Surgical strategy and clinical outcomes of reoperative aortic root replacement after prior aortic valve replacement_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

DUN Yaojun , SHI Yi , GUO Hongwei , WEI Bo , WEI Yizhen , QIAN Xiangyang ,  SUN Xiaogang , YU Cuntao

Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, 100037, P. R. China;

Corresponding author：

SUN Xiaogang, Email: xiaogangsunl@163.com

Keywords：

Aortic valve replacement; aortic root replacement; aortic dissection; aortic root aneurysm; reoperation

DOI：

10.7507/1007-4848.202101019

Video：

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Objective To summarize the surgical strategy of reoperative aortic root replacement after prior aortic valve replacement (AVR), and analyze the early and mid-term outcomes.Methods From April 2013 to January 2020, 75 patients with prior AVR underwent reoperative aortic root replacement in Fuwai Hospital. There were 54 males and 21 females with a mean age of 56.4±12.7 years. An emergent operation was performed in 14 patients and an elective operation in 61 patients. The indications were aortic root aneurysm in 38 patients, aortic dissection involving aortic root in 30 patients, root false aneurysm in 2 patients, prosthesis valve endocarditis with root abscess in 2 patients, and Behçet's disease with root destruction in 3 patients. The survival and freedom from aortic events during the follow-up were evaluated with the Kaplan-Meier survival curve and the log-rank test.Results The operative procedures included prosthesis-sparing root replacement in 45 patients, Bentall procedure in 26 patients, and Cabrol procedure in 4 patients. Operative mortality was 1.3% (1/75). A composite of adverse events occurred in 5 patients, including operative death (n=1), stroke (n=1), and acute renal injury necessitating hemodialysis (n=3). The follow-up was available for all 74 survivors, with the mean follow-up time of 0.5-92.0 (30.3±25.0) months. Four late deaths occurred during the follow-up. The survival rate at 1 year, 3 years and 6 years was 97.2%, 91.4% and 84.4%, respectively. Aortic events developed in 2 patients. The rate of freedom from aortic events at 1 year, 3 years, and 6 years was 98.7%, 95.0% and 87.7%, respectively. There was no difference in rate of survival or freedom from aortic events between the elective patients and the emergent patients.Conclusion Reoperative aortic root replacement after prior AVR can be performed to treat the root pathologies after AVR, with acceptable early and mid-term outcomes.

Citation： DUN Yaojun, SHI Yi, GUO Hongwei, WEI Bo, WEI Yizhen, QIAN Xiangyang, SUN Xiaogang, YU Cuntao. Surgical strategy and clinical outcomes of reoperative aortic root replacement after prior aortic valve replacement. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2023, 30(1): 113-120. doi: 10.7507/1007-4848.202101019 Copy

1.	Preventza O, Coselli JS, Price MD, et al. Elective primary aortic root replacement with and without hemiarch repair in patients with no previous cardiac surgery. J Thorac Cardiovasc Surg, 2017, 153(6): 1402-1408.
2.	Svensson LG, Kouchoukos NT, Miller DC, et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg, 2008, 85(1 Suppl): S1-S41.
3.	Sandhu HK, Tanaka A, Zaidi ST, et al. Impact of redo sternotomy on proximal aortic repair: Does previous aortic repair affect outcomes? J Thorac Cardiovasc Surg, 2020, 159(5): 1683-1691.
4.	McClure RS, Narayanasamy N, Wiegerinck E, et al. Late outcomes for aortic valve replacement with the Carpentier-Edwards pericardial bioprosthesis: Up to 17-year follow-up in 1, 000 patients. Ann Thorac Surg, 2010, 89(5): 1410-1416.
5.	Glaser N, Jackson V, Holzmann MJ, et al. Prosthetic valve endocarditis after surgical aortic valve replacement. Circulation, 2017, 136(3): 329-331.
6.	Kliger C, Eiros R, Isasti G, et al. Review of surgical prosthetic paravalvular leaks: Diagnosis and catheter-based closure. Eur Heart J, 2013, 34(9): 638-649.
7.	Enseleit F, Grünenfelder J, Braun J, et al. Formation of pseudoaneurysm after aortic valve replacement without previous endocarditis: A case-control study. J Am Soc Echocardiogr, 2010, 23(7): 741-746.
8.	张良, 常谦, 孙晓刚, 等. 主动脉瓣置换术后患者再次主动脉外科干预47例. 中华胸心血管外科杂志, 2013, 29(8): 454-456.
9.	Regeer MV, Versteegh MI, Klautz RJ, et al. Effect of aortic valve replacement on aortic root dilatation rate in patients with bicuspid and tricuspid aortic valves. Ann Thorac Surg, 2016, 102(6): 1981-1987.
10.	Girardi LN, Krieger KH, Mack CA, et al. Reoperations on the ascending aorta and aortic root in patients with previous cardiac surgery. Ann Thorac Surg, 2006, 82(4): 1407-1412.
11.	Schepens MA, Dossche KM, Morshuis WJ. Reoperations on the ascending aorta and aortic root: Pitfalls and results in 134 patients. Ann Thorac Surg, 1999, 68(5): 1676-1680.
12.	Silva J, Maroto LC, Carnero M, et al. Ascending aorta and aortic root reoperations: Are outcomes worse than first time surgery? Ann Thorac Surg, 2010, 90(2): 555-560.
13.	陆杰, 薛清, 唐杨烽, 等. 心脏术后再次行主动脉根部置换的临床分析. 中国胸心血管外科临床杂志, 2021, 28(1): 99-103.
14.	Tsutsumi K, Inoue Y, Hashizume K, et al. Risk factor analysis for acute type A aortic dissection after aortic valve replacement. Gen Thorac Cardiovasc Surg, 2010, 58(12): 601-605.
15.	Itagaki S, Chikwe JP, Chiang YP, et al. Long-term risk for aortic complications after aortic valve replacement in patients with bicuspid aortic valve versus Marfan syndrome. J Am Coll Cardiol, 2015, 65(22): 2363-2369.
16.	Misra S, Koshy T, Patro SN, et al. Large pseudoaneurysm of aortic root after aortic valve replacement for rheumatic heart disease: A rare complication. Ann Card Anaesth, 2009, 12(2): 152-153.
17.	de Almeida Brandão CM, Pomerantzeff PM, Souza LR, et al. Multivariate analysis of risk factors for hospital mortality in valvular reoperations for prosthetic valve dysfunction. Eur J Cardiothorac Surg, 2002, 22(6): 922-926.
18.	Duncan BF, McCarthy PM, Kruse J, et al. Paravalvular regurgitation after conventional aortic and mitral valve replacement: A benchmark for alternative approaches. J Thorac Cardiovasc Surg, 2015, 150(4): 860-868.
19.	García E, Sandoval J, Unzue L, et al. Paravalvular leaks: Mechanisms, diagnosis and management. EuroIntervention, 2012, 8(Suppl Q): Q41-Q52.
20.	张宝仁, 徐志云, 邹良建, 等. 人工心脏瓣膜置换术后63例瓣周漏的外科治疗. 中国胸心血管外科临床杂志, 2007, 14(2): 81-84.
21.	Szeto WY, Bavaria JE, Bowen FW, et al. Reoperative aortic root replacement in patients with previous aortic surgery. Ann Thorac Surg, 2007, 84(5): 1592-1598.
22.	徐志云, 邹良建, 陆方林, 等. 严重主动脉瓣感染性心内膜炎患者主动脉根部置换的方法与疗效. 中国胸心血管外科临床杂志, 2009, 16(2): 82-85.
23.	Luciani N, De Geest R, Anselmi A, et al. Results of reoperation on the aortic root and the ascending aorta. Ann Thorac Surg, 2011, 92(3): 898-903.
24.	Jeong DS, Kim KH, Kim JS, et al. Long-term experience of surgical treatment for aortic regurgitation attributable to Behçet's disease. Ann Thorac Surg, 2009, 87(6): 1775-1782.
25.	Ghang B, Kim JB, Jung SH, et al. Surgical outcomes in Behcet's disease patients with severe aortic regurgitation. Ann Thorac Surg, 2019, 107(4): 1188-1194.
26.	唐杨烽, 徐激斌, 宋智钢, 等. 白塞氏病合并主动脉瓣置换术后瓣周漏的临床分析. 中国胸心血管外科临床杂志, 2010, 17(6): 506-508.
27.	Luciani N, Anselmi A, de Geest R, et al. Facilitated aortic root substitution after aortic valve replacement: Technique and results of the prosthesis-sparing operation. J Thorac Cardiovasc Surg, 2010, 139(3): 785-787.
28.	Esaki J, Leshnower BG, Binongo JN, et al. Reoperative aortic root replacement: Outcome in a contemporary series. J Thorac Cardiovasc Surg, 2017, 154(3): 800-808.
29.	Raanani E, David TE, Dellgren G, et al. Redo aortic root replacement: Experience with 31 patients. Ann Thorac Surg, 2001, 71(5): 1460-1463.
30.	Urbanski PP, Lakew F, Dinstak W, et al. Bentall procedure after previous aortic valve or complete root replacement: Usefulness of self-assembled aortic valve conduit. J Thorac Cardiovasc Surg, 2018, 156(1): 89-95.
31.	Garrido-Olivares L, Maganti M, Armstrong S, et al. Clinical outcomes of aortic root replacement after previous aortic root replacement. J Thorac Cardiovasc Surg, 2013, 146(3): 611-615.
32.	Haverich A, Hagl C. Organ protection during hypothermic circulatory arrest. J Thorac Cardiovasc Surg, 2003, 125(3): 460-462.

1. Preventza O, Coselli JS, Price MD, et al. Elective primary aortic root replacement with and without hemiarch repair in patients with no previous cardiac surgery. J Thorac Cardiovasc Surg, 2017, 153(6): 1402-1408.
2. Svensson LG, Kouchoukos NT, Miller DC, et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg, 2008, 85(1 Suppl): S1-S41.
3. Sandhu HK, Tanaka A, Zaidi ST, et al. Impact of redo sternotomy on proximal aortic repair: Does previous aortic repair affect outcomes? J Thorac Cardiovasc Surg, 2020, 159(5): 1683-1691.
4. McClure RS, Narayanasamy N, Wiegerinck E, et al. Late outcomes for aortic valve replacement with the Carpentier-Edwards pericardial bioprosthesis: Up to 17-year follow-up in 1, 000 patients. Ann Thorac Surg, 2010, 89(5): 1410-1416.
5. Glaser N, Jackson V, Holzmann MJ, et al. Prosthetic valve endocarditis after surgical aortic valve replacement. Circulation, 2017, 136(3): 329-331.
6. Kliger C, Eiros R, Isasti G, et al. Review of surgical prosthetic paravalvular leaks: Diagnosis and catheter-based closure. Eur Heart J, 2013, 34(9): 638-649.
7. Enseleit F, Grünenfelder J, Braun J, et al. Formation of pseudoaneurysm after aortic valve replacement without previous endocarditis: A case-control study. J Am Soc Echocardiogr, 2010, 23(7): 741-746.
8. 张良, 常谦, 孙晓刚, 等. 主动脉瓣置换术后患者再次主动脉外科干预47例. 中华胸心血管外科杂志, 2013, 29(8): 454-456.
9. Regeer MV, Versteegh MI, Klautz RJ, et al. Effect of aortic valve replacement on aortic root dilatation rate in patients with bicuspid and tricuspid aortic valves. Ann Thorac Surg, 2016, 102(6): 1981-1987.
10. Girardi LN, Krieger KH, Mack CA, et al. Reoperations on the ascending aorta and aortic root in patients with previous cardiac surgery. Ann Thorac Surg, 2006, 82(4): 1407-1412.
11. Schepens MA, Dossche KM, Morshuis WJ. Reoperations on the ascending aorta and aortic root: Pitfalls and results in 134 patients. Ann Thorac Surg, 1999, 68(5): 1676-1680.
12. Silva J, Maroto LC, Carnero M, et al. Ascending aorta and aortic root reoperations: Are outcomes worse than first time surgery? Ann Thorac Surg, 2010, 90(2): 555-560.
13. 陆杰, 薛清, 唐杨烽, 等. 心脏术后再次行主动脉根部置换的临床分析. 中国胸心血管外科临床杂志, 2021, 28(1): 99-103.
14. Tsutsumi K, Inoue Y, Hashizume K, et al. Risk factor analysis for acute type A aortic dissection after aortic valve replacement. Gen Thorac Cardiovasc Surg, 2010, 58(12): 601-605.
15. Itagaki S, Chikwe JP, Chiang YP, et al. Long-term risk for aortic complications after aortic valve replacement in patients with bicuspid aortic valve versus Marfan syndrome. J Am Coll Cardiol, 2015, 65(22): 2363-2369.
16. Misra S, Koshy T, Patro SN, et al. Large pseudoaneurysm of aortic root after aortic valve replacement for rheumatic heart disease: A rare complication. Ann Card Anaesth, 2009, 12(2): 152-153.
17. de Almeida Brandão CM, Pomerantzeff PM, Souza LR, et al. Multivariate analysis of risk factors for hospital mortality in valvular reoperations for prosthetic valve dysfunction. Eur J Cardiothorac Surg, 2002, 22(6): 922-926.
18. Duncan BF, McCarthy PM, Kruse J, et al. Paravalvular regurgitation after conventional aortic and mitral valve replacement: A benchmark for alternative approaches. J Thorac Cardiovasc Surg, 2015, 150(4): 860-868.
19. García E, Sandoval J, Unzue L, et al. Paravalvular leaks: Mechanisms, diagnosis and management. EuroIntervention, 2012, 8(Suppl Q): Q41-Q52.
20. 张宝仁, 徐志云, 邹良建, 等. 人工心脏瓣膜置换术后63例瓣周漏的外科治疗. 中国胸心血管外科临床杂志, 2007, 14(2): 81-84.
21. Szeto WY, Bavaria JE, Bowen FW, et al. Reoperative aortic root replacement in patients with previous aortic surgery. Ann Thorac Surg, 2007, 84(5): 1592-1598.
22. 徐志云, 邹良建, 陆方林, 等. 严重主动脉瓣感染性心内膜炎患者主动脉根部置换的方法与疗效. 中国胸心血管外科临床杂志, 2009, 16(2): 82-85.
23. Luciani N, De Geest R, Anselmi A, et al. Results of reoperation on the aortic root and the ascending aorta. Ann Thorac Surg, 2011, 92(3): 898-903.
24. Jeong DS, Kim KH, Kim JS, et al. Long-term experience of surgical treatment for aortic regurgitation attributable to Behçet's disease. Ann Thorac Surg, 2009, 87(6): 1775-1782.
25. Ghang B, Kim JB, Jung SH, et al. Surgical outcomes in Behcet's disease patients with severe aortic regurgitation. Ann Thorac Surg, 2019, 107(4): 1188-1194.
26. 唐杨烽, 徐激斌, 宋智钢, 等. 白塞氏病合并主动脉瓣置换术后瓣周漏的临床分析. 中国胸心血管外科临床杂志, 2010, 17(6): 506-508.
27. Luciani N, Anselmi A, de Geest R, et al. Facilitated aortic root substitution after aortic valve replacement: Technique and results of the prosthesis-sparing operation. J Thorac Cardiovasc Surg, 2010, 139(3): 785-787.
28. Esaki J, Leshnower BG, Binongo JN, et al. Reoperative aortic root replacement: Outcome in a contemporary series. J Thorac Cardiovasc Surg, 2017, 154(3): 800-808.
29. Raanani E, David TE, Dellgren G, et al. Redo aortic root replacement: Experience with 31 patients. Ann Thorac Surg, 2001, 71(5): 1460-1463.
30. Urbanski PP, Lakew F, Dinstak W, et al. Bentall procedure after previous aortic valve or complete root replacement: Usefulness of self-assembled aortic valve conduit. J Thorac Cardiovasc Surg, 2018, 156(1): 89-95.
31. Garrido-Olivares L, Maganti M, Armstrong S, et al. Clinical outcomes of aortic root replacement after previous aortic root replacement. J Thorac Cardiovasc Surg, 2013, 146(3): 611-615.
32. Haverich A, Hagl C. Organ protection during hypothermic circulatory arrest. J Thorac Cardiovasc Surg, 2003, 125(3): 460-462.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Surgical strategy and clinical outcomes of reoperative aortic root replacement after prior aortic valve replacement

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