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The Journal of Cardiovascular Surgery 2002 June;43(3):337-43


language: English

Factors influencing immediate and long-term results after button’s technique

Ruvolo G., Fattouch K., Sinatra R., La Francesca S., Macrina F., Tonelli E., Masciangelo R., Marino B.

From the Institute of Cardiac Surgery *Institute of Experimental Medicine and Pathology “La Sapienza” University of Rome, Rome, Italy


Background. Aim of ­this ­study was to eval­u­ate the fac­tors influ­enc­ing imme­di­ate and ­long-­term ­results in ­patients under­go­ing aor­tic ­root replace­ment ­with a com­pos­ite ­graft.
Methods. Between January 1989 and February 1999, 105 ­patients (83 ­males, 22 ­females) who under­went Bentall tech­nique ­were stud­ied. Preoperative diag­no­sis was annu­lo-aor­tic ecta­sia in 54, aor­tic dis­sec­tion in 27, ath­e­ros­cle­rot­ic aneu­rysm in 21, and aor­titis in 3 cas­es. Seventeen ­patients ­were affect­ed by Marfan’s syn­drome. All cas­es, elec­tive, ­urgent, and emer­gen­cy ­were includ­ed. Button tech­nique was per­formed and the asso­ciat­ed sur­gi­cal pro­ce­dures ­were cor­o­nary ­artery ­bypass graft­ing in 21, ­total aor­tic ­arch replace­ment in 15, prox­i­mal hemi ­arch in 5, and ­mitral ­valve replace­ment in 5 cas­es.
Results. The over­all hos­pi­tal mor­tal­ity ­rate was 7.6% (n=8). Univariate anal­y­sis ­using χ2 and/or two-sam­ple “t”-­test ­showed ­that dis­sec­tion, aor­titis, aneu­rysm rup­ture ­into-pleu­ra or per­i­car­di­um, emer­gen­cy stat­us, ­redo, pro­longed ­pump ­times and cir­cu­la­to­ry ­arrest, ­were pre­dic­tors influ­enc­ing in-hos­pi­tal mor­tal­ity. Coagulopathy, low car­diac out­put, ­stroke, per­i­op­er­a­tive myo­car­dial infarc­tion, sur­gi­cal bleed­ing lead­ing to reop­er­a­tion, ­were sig­nif­i­cant­ly relat­ed to in-hos­pi­tal mor­tal­ity (by cor­re­la­tion anal­y­sis). A mul­ti­var­i­ate anal­y­sis ­showed ­that, emer­gen­cy stat­us (p=0.027), aor­tic dis­sec­tion (p=0.029), per­i­op­er­a­tive myo­car­dial infarc­tion (p=0.0021), reop­er­a­tion for bleed­ing (p=0.0023), and ­pump ­time >180 min (p=0.011), ­were sig­nif­i­cant. The actu­ar­i­al sur­vi­val ­rate at 10 ­years fol­low-up was 84.7%. There ­were 8 ­late ­deaths. The Kaplan-Meier ­showed sig­nif­i­cant dif­fer­enc­es ­when con­sid­er­ing dis­sec­tion vs non-dis­sec­tion (p=0.018), but did not ­reach sig­nif­i­cance in Marfan vs non-Marfan ­groups (p=0.83). ­NYHA ­class IV (p=0.052), pre­vi­ous car­diac sur­gery pro­ce­dure (p=0.041), con­com­i­tant ­CABG (p=0.021), ­total aortic ­arch recon­struc­tion (p=0.001), and ­mitral ­valve replace­ment (p=0.016), ­were iden­ti­fied as sig­nif­i­cant by Log Rank ­test.
Conclusions. The Bentall pro­ce­dure for aor­tic ­root replace­ment is ­safe and dur­able; in hos­pi­tal mor­tal­ity in elec­tive stat­us it was 1.28%; ear­ly and ­long-­term mor­tal­ity high­er in ­patients ­with ­acute dis­sec­tion. Six ­late ­deaths ­were pro­ce­dures relat­ed. Sixty-six ­patients (76.4%) ­were in ­NYHA I ­class at fol­low-up. The inci­dence of ­late out­comes, throm­boem­bo­lism (1.03%), ­graft infec­tion (2.06%), pseu­do­aneu­rysm (0%), reop­er­a­tion in ascend­ing aor­ta or aor­tic ­valve (3.1%), oper­a­tions on the remain­ing aor­ta (6.7%), and hem­or­rhage due to anti­co­ag­u­lant ther­a­py (1.03%), are ­very low.

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