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



Cardiovascular Topics

Should patients undergo ascending aortic replacement

with concomitant cardiac surgery?

Mihriban Yalcin, Kaptan Derya Tayfur, Melih Urkmez



To determine whether concomitant surgery is a predic-

tor of mortality in patients undergoing surgery for ascending

aortic aneursym.


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,



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.


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.


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



: 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.



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.


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



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



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.


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