Management of Complex Aortic Root Disease: What if the coronary buttons cannot be reimplanted?

E. G. Danduch¹, A. Castro Varela², H. V. Schaff³, J. Dearani³, J. Crestanello³, A. Pochettino³, A. Todd³, N. Saran^4
1Mayo Clinic College of Medicine, Rochester, Minnesota ²Mayo Clinic, Tegucigalpa, Francisco Morazan ³Mayo Clinic, Rochester, Minnesota ⁴Mayo Clinic, Eau Claire, Wisconsin

Purpose: Aortic root replacement (ARR) in the setting of previous cardiac surgery can be challenging. Issues with coronary button reattachment can be unusually difficult to manage. Our purpose was to review the surgical techniques performed to address coronary button reattachment failures and analyze early and late outcomes.

Methods: We retrospectively analyzed the data of 554 adult patients (Median age 64.2 years, IQR 56.0, 71.3; Males n=408, 73.6%) with a history of previous cardiac surgery who underwent an ARR from 1/1996 to 12/2022. A modified Bentall surgery was performed in 479(86.5%) of the patients. In the remaining patients (n=75, 13.5%), when the coronary buttons could not be reattached to the aortic graft, alternative techniques for coronary revascularization (ART). ART was required for the left coronary system in 14(2.5%) patients, for the right side in 40(7.2%) patients, and for both sides in 18(3.2%) patients. The most frequent technique used for revascularization was vein interposition (n=53), followed by a Dacron graft interposition (n=19). However, in cases where the coronary ostia were too small, frail, or not visible, the ostium was ligated or sewn, and a subsequent coronary bypass graft was performed (n=23). Early and late outcomes were analyzed.

Results: Compared to the Bentall group, more patients with ART had previous aortic root replacement (24% vs 39.2%, p=0.007), root pseudoaneurysm (15.5% vs 30%, p=0.003), and non-elective reoperation (28% vs 42.7%, p=0.001).The ART group had more concomitant CABG for known coronary artery disease (15.2% vs 42.7%, p< 0.001), higher requirement for postoperative blood products (73.3% vs. 59.5%, p= 0.022), intra-aortic balloon pump (7.7% vs 20%, p< 0.001), Extra Corporeal Membrane Oxygenation (ECMO) (3.5% vs 21.3%, p< 0.001), prolonged mechanical ventilation (40% vs 28.2%, p=0.042), and longer stay in the intensive care unit (median 62.8hrs, IQR 24.0, 121.8 vs. Median 96.5hrs, IQR 39.0, 203.9, p= 0.035). In-hospital mortality was also higher in the ART group (5.9% vs 21.6%, p< 0.001). Only one patient in the ART group had coronary perfusion issues requiring re-exploration and revision of veins grafts to left and right coronary buttons in the perioperative period. Survival at 1, 5 and 10 years were 89.4%, 76.8% and 62% for the Bentall group and 65,6%, 53.8% and 40.8% for the ART group, respectively. Multivariable analysis identified age (HR 1.02, 95%CI 1.00-1.03) and ECMO (HR 2.13, 95%CI 1.10-4.13) as risk factors for late mortality while ART itself was not a risk factor.

Conclusion: In patients with history of previous cardiac surgery who undergo ARR, and where coronary buttons cannot be directly reattached, ART use may represent a bailout procedure. They have higher morbidity and worse early mortality, although coronary perfusion complications related to ART are rare. Age and ECMO use were identified as risk factors for late mortality while ART by itself was not.

Identify the source of the funding for this research project: Personal Fundings