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Aortic replacement in cardiac surgery

December 1, 2017|Cleveland Clinic Journal of Medicine
Eric E. Roselli, MD
Author and Disclosure Information

Eric E. Roselli, MD
Department of Thoracic and Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic

Correspondence: Eric E. Roselli, MD, Department of Thoracic and Cardiovascular Surgery, Heart & Vascular Institute, J4-1, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; roselle@ccf.org

This article is based on Dr. Roselli’s presentation at the Sones/Favaloro Scientific Program, “Transforming the Delivery of Cardiovascular Care: Research and Innovation in the Heart & Vascular Institute,” held in Cleveland, OH, November 18, 2016. It was also presented at the American Association for Thoracic Surgery. The article was drafted by Cleveland Clinic Journal of Medicine and was then reviewed, revised, and approved by Dr. Roselli.

Dr. Roselli reported research grant support from Gore; consulting fees from Bolton, Gore, and Medtronic; and honoraria for speaking/teaching from Vascutek.

ABSTRACT

The number of aorta procedures performed annually in the United States has grown substantially during the past decade. Cleveland Clinic is a leader in research on the risk of aortic dissection in patients with a bicuspid or tricuspid aortic valve and associated aneurysm, which has led to changes in the recommendations of when to operate. Safety and efficacy data support more proactive treatment for most patients with thoracic aortic aneurysm and/or dissection with a growing emphasis on the need to provide life-long care to patients with aortic conditions.

KEY POINTS 

  • Adding a proximal thoracic aortic procedure to cardiac surgery does not adversely affect safety and efficacy.
  • Presence of a bicuspid aortic valve does not significantly affect outcomes of aortic root procedures.
  • Data support aortic replacement in patients when the aortic root vessels reach 5.5 cm in diameter.
  • Use of circulatory arrest does not directly affect the stroke risk associated with ascending aortic replacement surgery, but it may be a marker for more serious pathology.

AORTIC DISSECTION RISK IN PATIENTS WITH A BICUSPID AORTIC VALVE AND AORTOPATHY

Figure 4. Risk of dissection in patients with bicuspid aortic valve increases more steeply in valves with a diameter larger than 5.5 cm.
To help stratify these risks, a Cleveland Clinic study published in 2015 analyzed data from 1,181 patients with bicuspid aortic valve and associated aortopathy. The goal was to determine the risk of aortic dissection based on the diameter of the ascending aorta.6 Results showed that the probability of dissection increased steeply when the aortic root was 5 cm and the ascending aorta reached about 5.5 cm (Figure 4).

These findings provided important evidence supporting the need to be more proactive in the decision to perform aortic replacement. Furthermore, the data prompted the American Heart Association and the American College of Cardiology to publish a clarification statement providing more detail to its thoracic aorta and aortic valve guidelines. This update indicates that in patients with a bicuspid aortic valve, it is reasonable to recommend surgery when the aorta is 5 cm instead of waiting until 5.5 cm in high-volume centers that have demonstrated excellent surgical outcomes. This clarification statement was based on Cleveland Clinic outcomes showing a mortality rate of 0.25% and a stroke rate of 0.75% in a population that included patients undergoing emergency aortic dissection surgery.6

This study also analyzed data on patients treated with expectant care with optimal medical management and imaging surveillance (ie, to monitor the dilated aorta). Results from this subset showed that the probability of needing an aortic intervention is about 60% during the next 10 years once the aorta is within the 4.5 cm to 5 cm range.

Another study addressing the correlation between risk and aortic size examined 771 patients with a dilated ascending aorta (≥ 4 cm) and a tricuspid aortic valve.7 This study confirmed the use of patient height as an important factor for indexing maximum aortic size to patient body size for predicting risk of late complications. Specifically, this study suggested that the risk of complications from aortic aneurysm rises when the maximum aortic area-to-height ratio exceeds 10. This serves as a follow-up to previously published data demonstrating the value of aortic cross-sectional area-to-height ratio as a predictor of risk in patients with bicuspid valves.8 In general, the results of all 3 studies suggest that we should be more proactive in operating on patients with a dilated ascending aorta to prevent later risk of rupture or dissection when the surgical risk is low.

When making decisions about patients who need aortic replacement, it is important to assess many patient details: their aortic disease, their other nonaortic comorbidities, and the institution’s outcomes. This decision is best made by a dedicated cardioaortic specialist at a dedicated center of excellence.

WHAT IS COMING?

Minimally invasive and endovascular surgery

More ascending aortic surgeries are being done using minimally invasive approaches. At Cleveland Clinic, about 40% of isolated ascending aortic operations are performed through a mini-sternotomy J incision approach. A Cleveland Clinic study published in 2017 evaluated outcomes from this less-invasive technique for proximal aortic surgery compared with full median sternotomy.9 Results showed it was an effective approach with fewer complications, shorter hospital stays, and lower costs.

Stent grafts

The role for stent-graft devices has continued to expand.10 At Cleveland Clinic, we have performed more than 40 ascending aortic stent-graft procedures, one of the largest numbers in the world. Having this stent-graft option has enabled us to provide treatment for the patients at exceedingly high risk who previously had few or no options. Industry partners are working to develop dedicated devices for these indications, and we are working with them to bring new device trials to this underserved population of patients. 

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