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

8 / 76

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 6, November/December 2016 338 AFRICA
Cardiovascular Topics
Should patients undergo ascending aortic replacement
with concomitant cardiac surgery?
Mihriban Yalcin, Kaptan Derya Tayfur, Melih Urkmez
Abstract
Aim: To determine whether concomitant surgery is a predic-
tor of mortality in patients undergoing surgery for ascending
aortic aneursym.
Methods: Ninety-nine patients who underwent ascending
aortic aneursym surgery between January 2010 and January
2015 were included in this study. Nineteen patients underwent
ascending aortic replacement (RAA) only, 36 underwent
aortic valve replacement (AVR) and RAA, 25 underwent
coronary artery bypass grafting (CABG) and RAA, 11
underwent the Bentall procedure, and eight underwent AVR,
CABG and RAA.
Results: Depending on the concomitant surgery performed
with RAA, the mortality risk increased 2.25-fold for AVR,
4.5-fold for CABG, 10.8-fold for AVR + CABG and four-fold
for the Bentall procedure, compared with RAA alone.
Conclusion: Concomitant cardiac surgery increased the
mortality risk in patients undergoing RAA, but the difference
was not statisticaly significant. Based on these study results,
patients undergoing cardiac surgery, with a pre-operative
ascending aortic diameter of over 45 mm, should undergo
concomitant RAA.
Keywords: ascending aortic aneurysm, ascending aortic replace-
ment, concomitant cardiac surgery, mortality
Submitted 27/12/15, accepted 8/3/16
Published online 12/4/16
Cardiovasc J Afr 2016; 27: 338–344
DOI: 10.5830/CVJA-2016-026
Ascending aortic dilatation is the most common cardiac
condition requiring surgery. Dilatation causes aneursym,
dissection and rupture, and aortic valve insufficiency.1 The
aorta is aneurysmatic when there is a 50% increase in its normal
diameter. Underlying physiological circumstances, body surface
area and the patient’s age are the main determinants of the size
of the ascending aorta.2
Valvular or coronary cardiac diseases frequently occur with
ascending aortic aneurysm. Indications for surgery depend
on the underlying pathology or when dissection or rupture
occur. Although there is weak evidence, the current ACC/
AHA guidelines recommend concomitant replacement of a
significantly enlarged ascending aorta at the time of cardiac
surgery.3
Many other factors, including patient age, co-morbidities,
type of valve prosthesis and surgeon-specific results must be
considered when determining whether or not to replace the
aorta.4 If the aortic valve leaflets, the annulus and the sinuses
of Valsalva are intact, the aneurysm is replaced with a simple
supracoronary Dacron tube graft. If the aortic valve is diseased
but the aortic sinuses and annulus are normal, then a Wheat
procedure [aortic valve replacement (AVR) and a separate
ascending aortic replacement (RAA)] are performed. In cases
with root dilation, a modified Bentall procedure (replacement of
a vascular tube graft with a biological or mechanical aortic valve
prosthesis and re-insertion of the graft into the coronary ostia)
is the gold standard.
This retrospective study aimed to establish the effect of
concomitant cardiac surgeries on mortality rates in patients
undergoing ascending aorta surgery.
Methods
Between January 2010 and January 2015, 99 patients underwent
surgery for RAA at the Ordu State Hospital. We retrospectively
reviewed the medical records of these patients. Those who
underwent either mitral valve replacement (MVR) or any other
cardiac surgery, or patients with aortic dissection were excluded.
Information about age, gender, ejection fraction (EF), diabetes
mellitus (DM), chronic obstructive pulmonary disease (COPD)
and peripheral arterial disease (PAD) was collected.
The diameter of the ascending aorta, aortic cross-clamp time,
cardiopulmonary bypass time, total circulatory arrest time, the
type of cardiac surgery that was performed, use of intra-aortic
balloon pump (IABP) support, and whether or not positive
inotropic support was required were also evaluated. Mechanical
ventilation time, total drainage amount, duration of intensive
care and hospital stay, and death were evaluated (Tables 1, 2).
There were 39 female and 60 male patients. The mean size
of the ascending aorta in our patients was 52.28 ± 5.78 mm in
females and 52.30 ± 5.36 mm in males. The mean age was 65.23
± 8.49 years for females and 65.05 ± 9.27 years for males.
Cardiovascular Surgery Department, Ordu State Hospital,
Ordu, Turkey
Mihriban Yalcin, MD,
Kaptan Derya Tayfur, MD
Melih Urkmez, MD