Cardiovascular Journal of Africa: Vol 27 No 6 (November/December 2016)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 6, November/December 2016 AFRICA 343
of whom 18 had aortic arch repair through mini-sternotomy.39
The minimal incision does not allow for easy manipulation of
the aortic arch while using selective antegrade cerebral perfusion.
The need for CABG was the exclusion criterion in our study.
There are several ways of dealing with an enlarged aorta.
One is by remodelling the aorta, using a supracoronary graft,
or with a valved conduit. Some surgeons40 suggest a conservative
approach and would rather remodel the aorta but we believe
that the risk of recurrent dilatation of the aorta remains, so a
more radical approach of supracoronary graft replacement is the
main choice in our clinic. We use hypothermic circulatory arrest
and antegrade cerebral perfusion generally, as we have more
experience with this approach. We do not have experience of the
minimal approach.
Some authors have argued against the strategy of routinely
replacing the enlarged ascending aorta, based on their
observations that significant increase in the ascending aorta
after simple AVR is infrequent.41 We have not experienced this.
The results of our study suggested that concomitant RAA did
not significantly increase the mortality rate despite an increase in
the aortic cross-clamp and total cardiopulmonary bypass times.
If type A aortic dissection is life threating but elective surgery
carries a low surgical risk, we prefer to perform surgery earlier.
According to the Society of Thoracic Surgeons, the operative
risk associated with replacement of the proximal aorta under
elective circumstances is 3.4%.42
In our study, the mortality rate was 5.3% in patients who
underwent RAA alone, 11.1% in those who underwent AVR,
20% in those who underwent CABG, 37.5% in patients who
underwent AVR + CABG, and 18.2% in those who underwent
the Bentall procedure. We found no statistically significant
differences between mortality rates. Therefore, this study
supports the strategy of concomitantly replacing the ascending
aorta at the time of cardiac surgery to prevent possible aortic
rupture, dissection or death.
Study limitations
This was a retrospective, single-centre, observational study
and it had a small patient population. These results were also
obtained in a small-volume centre (< 40 aortic operations per
year), therefore the results cannot be generalised. In addition, we
examined data from surgeries that were performed by different
surgical groups, which limits standardisation. This study reflects
clinical experiences in a small area and cannot be generalised for
all hospitals. Prospective studies are required to define optimal
prophylactic surgical techniques.
Conclusions
It is common to deal with an associated ascending aortic
aneurysm during concomitant surgery. In this retrospective
study, we investigated whether concomitant surgery was a
predictor for mortality after proximal aortic replacement. We
found that the procedure for simultaneous correction of the
ascending aorta and concomitant cardiac surgery (CABG, AVR,
Bentall procedure) could be performed safely and with good
results. Our study supports replacement of the ascending aorta
during AVR or CABG if the aortic dimension is larger than 45
mm, to prevent aortic dissection or rupture after the procedure.
As we have become more successful in performing the surgery,
a higher proportion of patients undergoing open-heart surgery
and requiring RAA will be operated on. A multicentre study
is necessary to develop the best strategy for treatment of these
patients.
We acknowledge medical writing assistance provided by AmericanManuscript
Editors ) for the final draft of the
manuscript. We thank to Prof Arisan Ergin for sharing his surgical experi-
ences with us.
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