Long-Term Mortality and Morbidity after Button Bentall Operation
Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Sejong Heart Institute, Bucheon, Republic of Korea. Journal of Cardiac Surgery
(Impact Factor: 0.89).
03/2013; 28(3). DOI: 10.1111/jocs.12085
The purpose of this study is to evaluate the long-term outcomes of the button Bentall procedure for the correction of aortic root disease.
A total of 195 patients who underwent the button Bentall procedure between 1997 and 2010 were studied. The main pathology was annuloaortic ectasia. A mechanical valve was used in 163 patients (83.6%). The median duration of follow-up was 64 months (14133.0 patient-years).
There were five operative deaths (2.6%). Late overall mortality was 7.9%. The actuarial overall survival rate was 95.8 ± 1.5% at 5 years, 89.6 ± 3.4% at 10 years, and 75.9 ± 7.3% at 15 years. Multivariate logistic regression analysis identified preoperative poor mobility, cardiopulmonary bypass time, deep hypothermic circulatory arrest (DHCA) use, embolism, and bleeding event as significant independent risk factors for the late overall mortality. At 5, 10, and 15 years, actuarial composite valve graft-related event-free survival was 85.8 ± 2.8%, 75.5 ± 4.4%, and 69.3 ± 7.3%, respectively. Hypertension and concomitant coronary artery bypass graft (CABG) were independent predictors of composite valve graft-related events. Age, concomitant CABG, and DHCA use were associated with bleeding.
Valve-related morbidities, such as embolism and bleeding, determine the long-term overall mortality in aortic root replacement with button Bentall operation, similar to that in routine valve surgery. doi: 10.1111/jocs.12085 (J Card Surg 2013;28:280–284)
Available from: cardiothoracicsurgery.org
- "With improvements in operative technique and postoperative management years, Marfan syndrome, diabetes, hypertension, bicuspid aortic valve, hyperlipidaemia , coronary artery disease, cerebral vascular accident, concomitant cardiac surgery, longer operation, aortic crossclamp time and dissection did not prove to be risk factors for mortality in this study.There are many debates as to whether Marfan syndrome had an influence in long-term survival after the Bentall procedure. Although several papers have been published[2,8,11], on the subject regarding the impact of presence of Marfan syndrome on survival rate, but only few of them studied the Marfan group as a separate patient group. Since Marfan patients are usually operated in younger age and with less comorbidities, therefore they should be managed as a distinct patient group. "
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We retrospectively analyzed 25 years of experiences with the button Bentall procedure in patients with aortic root pathologies. Even though this procedure has become widespread, there are only a few very long term follow-ups available in the clinical literature, especially regarding single surgeon results.
Between 1988 and 2013, a total of 147 patients underwent the Bentall procedure by the same surgeon. Among them there were 62 patients with Marfan syndrome. At the time of the surgery the mean age was 46.5 ± 17.6 years. The impact of surgical experience on long-term survival was evaluated using a cumulative sum analysis chart.
The Kaplan-Meier estimated overall survival rates for the 147 patients were 91.8 ± 2.3 %, 84.3 ± 3.1 %, 76.3 ± 4.9 % and 59.5 ± 10.7 % at 1,5,10 and 20 years, respectively. Multivariate Cox regression analysis identified EuroSCORE II over 3 % (OR 4.245, 95 % CI, 1.739-10.364, p = 0.002), acute indication (OR 2.942, 95 % CI, 1.158-7.480, p = 0.023), use of deep hypothermic circulatory arrest (OR 3.267, 95 % CI, 1.283-8.323, p = 0.013), chronic kidney disease (OR 6.865, 95 % CI, 1.339-35.189, p = 0.021) and early complication (OR 3.134, 95 % CI, 1.246-7.883, p = 0.015) as significant risk factors for the late overall death. The survival rate for freedom from early complication was 94.3 ± 2.2 %, 88.0 ± 3.3 %, 82.9 ± 4.7 % and 69.2 ± 8.4 % at 1,5,10 and 20 years. The main pathological findings of the aortic wall were cystic medial degeneration in 75 %, fibrosis in 6 %, atherosclerosis in 13 % and no pathological alteration in 6 % of the samples. The overall survival rate was significantly lower in patients operated in first 15 years compared to patients operated in the last decade (log-rank p = 0.011).
According to our long-term follow-up the Bentall operation provides an appropriate functional result by resolving the lesions of the ascending aorta. Based on our results, 25-30 operations done is necessary to gain such a level of confidence and experince to aquire better results on long-term survival. In addition, we discussed that there were no co-morbidities affecting on the survival of Marfan patients and prophylactic aortic root replacement ensures a longer survival among patients with Marfan syndrome.
Available from: Amgad N Makaryus
- "Long-term mortality of the Button Bentall method was shown to be related to embolism and bleeding events similar to valve surgery. Contaminant CABG also increased bleeding risk for patients undergoing the Bentall procedure . Midulla and colleagues comment that late mortality in patients is often due to a subsequent aneurysm or dissection along the aorta even in patients not presenting with a genetic defect affecting aortic structure. "
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ABSTRACT: Ascending aortic aneurysms involving the proximal aortic arch, arising anywhere from the aortic valve to the innominate artery, represent various problems in which open surgery is generally required. Surgical options include excision of the aortic pathology or wrapping the aneurysm shell with an aortic Dacron graft. Intervention using the latter method can lead to extravasation of blood along the suture lines resulting in continuous bleeding within the periprosthetic space. The Cabrol technique was developed as a method for decompression of postoperative leaks by the formation of a conduit system from the periprosthetic space to the right atrium. The coronary ostia are anastomosed to a second graft in an end-to-end fashion, which is then anastomosed to the ascending aortic conduit side to side. The native aorta is then sewn around the prosthesis, hereby creating a shunt to drain anastomotic leakage. This shunt reduces postsurgical risk of pseudoaneurysm formation and normally closes a few days following surgery. We discuss the case of a patient who underwent Cabrol's variation and six months later was demonstrated to have a patent shunt.
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ABSTRACT: ANEURYSM OF THE ASCENDING AORTA MAY CAUSE ACUTE TYPE A AORTIC DISSECTION, and the primary aim of a prophylactic operation is avoidance of this life-threatening complication. Current guidelines recommend prophylactic replacement of the aneurysmal ascending aorta at a diameter of ≥5.5 cm. However, several reports have shown that nearly 50% of patients with an acute type A aortic dissection present with an aortic diameter <5.5 cm. It is controversial how to best respond to these observations. Because surgical advances have led to a reduction of early surgical mortality between 1% and 3%, many clinicians believe that surgery is warranted in smaller aortas. Given the frequency of a bicuspid aortic valve (BAV), such a strategy has health implications for this population.
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