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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 6, November/December 2016



ascending aorta. One possible cause of dilation is haemodynamic

flow disturbance in the aorta beyond the stenotic valve. The

second possibility is a genetic predisposition to aortic dilation.

We performed AVR and RAA in 36 patients and Bentall in

11 patients. In recent years, ascending aortic surgery has been

performed in an increasingly elderly population, with a 15–40%

incidence of co-existing CAD. Therefore pre-operative coronary

angiography is routinely performed in elective patients, and

concomitant CABG has begun to be performed more frequently,

with an incidence of between 11 and 25% in some larger

aortic surgery studies.


We performed CABG and RAA in 25

patients, and eight underwent both CABG and AVR with RAA.

In our study it was shown that the aneurysm was discovered in

patients who underwent coronary angiography for symptoms of



et al.

identified incomplete coronary revascularisation

as a risk factor for cardiovascular events.


Atherosclerosis and

inflammation are important factors in the development of valve

stenosis and CAD.


CAD is also a common finding in patients

undergoing endovascular or surgical repair of descending,

thoraco-abdominal or abdominal aortic aneurysms.


In older

patients undergoing planned aortic reconstruction, pre-operative

coronary angiography should be performed and appropriate

revascularisation must be performed.


We suggest that surgery

of the ascending aorta with concomitant CABG may increase

the mortality rate.

A study in the UK showed that the overall mortality rate was

3.2% for isolated aortic valve procedures and 6.8% for aortic

valve procedures with concomitant CABG.


However, Ueda



reported that complete revascularisation of major coronary

arteries with significant stenosis is essential to reduce post-

operative cardiac events.


In a report by Houel and colleagues from France, the type of

surgery had no effect on long-term survival, but AVR + RAA

was associated with more aortic wall complications (aortic

root dilation and false aneurysms) than the Bentall procedure.

However, AVR + RAA was performed in patients with Marfan

syndrome and others with aortic root aneurysm.


Yun and colleagues compared 255 patients who underwent

AVR + RAA, and 135 patients who underwent the Bentall

procedure between 1965 and 1995.


In the AVR + RAA group,

the surgical mortality rate was 15.3%. Survival at 10 years was



3% and at 15 years it was 36


3%. Urbanski and colleagues

reported a similar operative risk and late mortality and morbidity

among 100 patients who underwent AVR + RAA or a modified

Bentall procedure using Carbomedics mechanical valves.


Sioris and associates reported no differences in peri-operative

mortality rate or freedom from re-operation in 133 patients after

10 years between AVR associated with RAA and a modified

Bentall procedure.


Rizzoli and colleagues, in their study of

809 patients undergoing AVR, including 110 RAA patients,

reported a 30-day mortality rate of 5.5%.





. reported on combined AVR and supracoronary RAA in 89

patients with an operative mortality rate of 2.3%.


Simple AVR does not prevent the enlargement of the

ascending aorta. Patients who have dilated ascending aortas at

the time of AVR are at high risk of developing postoperative

ascending aortic complications.


This is not because of the

primary surgery but due to intrinsic changes in the aortic wall.

The time interval between initial AVR and late ascending aortic

events ranged from two to 18 years. In a study by Tsutsumi




50% of patients who developed late ascending aortic events

during the follow-up period died.


Replacement of the ascending aorta does not significantly

increase the mortality risk. Moreover, AVR cannot reduce

the risk of fatal aortic complications. Some authors reported

that in patients with bicuspid aortic valve after AVR only, the

aorta continues to enlarge and aorta-related complications



It was shown that concomitant RAA during AVR

did not increase the rate of morbidity and mortality in the

short-term, despite an increase in aortic cross-clamp and total

cardiopulmonary bypass times.


Our findings are compatible

with these studies.

The goal should be to avoid the catastrophic consequences

of acute aortic dissection or rupture. The decision for surgical

treatment is primarily based on comparative estimation of

the natural prognosis of the disease versus the prognosis with



The spontaneous prognosis is related to aortic

diameter, mechanical properties of the vascular wall, and blood

pressure. Aortic diameter has been best studied and is considered

the primary prognostic parameter.


The prognosis after treatment

depends on complications of surgery and its mortality risk. In our

study the mortality rate was increased insignificiantly.

Type I aortic dissection occurs in 0.6% of patients late after



Thirteen per cent of patients with acute type I aortic

dissections had a history of previous AVR.


In contrast to

previous AVR, a history of CABG alone is not an independent

risk factor for type I aortic dissection.


However, diameter is not

specific enough to affect the risk of dissection, and the law of

Laplace must be taken into account; the incidence of dissection

and rupture increases with increasing size of the ascending aortic



The primary aim of prophylactic replacement is to

prevent this catastrophic complication.

Our decision to replace the ascending aorta was based on

the size of the aortic diameter. Patients with ascending aortic

diameter more than 45 mm underwent concomitant ascending

aorta replacement.

In their study, Davies

at al

. reported that relative aortic

size is more important than absolute aortic size in predicting

complications. A new measurement, the aortic size index, which

takes into account both aortic diameter and body surface area,

was used for calculating the risk of negative events. According to

them, increasing aortic size index was a significant predictor of

increasing rates of rupture.



at al

. reported their initial experience for ascending

aortic surgery with or without valve or root surgery via a mini-

sternotomy approach. Surgery of the aortic root and ascending

aorta has traditionally been performed via a conventional

median full sternotomy. The development of minimally invasive

surgical techniques reduces surgical trauma, length of mechanical

ventilation and ICU stay, improves post-operative outcomes and

also has cosmetic benefits.


Especially in high-risk patients, a mini-sternotomy approach

can improve recovery of respiratory function and allow earlier

extubation, reducing ICU and hospital stay in complex aortic

surgery. There are a few examples of this procedure: Tabata

et al



and Perrotta

et al



reported on a Bentall procedure

with mini-sternotomy, using this approach on both elective

and emergency patients, and in redo surgery. Svensson

et al.

reported 36 patients operated for ascending aorta replacement,