Diagnosis and management of severe atherosclerosis of the ascending aorta and aortic arch during cardiac surgery: focus on aortic replacement.
OBJECTIVE
Severe atherosclerosis of the ascending aorta and arch frequently causes difficulties during heart operations, hindering surgical manoeuvres and potentially leading to systemic embolism. The aim of our study was to assess the safety and effectiveness of replacing the atherosclerotic ascending aorta in this setting.


METHODS
Aortic atherosclerosis was characterized by epiaortic ultrasonographic scanning in 90.1% of 1927 consecutive adult patients undergoing cardiac operations, and by computed tomographic chest scanning in selected cases. Thirty-six of the 152 patients requiring major derangements from our standard practice due to aortic atherosclerosis underwent replacement of the ascending aorta and constitute the study group. Replacement of the aorta was extended to the arch in 13 cases (36.1%). It was associated with single or multiple valve surgery in 34 patients (94.4%) and with coronary revascularization in 30 (83.3%). Two patients (5.6%) underwent coronary bypass grafting without valve surgery. A cryoablation procedure was associated in three patients with permanent atrial fibrillation. Deep hypothermic circulatory arrest was employed in 34 patients (94.4%), while proximal aortic disease allowed conventional distal crossclamping in 2 cases. The risk of operative mortality was estimated by the logistic EuroSCORE both with and withholding the variable "surgery of the thoracic aorta". All survivors were followed-up for 1-41 months (16+/-12).


RESULTS
Two patients died in the hospital (5.6%) and two during follow-up, for a cumulative survival of 91.3% and 85.6% at 1 and 3 years, respectively (hospital deaths included). The hospital death rate compared favourably with the expected estimates of 25.5% (p<0.05) and 10.3% (p=0.67) obtained by the EuroSCORE full model and without "aortic surgery", respectively. In-hospital adverse neurologic events occurred in six patients (16.7%), including stroke in one patient (2.8%) and neurocognitive disturbances in five (13.9%), although they were all transient and cleared before discharge. Excess bleeding required re-exploration in four patients (11.1%), and one more patient underwent emergency grafting for acute postoperative coronary occlusion. Ten patients (38.5%) were intubated for longer than 24h.


CONCLUSIONS
Despite significant perioperative morbidity, replacement of the severely atherosclerotic aorta is worth consideration to avert expectedly higher death and stroke rates.
Zingone
Bartolo
B
Cardiovascular Department, Cardiac Surgery Unit, Ospedali Riuniti di Trieste, Italy. bartolo.zingone@aots.sanita.fvg.it
Rauber
Elisabetta
E
Gatti
Giuseppe
G
Pappalardo
Aniello
A
Benussi
Bernardo
B
Forti
Gabriella
G
Tognolli
Umberto
U
Gabrielli
Marco
M
D000368:Aged; D000369:Aged, 80 and over; D001011:Aorta / Q000601:surgery*; D001013:Aorta, Thoracic / Q000601:surgery; D001018:Aortic Diseases / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D050197:Atherosclerosis / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D006348:Cardiac Surgical Procedures / Q000379:methods; D001026:Coronary Artery Bypass; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012086:Reoperation; D013997:Time Factors; D016896:Treatment Outcome