doi: 10.1510/MMCTS.2003.000001
Composite graft replacement of the aortic root: ‘button’ technique Marko Turina* University Hospital Zurich, Clinic for Cardiovascular Surgery, Ra¨mistrasse 100, CH-8091 Zurich, Switzerland Presentation of the ‘button’ technique for composite graft replacement of the aortic root: dilated ascending aorta is removed, both coronary ostia are dissected free, a composite graft is fixed to the aortic annulus with interrupted mattress sutures, coronary arteries are implanted into the graft with a running stitch, and distal portion of the graft is connected to the distal aorta by means of a running suture. Additional techniques for improvement of hemostasis are shown, and an overview of the literature is presented.
Keywords: Composite graft, ascending aorta Introduction History
Surgical technique Procedure is performed through a median sternotomy.
The technique of composite graft replacement of the ascending aorta and aortic valve, with reimplantation of the coronary arteries, was first described by Hugh Bentall and Antony De Bono in 1968 w1x (Schematic 1). The original description of the technique involves direct implantation of the coronary arteries into the tube graft and tidily wrapping the rest of the aorta around the prosthesis. Numerous modifications of the technique have been suggested since: the new technique of open or button anastomosis was introduced by Nick Kouchoukos in 1981 w2x. Although inclusion wrap technology is still being used, present state-of-the-art requires the performance of open anastomosis. For the composite graft of the replacement of the aortic root a prefabricated ready-made composite graft from valve manufacturers is being used (MMCTSLink 1, MMCTSLink 2, MMCTSLink 3, MMCTSLink 4, MMCTSLink 5, MMCTSLink 6). Corresponding author: Tel.: q41-1-2553298; fax: q41-1-2554446, Email: [email protected] 䉷 2003 European Association for Cardio-thoracic Surgery
Schematic 1. (Reproduced from Ref. w1x with permission from the BMJ Publishing Group.) Combined prostheses in situ. Insets 1 to 4 show details of holes fashioned in the sidewall of the Teflon tube to reincorporate the coronary ostia within the lumen of the new ascending aorta. Inset 5 shows the vertical slit in the prosthesis.
1
Composite graft replacement of the aortic root: ‘button’ technique
Video 1. Mobilizing the aortic arch. It is essential to continue dissection of the aorta well beyond the pericardial reflection, and to apply continuous traction on the tape, which is passed around the ascending aorta. This brings the innominate artery and the left carotid in view, so that a high cannulation of the aortic arch can be performed, leaving place for the aortic cross-clamp close to the origin of the innominate artery.
Video 2. Preparing the arch for arterial cannulation. With continuous traction on the tape, which was previously passed around the ascending aorta, the arch is brought into view and one (or 2, when the aorta is friable) purse string suture(s) is passed through the adventitia, taking care not to penetrate full thickness of the aorta.
Video 3. Arterial cannulation. Good fixation of the cannula to the tourniquet is essential to prevent the migration of the cannula during manipulation on the arch. When a short arterial cannula is used, a second ligature, which fixes the cannula to skin, should be used.
Sufficient mobilization of the aortic arch is essential to allow high arch cannulation and removal of the whole diseased portion of the aorta (Video 1). Cannulation is performed either in the aortic arch or – if the disease extends into the arch – the subclavian artery is cannulated instead (Videos 2, 3). Standard two-stage arterial cannula (MMCTSLink 3) and LV vent are used (Video 4). 2
Video 4. Venous cannulation and placing the LV vent. A two-stage cannula is placed in the right atrium, and a LV vent is introduced through the right upper pulmonary vein.
Video 5. Cross-clamping of the aorta and opening of the aneurysm. The clamp is placed on the distal ascending aorta after traction has been applied to the tape, which was placed around the aorta. This brings the innominate artery into view; the clamp is placed just at the origin of this artery to assure that the diseased part of the ascending aorta is removed. The vent is placed on suction, and the aorta is opened after it collapses.
Video 6. Antegrade cardioplegia. In cases with substantial aortic incompetence, an initial dose of antegrade cardioplegia is administered directly into the coronary arteries using hand-held cannulas.
Surgical procedure At a moderate hypothermia of 268C the ascending aorta is cross-clamped (Video 5), heart is arrested with cardioplegia antegrade cardioplegia (Video 6), the cardioplegia is continued in retrograde mode, and coronaries are continuously perfused with cold (168C) blood. Aneurysm is totally removed (Photo 1), (Videos 7, 8). The aneurysm is totally removed until only the buttons with left and right coronary arteries and the aortic annulus with a 3–4 mm remnant of the aorta are left (Photo 2), (Videos 9, 10).
Composite graft replacement of the aortic root: ‘button’ technique
Photo 1. Aortic root after removal of the aorta of the aortic valve, with both coronaries detached and mobilised.
Video 7. Resection of the distal part of aortic aneurysm. The aneurysm has been opened longitudinally, and the incision is carried to the cross-clamp. The aortic remnant is dissected away from the pulmonary artery and the aorta is divided circumferentially.
Video 8. Resection of the proximal portion of the aneurysm and resection of the valve leaflets. Longitudinal aortic incision is carried into the non-coronary sinus, aortic leaflets are removed, and a circumferential incision is carried along the sino-tubular junction to the ostia of both coronary arteries.
Stay sutures are placed in the commissures to facilitate exposure (Video 11). Valve seating is tested (Video 12). A standard composite graft is selected (MMCTSLink 4, MMCTSLink 5, MMCTSLink 6) and the valve implantation is performed using interrupted Ticron sutures (MMCTSLink 7). This surgery can be supported with Teflon felt or pericardium in friable aortic roots (Photo 3), (Videos 13, 14, 15).
Photo 2. Composite graft implantation using Teflon felt buttressing in a patient with Marfan disease.
Video 9. Dissecting out the left main coronary artery. Under continuous coronary retrograde perfusion with cold (168C) oxygenated blood the wall of the aneurysm is dissected away from the pulmonary artery using cautery. The ostium of the left coronary artery is extensively mobilized, leaving a 3–5 mm button of aortic tissue to facilitate the anastomosis. Dissection is carried along the left main coronary artery for at least 1–1.5 cm.
Prefabricated graft is cut to size to facilitate the implantation of coronary arteries (Video 16). The coronary arteries are implanted into the graft using 4-5 Prolene (MMCTSLink 8) with a small needle, starting with the left main coronary artery, which must be sufficiently mobilised (Videos 17, 18). The right coronary artery is implanted next (Videos 19, 20); a short clamping of the venous line allows a dilatation of the right ventricle to determine the exact position of the right coronary artery in relation to the graft. Distal anastomosis is performed either to the 3
Composite graft replacement of the aortic root: ‘button’ technique
Video 10. Dissecting out the right coronary artery. Ostium of the right coronary artery is mobilized in a similar fashion, taking care to preserve the conal branch of the right coronary artery (RCA), which usually curves towards the right ventricular outflow tract and can be easily damaged during mobilization.
Video 11. Stay sutures at the commissures. Traction sutures are placed in all three commissures and tension is applied: this lifts the aortic annulus upward and facilitates the implantation of the composite graft.
Video 12. Testing the seating of the prosthesis. After sizing and selecting the graft to be used, seating of the prosthesis in the annulus is checked.
Photo 3. Commercially available, preclotted composite graft.
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Video 13. Suturing composite graft into position. Pledgetted sutures are placed through the annulus of the aorta using supra-annular stitching. In a small aortic root these sutures would have been placed from below the annulus. After placing the stitch through the aortic annulus, the pledgetted sutures are immediately carried through the sewing ring of the prosthesis.
Video 14. Placement of the sutures in the non-coronary sinus. Keeping previously placed stitches under tension, further sutures are placed in the non-coronary sinus.
Video 15. Tying the knots. While the assistant pushes the composite graft into the annulus by applying pressure to the valve holder, sutures are being tied; twocolor stitches facilitate quick orientation.
Video 16. Cutting the graft to size. After tying the prosthesis in place, the graft is cut to appropriate length and the position of the left coronary orifice is assessed. A round hole is cut with a thermal cutter, reducing the fraying of the graft.
Composite graft replacement of the aortic root: ‘button’ technique
Video 17. Implantation of the left main coronary artery. The left coronary is attached to the graft with a running 4-0 or 5-0 suture under continuous retrograde coronary perfusion. This can be interrupted to improve vision. Reinforcement with Teflon felt or pericardium is necessary only in Marfan and connective tissue disorders.
Video 21. Distal anastomosis with the aortic arch. This suture is performed during rewarming, with retrograde warm blood reperfusion already initiated. A small 4-0 needle is used for a continuous stitch; wall reinforcement can be necessary in acute dissection or connective tissue disorders.
Video 18. Finishing the suture at the left coronary artery.
Video 19. Implantation of the right coronary into the graft. The exact positioning of the opening for right coronary artery is much more critical than the one for the left, because the right ventricle distends and rolls over the graft when the heart resumes action. A short clamping of the venous line helps to establish the position of the coronary opening in the graft.
Schematic 2. (Reproduced from Ref. w3x with permission from the Society of Thoracic Surgeons.) Graft inclusion technique, as shown in this illustration, is avoided because it might place undue tension on the coronary anastomosis.
arch or to the remnants of the ascending aorta (Video 21) also using a small needle.
Video 20. Implantation of the right coronary into the graft (continued). The same technique is applied for the right coronary artery, keeping continuous retrograde coronary perfusion.
Graft inclusion technique (Schematic 2) w3x is avoided as a rule because of the undue tension of the coronary orifices, which can lead to late complications. With proper attention to suturing and buttressing the suture lines with pericardium or Teflon felt, a safe 5
Composite graft replacement of the aortic root: ‘button’ technique
Video 22. Finished procedure after decannulation. Schematic 5. (Left: reproduced from Ref. w6x with permission from the Society of Thoracic Surgeons. Right: reproduced from Ref. w7x with permission from the Texas Heart Institute Journal.) Detail of the ‘button’-buttress technique used for anastomosis of the coronary ostia to the graft. Folding of the large remnant of the aortic wall over the neo-ostium of the coronaries improves the hemostasis.
Schematic 3. (Reproduced from Ref. w4x with permission from the Society of Thoracic Surgeons.) Running suture line between the cut edge of the aortic wall and the distal portion of the valve sewing ring. The inset shows a cutaway view from the inside.
In case of redo operation, where considerable difficulties can be experienced when mobilizing coronary arteries, short segments of graft material can be used to attach coronary arteries to the graft (Schematic 4) w5x. The improvement in coronary anastomosis can be achieved by performing a doubling of tissue at their coronary orifices as described by Hilgenberg et al. w6x and Pratali et al. w7x (Schematic 5). Finally, in difficult redo operations the Cabrol technique has to be utilised, employing a graft which connects both coronary ostia and is anastomosed to the composite graft itself (Schematic 6) w8x.
Results ● The mortality on a procedure, when performed electively is considered to be low (less than 5%).
Schematic 4. (Reproduced from Ref. w5x with permission from the Society of Thoracic Surgeons.) Separate grafts to both coronary arteries. This procedure can be used in reoperations, when a good mobilization of coronary arteries is not possible due to dense adhesions.
● The risk is increased in all the patients with connective tissue disorders (Marfan), and in patients operated under emergency conditions. ● This procedure also carries considerable risk when performed in acute Type A dissection.
hemostasis is possible without resorting to the graft inclusion (Video 22).
● Long-term results have been reported by several authors (Bachet et al. w9x, Niederha¨user et al. w10x, and Dossche et al. w11x) – see Graphs 1 and 2.
Technical innovations
● They show that long-term results seem to be best when utilising the button technique.
Several modifications of the technique have been proposed in order to eliminate the risk of bleeding (Schematic 3). This particular modification by Copeland et al. w4x improves the hemostasis at the aortic root by running an additional suture after placement of the valve fixation sutures in the annulus. 6
References w1x Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338 w2x Kouchoukos N, Karp RB. Resection of ascending aortic aneurysm and replacement of
Composite graft replacement of the aortic root: ‘button’ technique
Graph 2. (Reproduced from Ref. w11x with permission from the Society of Thoracic Surgeons.) Survival in button technique vs. graft inclusion. Although the results do not reach the level of statistical significance, they point out the advantages of the button technique.
Schematic 6. (Reproduced from Ref. w8x with permission from Elsevier.) Classical Cabrol technique for attaching coronary arteries to a separate graft, which is in turn anastomosed with composite graft in a side-side fashion.
Graph 1. (Reproduced from Ref. w9x with permission from Elsevier.) Survival and coronary reattachment. Long term survival seems to be best with button technique; but the results are obtained at different time intervals, button technique being used most recently.
aortic valve. J Thorac Cardiovasc Surg 1981;81(1):142–3 w3x Gott VL, Pyeritz RE, Cameron DE, Greene PS, McKusick VA. Composite graft repair of Marfan aneurysm of the ascending aorta: results in 100 patients. Ann Thorac Surg 1991;52:38–45
w4x Copeland JG, Rosado LJ, Snyder SL. New technique for improving hemostatis in aortic root replacement with composite graft. Ann Thorac Surg 1993;55:1027–9 w5x Mills NL, Morgenstern DA, Gaudiani VA, Ordoyne F. ‘Legs’ technique for management of widely separated coronary arteries during ascending aortic repair. Ann Thorac Surg 1996;61:869–74 w6x Hilgenberg AD, Akins CW, Logan DL, Vlahakes GJ, Buckley MJ, Madsen JC, Torchiana DF. Composite aortic root replacement with direct coronary artery implantation. Ann Thorac Surg 1996;62:1090–95 w7x Pratali S, Milano A, Codecasa R, De Carlo M, Borzoni G, Bortolotti U. Improving hemostasis during replacement of the ascending aorta and aortic valve with a composite graft. Tex Heart Inst J 2000;27:246–9 w8x Cabrol C, Pavie A, Mesnildrey P, Gandjbakhch I, Laughlin L, Bors V, Corcos, T. Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries. J Thorac Cardiovasc Surg 1986;91:17–25 w9x Bachet J, Termignon JL, Goudot B, Dreyfus G, Piquois A, Brodaty D, Dubois C, Delentdecker P, Guilmet D. Aortic root replacement with a composite graft. Factors influencing immediate and long-term results. Eur J Cardiothorac Surg 1996;10:207–13 w10x Niederha¨user U, Ku¨nzli A, Seifert B, Schmidli J, Lachat M, Zu¨nd G, Vogt P, Turina M. Conservative treatment of the aortic root in acute type A dissection. Eur J Cardiothorac Surg 1999;15:557–63 w11x Dossche KM, Schepens, MA, Morshuis WJ, de la Rivie`re AB, Knaepen, PJ, Vermeulen FE. A 23-year experience with composite valve graft replacement of the aortic root. Ann Thorac Surg 1999;67:1070–7
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Composite graft replacement of the aortic root: ‘button’ technique Marko Turina* University Hospital Zurich, Clinic for Cardiovascular Surgery, Ra¨mistrasse 100, CH-8091 Zurich, Switzerland Presentation of the ‘button’ technique for composite graft replacement of the aortic root: dilated ascending aorta is removed, both coronary ostia are dissected free, a composite graft is fixed to the aortic annulus with interrupted mattress sutures, coronary arteries are implanted into the graft with a running stitch, and distal portion of the graft is connected to the distal aorta by means of a running suture. Additional techniques for improvement of hemostasis are shown, and an overview of the literature is presented.
Keywords: Composite graft, ascending aorta Introduction History
Surgical technique Procedure is performed through a median sternotomy.
The technique of composite graft replacement of the ascending aorta and aortic valve, with reimplantation of the coronary arteries, was first described by Hugh Bentall and Antony De Bono in 1968 w1x (Schematic 1). The original description of the technique involves direct implantation of the coronary arteries into the tube graft and tidily wrapping the rest of the aorta around the prosthesis. Numerous modifications of the technique have been suggested since: the new technique of open or button anastomosis was introduced by Nick Kouchoukos in 1981 w2x. Although inclusion wrap technology is still being used, present state-of-the-art requires the performance of open anastomosis. For the composite graft of the replacement of the aortic root a prefabricated ready-made composite graft from valve manufacturers is being used (MMCTSLink 1, MMCTSLink 2, MMCTSLink 3, MMCTSLink 4, MMCTSLink 5, MMCTSLink 6). Corresponding author: Tel.: q41-1-2553298; fax: q41-1-2554446, Email: [email protected] 䉷 2003 European Association for Cardio-thoracic Surgery
Schematic 1. (Reproduced from Ref. w1x with permission from the BMJ Publishing Group.) Combined prostheses in situ. Insets 1 to 4 show details of holes fashioned in the sidewall of the Teflon tube to reincorporate the coronary ostia within the lumen of the new ascending aorta. Inset 5 shows the vertical slit in the prosthesis.
1
Composite graft replacement of the aortic root: ‘button’ technique
Video 1. Mobilizing the aortic arch. It is essential to continue dissection of the aorta well beyond the pericardial reflection, and to apply continuous traction on the tape, which is passed around the ascending aorta. This brings the innominate artery and the left carotid in view, so that a high cannulation of the aortic arch can be performed, leaving place for the aortic cross-clamp close to the origin of the innominate artery.
Video 2. Preparing the arch for arterial cannulation. With continuous traction on the tape, which was previously passed around the ascending aorta, the arch is brought into view and one (or 2, when the aorta is friable) purse string suture(s) is passed through the adventitia, taking care not to penetrate full thickness of the aorta.
Video 3. Arterial cannulation. Good fixation of the cannula to the tourniquet is essential to prevent the migration of the cannula during manipulation on the arch. When a short arterial cannula is used, a second ligature, which fixes the cannula to skin, should be used.
Sufficient mobilization of the aortic arch is essential to allow high arch cannulation and removal of the whole diseased portion of the aorta (Video 1). Cannulation is performed either in the aortic arch or – if the disease extends into the arch – the subclavian artery is cannulated instead (Videos 2, 3). Standard two-stage arterial cannula (MMCTSLink 3) and LV vent are used (Video 4). 2
Video 4. Venous cannulation and placing the LV vent. A two-stage cannula is placed in the right atrium, and a LV vent is introduced through the right upper pulmonary vein.
Video 5. Cross-clamping of the aorta and opening of the aneurysm. The clamp is placed on the distal ascending aorta after traction has been applied to the tape, which was placed around the aorta. This brings the innominate artery into view; the clamp is placed just at the origin of this artery to assure that the diseased part of the ascending aorta is removed. The vent is placed on suction, and the aorta is opened after it collapses.
Video 6. Antegrade cardioplegia. In cases with substantial aortic incompetence, an initial dose of antegrade cardioplegia is administered directly into the coronary arteries using hand-held cannulas.
Surgical procedure At a moderate hypothermia of 268C the ascending aorta is cross-clamped (Video 5), heart is arrested with cardioplegia antegrade cardioplegia (Video 6), the cardioplegia is continued in retrograde mode, and coronaries are continuously perfused with cold (168C) blood. Aneurysm is totally removed (Photo 1), (Videos 7, 8). The aneurysm is totally removed until only the buttons with left and right coronary arteries and the aortic annulus with a 3–4 mm remnant of the aorta are left (Photo 2), (Videos 9, 10).
Composite graft replacement of the aortic root: ‘button’ technique
Photo 1. Aortic root after removal of the aorta of the aortic valve, with both coronaries detached and mobilised.
Video 7. Resection of the distal part of aortic aneurysm. The aneurysm has been opened longitudinally, and the incision is carried to the cross-clamp. The aortic remnant is dissected away from the pulmonary artery and the aorta is divided circumferentially.
Video 8. Resection of the proximal portion of the aneurysm and resection of the valve leaflets. Longitudinal aortic incision is carried into the non-coronary sinus, aortic leaflets are removed, and a circumferential incision is carried along the sino-tubular junction to the ostia of both coronary arteries.
Stay sutures are placed in the commissures to facilitate exposure (Video 11). Valve seating is tested (Video 12). A standard composite graft is selected (MMCTSLink 4, MMCTSLink 5, MMCTSLink 6) and the valve implantation is performed using interrupted Ticron sutures (MMCTSLink 7). This surgery can be supported with Teflon felt or pericardium in friable aortic roots (Photo 3), (Videos 13, 14, 15).
Photo 2. Composite graft implantation using Teflon felt buttressing in a patient with Marfan disease.
Video 9. Dissecting out the left main coronary artery. Under continuous coronary retrograde perfusion with cold (168C) oxygenated blood the wall of the aneurysm is dissected away from the pulmonary artery using cautery. The ostium of the left coronary artery is extensively mobilized, leaving a 3–5 mm button of aortic tissue to facilitate the anastomosis. Dissection is carried along the left main coronary artery for at least 1–1.5 cm.
Prefabricated graft is cut to size to facilitate the implantation of coronary arteries (Video 16). The coronary arteries are implanted into the graft using 4-5 Prolene (MMCTSLink 8) with a small needle, starting with the left main coronary artery, which must be sufficiently mobilised (Videos 17, 18). The right coronary artery is implanted next (Videos 19, 20); a short clamping of the venous line allows a dilatation of the right ventricle to determine the exact position of the right coronary artery in relation to the graft. Distal anastomosis is performed either to the 3
Composite graft replacement of the aortic root: ‘button’ technique
Video 10. Dissecting out the right coronary artery. Ostium of the right coronary artery is mobilized in a similar fashion, taking care to preserve the conal branch of the right coronary artery (RCA), which usually curves towards the right ventricular outflow tract and can be easily damaged during mobilization.
Video 11. Stay sutures at the commissures. Traction sutures are placed in all three commissures and tension is applied: this lifts the aortic annulus upward and facilitates the implantation of the composite graft.
Video 12. Testing the seating of the prosthesis. After sizing and selecting the graft to be used, seating of the prosthesis in the annulus is checked.
Photo 3. Commercially available, preclotted composite graft.
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Video 13. Suturing composite graft into position. Pledgetted sutures are placed through the annulus of the aorta using supra-annular stitching. In a small aortic root these sutures would have been placed from below the annulus. After placing the stitch through the aortic annulus, the pledgetted sutures are immediately carried through the sewing ring of the prosthesis.
Video 14. Placement of the sutures in the non-coronary sinus. Keeping previously placed stitches under tension, further sutures are placed in the non-coronary sinus.
Video 15. Tying the knots. While the assistant pushes the composite graft into the annulus by applying pressure to the valve holder, sutures are being tied; twocolor stitches facilitate quick orientation.
Video 16. Cutting the graft to size. After tying the prosthesis in place, the graft is cut to appropriate length and the position of the left coronary orifice is assessed. A round hole is cut with a thermal cutter, reducing the fraying of the graft.
Composite graft replacement of the aortic root: ‘button’ technique
Video 17. Implantation of the left main coronary artery. The left coronary is attached to the graft with a running 4-0 or 5-0 suture under continuous retrograde coronary perfusion. This can be interrupted to improve vision. Reinforcement with Teflon felt or pericardium is necessary only in Marfan and connective tissue disorders.
Video 21. Distal anastomosis with the aortic arch. This suture is performed during rewarming, with retrograde warm blood reperfusion already initiated. A small 4-0 needle is used for a continuous stitch; wall reinforcement can be necessary in acute dissection or connective tissue disorders.
Video 18. Finishing the suture at the left coronary artery.
Video 19. Implantation of the right coronary into the graft. The exact positioning of the opening for right coronary artery is much more critical than the one for the left, because the right ventricle distends and rolls over the graft when the heart resumes action. A short clamping of the venous line helps to establish the position of the coronary opening in the graft.
Schematic 2. (Reproduced from Ref. w3x with permission from the Society of Thoracic Surgeons.) Graft inclusion technique, as shown in this illustration, is avoided because it might place undue tension on the coronary anastomosis.
arch or to the remnants of the ascending aorta (Video 21) also using a small needle.
Video 20. Implantation of the right coronary into the graft (continued). The same technique is applied for the right coronary artery, keeping continuous retrograde coronary perfusion.
Graft inclusion technique (Schematic 2) w3x is avoided as a rule because of the undue tension of the coronary orifices, which can lead to late complications. With proper attention to suturing and buttressing the suture lines with pericardium or Teflon felt, a safe 5
Composite graft replacement of the aortic root: ‘button’ technique
Video 22. Finished procedure after decannulation. Schematic 5. (Left: reproduced from Ref. w6x with permission from the Society of Thoracic Surgeons. Right: reproduced from Ref. w7x with permission from the Texas Heart Institute Journal.) Detail of the ‘button’-buttress technique used for anastomosis of the coronary ostia to the graft. Folding of the large remnant of the aortic wall over the neo-ostium of the coronaries improves the hemostasis.
Schematic 3. (Reproduced from Ref. w4x with permission from the Society of Thoracic Surgeons.) Running suture line between the cut edge of the aortic wall and the distal portion of the valve sewing ring. The inset shows a cutaway view from the inside.
In case of redo operation, where considerable difficulties can be experienced when mobilizing coronary arteries, short segments of graft material can be used to attach coronary arteries to the graft (Schematic 4) w5x. The improvement in coronary anastomosis can be achieved by performing a doubling of tissue at their coronary orifices as described by Hilgenberg et al. w6x and Pratali et al. w7x (Schematic 5). Finally, in difficult redo operations the Cabrol technique has to be utilised, employing a graft which connects both coronary ostia and is anastomosed to the composite graft itself (Schematic 6) w8x.
Results ● The mortality on a procedure, when performed electively is considered to be low (less than 5%).
Schematic 4. (Reproduced from Ref. w5x with permission from the Society of Thoracic Surgeons.) Separate grafts to both coronary arteries. This procedure can be used in reoperations, when a good mobilization of coronary arteries is not possible due to dense adhesions.
● The risk is increased in all the patients with connective tissue disorders (Marfan), and in patients operated under emergency conditions. ● This procedure also carries considerable risk when performed in acute Type A dissection.
hemostasis is possible without resorting to the graft inclusion (Video 22).
● Long-term results have been reported by several authors (Bachet et al. w9x, Niederha¨user et al. w10x, and Dossche et al. w11x) – see Graphs 1 and 2.
Technical innovations
● They show that long-term results seem to be best when utilising the button technique.
Several modifications of the technique have been proposed in order to eliminate the risk of bleeding (Schematic 3). This particular modification by Copeland et al. w4x improves the hemostasis at the aortic root by running an additional suture after placement of the valve fixation sutures in the annulus. 6
References w1x Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338 w2x Kouchoukos N, Karp RB. Resection of ascending aortic aneurysm and replacement of
Composite graft replacement of the aortic root: ‘button’ technique
Graph 2. (Reproduced from Ref. w11x with permission from the Society of Thoracic Surgeons.) Survival in button technique vs. graft inclusion. Although the results do not reach the level of statistical significance, they point out the advantages of the button technique.
Schematic 6. (Reproduced from Ref. w8x with permission from Elsevier.) Classical Cabrol technique for attaching coronary arteries to a separate graft, which is in turn anastomosed with composite graft in a side-side fashion.
Graph 1. (Reproduced from Ref. w9x with permission from Elsevier.) Survival and coronary reattachment. Long term survival seems to be best with button technique; but the results are obtained at different time intervals, button technique being used most recently.
aortic valve. J Thorac Cardiovasc Surg 1981;81(1):142–3 w3x Gott VL, Pyeritz RE, Cameron DE, Greene PS, McKusick VA. Composite graft repair of Marfan aneurysm of the ascending aorta: results in 100 patients. Ann Thorac Surg 1991;52:38–45
w4x Copeland JG, Rosado LJ, Snyder SL. New technique for improving hemostatis in aortic root replacement with composite graft. Ann Thorac Surg 1993;55:1027–9 w5x Mills NL, Morgenstern DA, Gaudiani VA, Ordoyne F. ‘Legs’ technique for management of widely separated coronary arteries during ascending aortic repair. Ann Thorac Surg 1996;61:869–74 w6x Hilgenberg AD, Akins CW, Logan DL, Vlahakes GJ, Buckley MJ, Madsen JC, Torchiana DF. Composite aortic root replacement with direct coronary artery implantation. Ann Thorac Surg 1996;62:1090–95 w7x Pratali S, Milano A, Codecasa R, De Carlo M, Borzoni G, Bortolotti U. Improving hemostasis during replacement of the ascending aorta and aortic valve with a composite graft. Tex Heart Inst J 2000;27:246–9 w8x Cabrol C, Pavie A, Mesnildrey P, Gandjbakhch I, Laughlin L, Bors V, Corcos, T. Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries. J Thorac Cardiovasc Surg 1986;91:17–25 w9x Bachet J, Termignon JL, Goudot B, Dreyfus G, Piquois A, Brodaty D, Dubois C, Delentdecker P, Guilmet D. Aortic root replacement with a composite graft. Factors influencing immediate and long-term results. Eur J Cardiothorac Surg 1996;10:207–13 w10x Niederha¨user U, Ku¨nzli A, Seifert B, Schmidli J, Lachat M, Zu¨nd G, Vogt P, Turina M. Conservative treatment of the aortic root in acute type A dissection. Eur J Cardiothorac Surg 1999;15:557–63 w11x Dossche KM, Schepens, MA, Morshuis WJ, de la Rivie`re AB, Knaepen, PJ, Vermeulen FE. A 23-year experience with composite valve graft replacement of the aortic root. Ann Thorac Surg 1999;67:1070–7
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