Cardiovascular Journal of Africa: Vol 28 No 2 (March/April 2017)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 2, March/April 2017

118

AFRICA

The effect of proximal anastomosis on the expansion

rate of a dilated ascending aorta in coronary artery

bypass surgery: a prospective study

Ahmet Yavuz Balcı, Unsal Vural, Rezan Aksoy, MD Fatih Özdemir, Seçkin Satılmı

, Mehmet Kızılay,

Mutlu

enocak, Huseyin

kın,

lyas Kayacıo

lu,

brahim Yekeler

Abstract

Background:

This study was designed to determine the

short- and long-term effects of proximal aortic anastomosis,

performed during isolated coronary artery bypass grafting

(CABG) in patients with dilatation of the ascending aorta

who did not require surgical intervention.

Methods:

The study was performed on 192 (38 female and

160 male patients; mean age, 62.1

9.2 years; range, 42–80

years) patients with dilatation of the ascending aorta who

underwent CABG surgery between 1 June 2006 and 31 May

2014. In group 1 (

114), the saphenous vein and left inter-

nal mammarian artery grafts were used, and proximal anas-

tomosis was performed on the ascending aorta. In group 2 (

78), left and right internal mammarian artery grafts were

used, and proximal aortic anastomosis was not performed.

Pre-operatively and in the first and third years postoperative-

ly, the ascending aortic diameter was measured and recorded

using transthoracic echocardiography at four different regions

(annulus, sinus of Valsalva, sinotubular junction and tubular

aorta).

Results:

A statistically significant difference was found

between the groups for the number of grafts used and the

duration of aortic cross-clamping and cardiopulmonary

bypass. No significant intergroup difference was seen for the

mean diameter of the ascending aorta (

0.05). Annual

changes in the aortic diameter were found to be extremely

significantly different in both groups (

0.0001). Mean

values of the aortic diameter at the level of the sinotubular

junction and tubular ascending aorta, mean aortic diameters

(

0.002 and

0.0001, respectively), annual increase in

diameter (

0.0001 and

0.0001, respectively), and mean

annual difference in diameter (

0.0001 and

0.0001,

respectively) at one and three years postoperatively were

statistically significantly different between the groups.

Conclusion:

In patients with ascending aortic dilatation who

did not require surgical intervention and who had proximal

anastomosis of the ascending aorta and underwent only

CABG, we detected statistically significant increases in the

diameter of the sinotubular junction and tubular aorta up to

three years postoperatively.

Keywords:

coronary artery bypass grafting, aortic dilatation,

proximal anastomosis

Submitted 23/11/15, accepted 10/7/16

Published online 22/8/16

Cardiovasc J Afr

2017;

: 118–124

www.cvja.co.za

DOI: 10.5830/CVJA-2016-071

Aortic dilatation is a clinical entity with many aetiological

factors, which can be seen singly or in association with other

cardiac pathologies. Generally, anuloaortic ectasia, Marfan

syndrome, atherosclerotic aortic degeneration, aortic dissection

and bicuspid aortic valve disease accompany aortic dilatation.

Despite novel approaches in surgical and endovascular

treatment procedures for aneurysms, the same degree of

advancement has not been achieved with regard to the molecular

and cellular mechanisms that trigger its pathogenesis and

progression. Genetic factors and inflammatory responses

are recognised as important aspects in the development of

aneurysms. Fedak

et al.

reported the fundamental role of matrix

metalloproteinases (MMP) in the structural integrity of the

aorta.

In some studies, loss of elastin and collagen of the aortic

wall has been demonstrated to induce the development of

aneurysms. Loss of elastin and collagen is caused by an increase

in the activity of matrix proteinases (elastase and collagenase)

or a decrease in the activity of anti-proteases [mellaproteinase

tissue inhibitor (TIMP)] and alpha-1-antitrypsin.

Increase in

the levels of intercellular adhesion molecules induces migration

of macrophages to this region, with the resultant increase in

the production of MMP2 and MMP9, fragmentation of elastin

and triggering of aneurysm formation. Macrophages degrade

elastin by activating tumour necrosis factor and interleukin-1.

The production of elastin and collagen may also be impaired

Department of Cardiovascular Surgery, Dr Siyami Ersek

Cardiovascular Surgery and Thoracic Hospital, Istanbul,

Turkey

Ahmet Yavuz Balcı, MD

Unsal Vural, MD,

unsalvural@gmail.com

MD Fatih Özdemir MD

Mehmet Kızılay MD

Mutlu

enocak MD

lyas Kayacıo

lu MD, PhD

brahim Yekeler, MD

Department of Cardiovascular Surgery, Ko

uyolu Training

and Research Hospital, Istanbul, Turkey

Rezan Aksoy, MD

Department of Cardiology, Acibadem University, Istanbul,

Turkey

Seçkin Satılmı

, MD

Department of Cardiovascular Surgery, Derince Training

and Research Hospital, Istanbul, Turkey

Huseyin

kın, MD