Eur J Cardio-thorac Surg (1996) 10:428-432

© Springer-Verlag 1996

T. Savunen Composite graft in annulo-aortic ectasia

M. Inberg
J. Niinikoski Nineteen years' experience without graft inclusion
V. Rantakokko
E. V~inttinen

Abstract Objective. The original Results. The overall hospital mortal-

Received: 14 ApriI 1995
Accepted: 26 June 1995 Bentall procedure for the surgery of
annulo-aortic ectasia (AAE) includes
the risk of leakage and pseudo-
aneurysm formation in the coronary
anastomosis. To avoid the complica-
tions mentioned above we have used
the open technique without the graft
inclusion. In this study we evaluate
our early and late results.
Material and methods. One hundred
consecutive patients with annulo-
aortic ectasia underwent surgical re-
pair with composite graft between
December 1975 and February 1994.
In all cases the aneurysmal tissue
was radically resected and the ori-
gins of the coronary arteries were
directly reimplanted to the tube
prosthesis. No wrapping was used.
Twenty-tWO patients met the clinical
criteria of Marfan syndrome. Thir-
teen of the patients underwent an
emergency operation, because of a
rupture of aneurysm in 2 cases and
an acute dissection in 11 cases_ Ad-
ditional procedures were performed
in 16 patients: mitral valve replace-
T. Savunen ([]) • M_ Inberg. J. Niinikoski. ment in 2, coronary artery bypass
V. Rantakokko. E. V~inttinen grafting in 12 patients a n d i n 2 cases
Department of Surgery,
University of Turku, the tube prosthesis included aortic
FIN-20520 Turku, Finland arch, too.
ity was 3.0% (3/100). In the elective
group there was one hospital death
(1/87; 1_1%). In the emergency group
two patients died in the operation
room (2/13; 16.7%). There have been
13 late deaths among the 97 hospital
survivors (13.4%). Four of the late
deaths were surgery related. Routine
control angiography was performed
in all patients 6 months after surgery.
Sixty patients who had lived at least
3 years after surgery were called to
reangiography and 53 of them came.
No pseudo-aneurysm or leakage at
distal anastomosis or coronary anas-
tomosis could be seen. A slight dila-
tation of one or both coronary origins
was observed on 15 patients; 9 of
whom had Marfan syndrome.
Conclusions. The open technique is
simple and can be used in all anatom-
ical variations of the annulo-aortic
ectasia. The early and late results are
at least comparable with those achie-
ved by other techniques.[Eur J Car-
dio-thorac Surg (1996) 10:428-432]
K e y w o r d s Annulo-aortic ectasia •
Open method surgery •
Composite graft •
Aneurysm of the ascending aorta

Introduction
Annulo-aortic ectasia (AAE) is an anatomical entity con-
sisting of the aneurysm in the ascending aorta and insuffi-
ciency of the aortic valve. The term was introduced by Ben-
tall and Debono in 1968 [2]_ The first total repair of AAE
was described in the same article. The procedure was also
performed by Bircks and Schulte about the same time [23].
In the early 70s nine patients with AAE were operated on
in our institution with supracoronary technique. However,
the primary results were not satisfactory and late results

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w i t h f o r m a t i o n o f r e - a n e u r y s m s w e r e e v e n w o r s e . In 1975
w e c h a n g e d the o p e r a t i o n t e c h n i q u e to a m o d i f i c a t i o n o f
B e n t a l l ' s o p e r a t i o n . T h e p r o c e d u r e , w i t h r e s e c t i o n o f the
a n e u r y s m a l t i s s u e and w i t h o u t a n y w r a p p i n g , w a s later
c a l l e d the o p e n t e c h n i q u e . In this r e p o r t w e p r e s e n t o u r en-
tire e x p e r i e n c e o f e l e c t i v e and e m e r g e n c y s u r g e r y for A A E
in 100 c o n s e c u t i v e p a t i e n t s d u r i n g a 1 9 - y e a r p e r i o d f r o m
1975 to 1994.
Patients and methods
From December 1975 to February 1994, a total of 100 consecutive
patients with AAE underwent replacement of the ascending aorta and
aortic valve with a composite graft. There were 86 males and 14 fe-
males. Three of the patients were children aged 10, 12 and 13 years,
respectively. Thirteen patients were operated on as emergencies: 2
because of rupture of the aneurysm in the ascending aorta and 11 for
acute type A aortic dissection. Six patients had chronic type A dis-
section in addition to the aneurysm. Altogether 22 patients fulfilled
the strict clinical criteria of classic Marfan syndrome [ 1]. The mean
age of all patients was 44.9 years (range 10-72 years): that of the
Marfan patients 32.6 years (range 10-52 years) and that of the non-
Marfan patients 48.5 years (range 19-72), respectively (Fig_ 1)_ The
aortic valve was bicuspid in 20 cases.
Three patients had previously been operated on for aortic valve
insufficiency; the interval between the primary and secondary oper-
ation varied from 10 to 131 months. Two patients had undergone re-
pair of AAE with supracoronary technique before, but subsequent
re-aneurysm formation necessitated reoperation with total repair. In
addition to AAE, the mitral valve was replaced in to cases because
of insufficiency of this valve. In two patients the aortic arch was al-
so resected because of the extension of the aneurysm to the origin of
the left subclavian artery. Twelve patients had concomitant coronary
artery disease necessitating bypass grafting.
An aortic wall biopsy was performed in all patients and histolog-
ic changes of cystic medial necrosis were seen in 79 specimens. These
changes were more accentuated in the aortas of the Marfan patients,
even in the younger ones.
Surgical technique
Conventional cardiopulmonary bypass was used. In the first four pa-
tients the myocardium was protected by selective coronary artery
perfusion. In all other 96 operations the measures for myocardial pro-
tection were as follows: systemic moderate hypothermia (28 °C),
crystalloid cardioplegic solution (modified St. Thomas II) infused
antegradely, topical cooling with ice-cold saline and cooling device
(TCD) 1. The aortic valve was excised and the aneurysmal tissue re-
sected. Coronary ostia with a collar and the proximal parts of the cor-
onary arteries were dissected free from the surrounding tissue. The
composite graft was made simultaneously by sewing a Bj6rk-Shiley
tilting disc valve (standard from 1975 to 1978, convex-concave to
March 1983 and monostrut since then) inside a woven Dacron tube
graft (standard woven in the first four cases, Cooley low porosity in
15 cases and Cooley very soft low porosity in the remaining cases).
The composite graft was sewn to the aortic annulus with single 2-0
Ticron sutures. For implantation of the coronary arteries the tissue
collar around the coronary ostia was sutured, with continuous 4-0
Prolene sutures, to the holes made by a knife in the tube prosthesis.
The distal anastomosis was made with continuous 4-0 Prolene su-
1 Code Laboratories, Lakewood, Colo., USA
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429
Patients
30
] = Marfan patients
• = non-Marfan patients
20
10
10-19 20-29 30-39 40-49 50-59 60-69 70-79
Age (years}
Fig. 1 Age distribution of the Marfan and non-Marfan patients op-
erated on for annulo-aortic ectasia
tures (Fig. 2). In the cases with dissection the distal anastomosis was
supported by two circular Teflon felts.
The twelve patients with concomitant coronary artery disease re-
ceaved, additionally, saphenous vein bypass grafting from the tube
prosthesis to the coronary arteries. In two cases, where total repair
also included the aortic arch, moderate hypothermia and selective
cannulation of the innominate artery and left common carotid artery
were used for brain protection during the operation_ The distal anas-
tomosis was made end-to-end distal to the left subclavian artery and
the branches of the aortic arch were implanted with a collar to the
tube prosthesis.
The mean aortic clamping time in the group of elective operations
was 102 rain (range: 70-186 rain) and in the group of emergency op-
erations 111 rain (range: 79-136 rain). Anticoagulant therapy with
dicoumarin was started on the 2nd postoperative day in all patients.
Follow-up
The mean follow-up time until December 1994 was 97 months
(range: 10 months-19 years)_ Each patient underwent a routine con-
trol angiography 6 months after surgery. Additionally, another con-
trol angiography was undertaken in 53 patients with a mean follow-
up time of 56 months (range: 36-142 months). All patients have
undergone annual check-ups by our cardiologists.
Results
E a r l y results
In the e l e c t i v e g r o u p o n e p a t i e n t d i e d d u r i n g the o p e r a t i o n
(1.3%). H e h a d b e e n o p e r a t e d on 6 y e a r s b e f o r e for the
A A E u s i n g the s u p r a c o r o n a r y t e c h n i q u e . T h e d i s e a s e d
z o n e b e t w e e n the v a l v e p r o s t h e s i s and the t u b e p r o s t h e s i s
h a d w i d e n e d to a h u g e r e - a n e u r y s m . In the e m e r g e n c y
group two patients, both having acute dissection, died dur-
i n g s u r g e r y ( 1 6 . 6 % ) . R e s t e r n o t o m y for e x c e s s i v e p o s t -
 430

Fig. 2 Total repair of annulo- patient died 3 years postoperatively due to a brain abscess
aortic ectasia accomplished us- probably caused by prosthetic endocarditis. In one case
ing the open technique
with chronic dissection in addition to AAE, the dissection
progressed to aneurysm in the thoracic aorta and the pa-
tient died due to rupture of the aneurysm. Three of the 13
deaths were suicides. Five patients succumbed to acute
myocardial infarction. One patient died due to esophageal
carcinoma. The actuarial survival curve for the 78 patients
without Marfan syndrome and 22 with the syndrome are
shown in Fig. 3.
In the control angiograms carried out 6 months after sur-
gery no pseudo-aneurysms at the coronary ostia, distal
anastomosis or proximal anastomosis could be seen, and
none were detected in later angiograms either. Of 53 cases,
a slight-to-moderate dilatation in one or both coronary or-
igins was observed in 15 (Figs. 4a, and 4b) of whom
Patients (N) 9 were patients with classic Marfan syndrome.
100

Discussion

In Bentall's procedure the aneurysmal sac is wrapped to

• = Marfan patients avoid bleeding through the prosthesis. Bleeding between
80
the tube prosthesis and the wrapped aneurysmal sac may
• = n o n - M a r f a n patients
cause tension in the coronary anastomosis and a paraval-
vular leakage with pseudo-aneurysm formation [7, 8, 13,
15, 16]. Tension-free anastomosis in the coronary origins
was the goal of the modification proposed by Cabrol [4].
In another modification by Cabrol the blood was drained
to the right atrium [5]. In our series the wrapping was never
60 I I i I I 1 b I I d

0 1 2 3 4 5 6 7
Follow-up (years)
Fig. 3 Actuarial survival of the Marfan and non-Marfan patients
following the open surgical procedure for annulo-aortic ectasia
operative bleeding was performed in five patients (5.0%).
Four patients needed permanent pacemakers because of
total atrio-ventricular (AV) block caused by surgery.
Late results
In the follow-up period of up to 19 years there were 13 late
deaths altogether, four of which were related to surgery.
One patient died 3 months after surgery due to anoxic brain
damage caused iatrogenically during an emergency rester-
notomy in the intensive care unit. Another patient suc-
cumbed 3 months postoperatively due to multiple emboli
caused by neglected anticoagulant therapy. An autopsy
showed emboli and infarctions in the heart, left kidney and
brain, but also pseudo-aneurysm surrounding the tube
prosthesis and compressing the left coronary artery. One
8 9 10
used; the aneurysmal tissue was nearly totally removed and
the origins of the coronary arteries were dissected free from
the surrounding tissue. The advantages of this open method
are obvious: no tension in the coronary anastomoses, no
later pseudo-aneurysms. The procedure can be carried out
in both elective and emergency cases with acute dissection
superimposed on the aneurysm. The open method can also
be applied in cases without any upward dislocation of the
coronary origins, even though the opposite is claimed by
others [18].
In all cases we used the same type of non-porous tube
prosthesis with good results; the incidence of resternoto-
mies for excessive postoperative bleeding is comparable
with those in other series [14, 20]. The only disadvantage
of the tube prosthesis is its hard texture, which makes it
difficult to handle.
During the last 10 years many centers have switched
from the original Bentall procedure and its modifications
to the open method [9, 13, 19]. We have used the same
method since 1975 and can present early and late results
which are at least comparable with those achieved using
other procedures, Our primary mortality in the elective
group is very low and in the emergency group within the
range reported by others [3, 6, 13, 14, 19, 20]. In our ex-
perience the most important single factor contributing to

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Fig. 4A, B Follow-up angio-
grams carried out more than
3 years after surgery of annulo-
aortic ectasia. A angiogram
with normal coronary origins
B angiogram with dilation of
the left coronary origin
the mortality of urgent cases is diagnostic delay. At least
in our hands, transthoracic echocardiography combined
with the transesophageal echo is the fastest way to diag-
nose acute cases.
In the group with late mortality there were only four
deaths which were related to surgery. Two points concern-
ing late mortality should be emphasized. One patient died
due to complication of a remaining chronic dissection.
However, the incidence of complications developing in the
aortic arch and thoracic aorta has been higher in other re-
ports [12, 13]. To us it is an indication for closer follow-
up of the remaining thoracic aorta in the patients operated
on for AAE. We are also concerned about the number of
suicides in our late mortality. Two of them were in the ira-
mediative postoperative phase and the third 3 years after
surgery. That provoked us to start a study on the quality of
life in these patients, who were often actually operated on
prophylactically without any preoperative symptoms.
The need for permanent pacemakers in our series has
not been reported by others. In the open method, where
there is no wrapping, sufficient tissue in the aortic annu-
lus must be sutured to the rim of the valve prosthesis to
avoid paraprosthetic leakage. Some of these deep stitches
could damage the conductive tissue. Since we have started
using tissue glue to reinforce aortic valve sutured and cor-
onary artery anastomoses, the stitches have been more
superficial and we have not seen any more total blocks.
The dilatations at the coronary origins seen in the fol-
low-up angiograms have not been reported by others. On
the other hand, there are only a few reports with angio-
graphic follow-up [ 18]. The reason for the dilatation could
be diseased connective tissue in the walls of the coronary
arteries. In the patients operated on with the supracoronary
technique, we have seen how the narrow rim between valve
prosthesis and tube prosthesis progressively dilates to an
aneurysm. These findings are supported by the fact that
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431
most of the patients having the dilation in coronary arter-
ies had classic Marfan syndrome with accentuated connec-
tive tissue changes in the aortic wall. More important, no
leakages or pseudo-aneurysms could be seen in coronary
anastomoses.
Despite the improved results in the surgery of AAE, there
are still two issues which should be emphasized: one is the
timing of the surgery and the other is the diagnosis of the
disease. The recommendations concerning the critical
upper limit of the aneurysm in the ascending aorta, with or
without insufficiency in the aortic valve, have changed with
time. For instance, Gott and his group operated on Marfan
patients with AAE, even prophylactically, if the aneurysm
was more than 60 m m wide [11]_ However, today their
recommendation for the limit is 55 m m or even only 50 m m
if the patient has a strong family history [10]. The others
do not want to give any strict limit in absolute width but
recommend surgery if the aneurysm is twice the diameter
of the adjacent normal aorta [17]. Roman and her group
have emphasized the significance of the pattern of aortic
root dilation, at least in the Marfan patients [21]. Our policy
is to operate, even without aortic valve insufficiency, if the
aortic aneurysm exceeds 60 mm.
The diagnosis of AAE is relatively easy in cases with
classic Marfan syndrome because of the typical habitus of
the patients and the well-known heredity of the disease [1].
Most of us today are familiar with the cardiovascular man-
ifestations of Marfan syndrome and its fatal complications,
such as acute dissection or rupture of the aneurysm. On the
other hand, to identify the patients with AAE but without
Marfan syndrome is much more difficult. However, the he-
redity of AAE, even without classic Marfan syndrome,
seems probable [22]. That is why the relatives, at least the
children and siblings of the patients operated on for AAE,
routinely undergo clinical examination and echocardiog-
raphy in our institution.
 432
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