [45,86,87]. The occurrence of interposition graft
stenosis, thrombosis, and occlusion requiring reoperation is one of the reasons for the Cabrol technique to be sidelined from
routine use and reserved only for the most complex cases of aortic replacement, often redo-procedures with displaced and
calcified coronary ostia.
The flanged technique is an attractive modification of the Bentall procedure and has a wide range of applications during ARR with excellent early and late outcomes [49,88,89]. The overall 30-day mortality ranges between 4.2% and 11.8%
depending on emergency and severity of pathologies, but mortality in elective procedures is comparable with the standard
button Bentall technique. Late mortality ranges between 1.4% and 16.5%. Freedom from late reintervention for the composite graft is 100% at 15 years. Pseudoaneurysm (0%), thromboembolic complications (0%), or prosthetic valve endocarditis (1.4%) are very low compared with the modified Bentall procedure.
Pseudoaneurysm formation after an ARR procedure is a rare complication (<1%), and it can occur almost at every
anastomosis and structure around the neo-aortic root such as aorticomitral curtain [90], LVOT [91], aortic annulus [92],
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ascending aorta and mostly from the coronary buttons [93], or from the biologic composite graft [94]. Early repair is essential after diagnosis. Although surgical repair or re-replacement is necessary, some endovascular treatment options have been
reported [95].
Remodeling or Reimplantation
In a metaanalysis, a total of 31 studies were reviewed with a total number of 4777 patients operated between 1988 and
2012 (reimplantation 72%, remodeling 22%, and other 1%) with 21,716 patient-years of follow-up [96]. The most observed
indications were connective tissue disease (24%), bicuspid aortic valve (14%), acute type A dissection (10.5%), and reoperation (5%). The aneurysm affected the aortic valve and caused aortic regurgitation in half of the patients (46%). During
surgery, one-third of the patients required simultaneous aortic cusp repair. Early mortality was 2.2% and late mortality 5.6%
during the mean 4.5-year follow-up. Important native valve-related complications after primary surgery were aortic valve
reintervention (4.9%), thromboembolism (0.9%), and endocarditis (0.6%) during the postoperative period. Major adverse
valve-related events were low (1.66% patient-years). There was a trend toward higher reoperation hazard for patients with
preoperative severe aortic regurgitation, but bicuspid structure was not a predictive factor. This metaanalysis did not reveal
any clinical advantages of either technique over the other (survival and reintervention). Remodeling and reimplantation
techniques have comparable survival and valve durability; therefore, when annulus dilatation is identified, the valve-sparing
root replacement should be supported with either proximal sutures in the reimplantation technique or an annuloplasty ring
in the remodeling technique. In our series with 43 patients operated on between 2009 and 2015, reimplantation procedure
provided excellent midterm effectiveness with very low risk of late events after discharge from the hospital, and 5-year
freedom from valve-related reoperation rate was very satisfactory (100%) [97].
Extensive Aortic Root Enlargement
A comparison of different surgical techniques shows no significant differences in early and late outcomes, whereas early
mortality rate is high (22%–25%), 5-year overall survival ranges between 50% and 59%, and freedom from endocarditis
ranges between 80% and 82% [19,81,98,99]. Freestyle xenografts can be used for extensive ARR because of their ease
and availability. Early mortality rate is between 11% and 19%, and late mortality ranges between 14% and 25% [78,100].
Freedom from valve-related mortality over 10 years is 95%, and freedom from reoperation for xenograft deterioration at
10 years is 92% [101]. Cryopreserved or antibiotic-sterilized allograft has lower early mortality rate (10%), but freedom
from endocarditis is 85% and valve-related reoperation is 75% at 15 years. These results are inferior to xenografts and
mechanical valves [102]. Extensive ARR with the extended flanged technique is a serious alternative for aortic root reconstruction with comparable and sometimes better results. Early (14.3% vs. 25%) and late (0% vs. 33.3%) mortality rates are
lower and freedom from any recurrence of infection (0% vs. 13.3%) or valve-related reoperation (0% vs. 13.3%) is higher
in extensive ARR group compared with AVR group during 15-year follow-up [19].
FUTURE
ARR is a procedure requiring an experienced surgeon, as it is complicated by conduits, surgical techniques, massive exten-
sion of the destructive pathology, and functional structure of the aortic valve. The first goal must be to spare the aortic valve
for freedom from prosthetic valve–related complications. With new technologies such as three-dimensional printing, case
special pathologies can be documented and the specific conduit for each individual can be prepared. Newly developed
prosthetic conduits with biologic structure, which will have very long-term durability, will prevent reoperations caused by
bioprosthetic degeneration or recurrent endocarditis.
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Chapter 27
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Current Status of Open Surgery in Aortic
Arch Surgery
David H. Tian
1
Royal North Shore Hospital, Sydney, NSW, Australia; 2Macquarie University, Sydney, NSW, Australia; 3University of Sydney, Sydney, NSW, Australia
1,2
, Tristan D. Yan
2,3
Chapter Outline
Introduction 307
Brain Protection 307
Deep Hypothermic Circulatory Arrest 307
Antegrade Cerebral Perfusion 308
Retrograde Cerebral Perfusion 309
Brain Monitoring 310
Surgical Considerations 310
Cannulation Site 310
Developments in Management of Type A
Aortic Dissections 310
Future Directions 311
Abbreviations 312
References 312
INTRODUCTION
Aortic surgery has undergone significant changes in the past half-century. Since the early series of aortic arch surgery in
the 1970s, advances in operative techniques, neuroprotection strategies, and surgical devices have renewed the field and
culminated in an armamentarium that makes it possible to safely repair aortic arch pathologies. Whereas mortality from
early cases ranged up to 50% [1], modern elective arch operations carry a mortality rate in the low single digits. In addition
to the natural evolution of cardiac surgery as a whole, the current status of open aortic arch surgery has been broadly driven
by two main domains, which will form the focus of this chapter, brain protection and the growing development of hybrid
procedures.
BRAIN PROTECTION
Despite considerable advances in cardiopulmonary bypass and myocardial protection, much less is known about cerebral
protection and its metabolism. As isolation of the supraaortic vessels is a prerequisite for open arch surgery, effective subjugation of brain perfusion demands is crucial. Complications arising from inadequate cerebral protection remain considerable and often represent the limiting factor for effective outcomes. To obviate these risks, surgeons can reduce metabolic
demands through deep hypothermic circulatory arrest (DHCA) or to separately supplement cerebral metabolites through
either retrograde or antegrade cerebral perfusion (RCP or ACP).
Deep Hypothermic Circulatory Arrest
DHCA has remained the cornerstone of effective brain protection strategy and is one of the most widely practiced
techniques today. Its physiologic rationale rests on the brain’s reduced metabolic demands as the body is cooled to
hypothermic temperatures (Table 27.1), at which point short interruptions of perfusion can be safely tolerated. At
normothermia, acute reductions in blood flow cause rapid functional and cellular biochemical changes that deplete
existing adenosine triphosphate stores, resulting in lactate accumulation through anaerobic glycolysis. Such accumulation induces an increasingly acidic intracellular environment, causing a biochemical cascade that culminates in the
creation of neurotoxins and eventual neuronal death [3]. Clinically, this subtle global perfusion mismatch manifests
as temporary neurologic deficit (TND), with symptoms such as confusion, lethargy, agitation, and/or psychosis. By
New Approaches to Aortic Diseases from Valve to Abdominal Bifurcation. http://dx.doi.org/10.1016/B978-0-12-809979-7.00027-4
Copyright © 2018 Elsevier Inc. All rights reserved.
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