Girrbach et al
Acquired Cardiovascular Disease
Longevity after mechanical aortic root replacement—do men live longer? Felix Girrbach, MD, Christian D. Etz, MD, PhD, Pascal M. Dohmen, MD, PhD, Konstantin von Aspern, MD, Maximilian Luehr, MD, Michael A. Borger, MD, PhD, Martin Misfeld, MD, PhD, Sandra Eifert, MD, PhD, and Friedrich-Wilhelm Mohr, MD, PhD Objective: To investigate whether longevity after mechanical aortic root replacement is influenced by the patient’s gender. Methods: From February 1998 to June 2011, 476 patients (376 men, 100 women, mean age, 53 12 years; range, 18-88) underwent composite aortic root replacement. Of these patients, 398 (312 men) were included in the present analysis. The indications for root replacement were aortic valve dysfunction (mostly stenosis) and concomitant aneurysmal disease in 334 (83.9%), acute type A aortic dissection in 51 (12.8%), and infective endocarditis in 10 (2.5%). Other indications were technical or anatomic considerations (0.8%).
ACD
Results: The women who presented for surgery were significantly older (men, 52 12 years vs women, 56 12 years; P ¼ .01). However, no significant differences were found with regard to previous cardiac surgery (5.3%, 20 men [6.4%] vs 1 woman [1.2%]; P ¼ .06), concomitant procedures (38%; 117 men [37.5%] vs 35 women [40.7%]; P ¼ .62), or additive EuroSCORE (men, 5.1 2.2; women, 5.2 2.2; P ¼ .55). The mean diameter of the ascending aorta was not significantly different between the 2 groups (men, 54 9 mm; women, 56 14 mm; P ¼ .97). The median follow-up period was 7.4 years (range, 0-13; 2366 cumulative patient-years), with no significant difference in hospital mortality (men, 6.7% vs women, 10.5%; P ¼ .25). Overall, men enjoyed significantly better longevity than did women. After 10 years, 73% 3% of the men and only 60% 6% of the women were alive (P ¼ .03). Although no long-term survival benefit for either gender was found in an age-matched subgroup among young patients (P ¼ .66), men experienced much more favorable longevity after 55 years of age (P ¼ .04). Consequently, the longevity in men—but not in women—was equal to an age-matched normal population. Conclusions: Overall, long-term survival after mechanical aortic root replacement was significantly better among men. However, comparing age-matched subgroups 55 years old, no significantly different life expectancy was found after mechanical root replacement. (J Thorac Cardiovasc Surg 2014;-:1-9)
A variety of surgical options have become available for the treatment of aortic root disease. With the incentive to avoid long-term anticoagulation, valve-sparing aortic root procedures—such as the David or Yacoub procedure—have been progressively promoted during the previous 2 decades.1,2 However, these techniques require preservable valve leaflets and have therefore been mainly limited to mild or moderate aortic regurgitation.3 Aortic root replacement—offering versatility in terms of the valve dysfunction treated and reliability in terms of
From the Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany. Disclosures: Authors have nothing to disclose with regard to commercial support. Drs F.G. and C.D.E. contributed equally to the present report. Received for publication Oct 14, 2013; revisions received March 12, 2014; accepted for publication March 21, 2014. Address for reprints: Felix Girrbach, MD, Department of Cardiac Surgery, Heart Centre Leipzig, University of Leipzig, Struempellstrasse 39, Leipzig D-04289, Germany (E-mail: [email protected]). 0022-5223/$36.00 Copyright Ó 2014 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2014.03.042
longevity—remains the reference standard for various aortic pathologic entities affecting the aortic valve and root.4 Since its invention in 1968 and after the initial experience,5,6 many modifications of the Bentall procedure have been developed until, in the early 1990s, the ‘‘biologic Bentall’’ was introduced—a ‘‘homemade’’ composite graft manufactured intraoperatively using stented bioprostheses. For the first time, it enabled root reconstruction in patients deemed unable to take anticoagulants.7 The biologic Bentall offered excellent long-term survival, very low rates of thrombembolic and bleeding complications in the long term, with only 1 late reoperation for structural failure in a series of 275 consecutive patients. That series for the first time revealed a less favorable outcome after aortic root replacement in women.7 However, whether men also experience better longevity after mechanical aortic root replacement remains unclear. Therefore, we investigated the potential gender-dependent outcome differences in a large cohort of mechanical aortic root replacements with the classic Bentall technique.
The Journal of Thoracic and Cardiovascular Surgery c Volume -, Number -
1
Acquired Cardiovascular Disease
Girrbach et al
Abbreviations and Acronyms CPB ¼ cardiopulmonary bypass PPM ¼ patient–prosthesis mismatch
METHODS
ACD
In a review of our institutional database, including >1200 patients treated for aortic root disease, we found 476 consecutive patients (376 men [79%] and 100 women [21%]) who had undergone aortic root replacement with a mechanical conduit (ATS Medical, Minneapolis, Minn) from February 1998 to June 2011. A total of 78 patients were excluded because the valve morphology had not been clearly specified (5%, n ¼ 25), because of previous aortic valve replacement (9%, n ¼ 41), or because of Marfan syndrome (2.5%, n ¼ 12). Specification of the valve morphology was required because the gender distribution among patients with bicuspid aortic valves might be distinct from that of those with tricuspid aortic valves. A total of 398 patients with primary composite root replacement (312 men [78.4%]; 86 women [21.6%]) were included in the statistical analysis. Additional patient characteristics and preoperative data are listed in Table 1. The indication for aortic root replacement was aortic valve pathologic features and an aneurysm of the aortic root and/or ascending aorta in 330 patients (82.9%) and acute type A aortic dissection in 51 patients (12.8%). Concomitant procedures were performed in 152 patients (117 of 312 men [37.5%] and 35 of 86 women [40.7%]; P ¼ .62). Concomitant total aortic arch (n ¼ 22) or partial arch replacement (n ¼ 56) was performed in 78 patients. Of the 56 patients receiving partial arch replacement, 43 were men (13.8% of 312) and 13 were women (15.1% of 86). Of the 22 patients receiving total arch replacement, 14 were men (4.5% of 312) and 8 were women (9.3% of 86). Additional operative data are listed in Table 2. The clinical data were completely drawn from our institutional database and patient records. All patients had provided written informed consent for their patient records and follow-up data to be used in an anonymized form
for retrospective studies. Thus, additional patient consent was not required by the local ethics committee.
Surgical Technique The modified button Bentall operation described by Kouchoukos and colleagues8 was performed in all cases. The native aortic valve and the diseased part of the ascending aorta were resected after preparing 2 buttons from the native aorta, including the coronary ostia. However, it has been our institutional policy to avoid the use of felt strips to prevent adhesions from developing and facilitate downstream repair or reoperation, if necessary. All patients received an ATS aortic valved graft conduit (ATS Medical). If concomitant procedures were performed, mitral valve repair (n ¼ 18 of 29) or replacement (n ¼ 11 of 29) were done after aortic valve excision. If coronary bypass grafting (n ¼ 51) was performed, the distal anastomoses were completed before the Bentall procedure. Arterial cannulation for cardiopulmonary bypass (CPB) depended on the extension of the diseased part of the aorta. The ascending aorta or proximal aortic arch were directly cannulated in most cases (303 of 398 patients [76%]). Cannulation of the right or left femoral artery was mostly used when emergency cannulation was performed in hemodynamically unstable patients with type A dissection or if the aneurysm was in close proximity to the sternum (n ¼ 41 of 398 [10%]). Cannulation of the right axillary artery (n ¼ 54 [13.6%]) was used if partial or complete arch replacement was anticipated (ie, in the case of acute type A dissection). Venous cannulation was usually performed through a 2-stage catheter in the right atrium. Cannulation of the femoral vein was performed as an alternative cannulation site, mostly with cannulation of the femoral artery. In accordance with the current guidelines, replacement of the ascending aorta was performed if the diameter exceeded 4.0 to 4.5 cm in bicuspid valve disease and >5.0 cm in tricuspid aortic valve disease or rapid progression was documented on computed tomography scan or magnetic resonance imaging. In most patients, intermittent cold antegrade crystalloid cardioplegia was used for myocardial protection (253 men [81%] and 77 women [90%]; P ¼ .08), mostly Bretschneider HTK solution (K€ohler Chemie,
TABLE 1. Preoperative patient characteristics Variable
All patients (n ¼ 398)
Men (n ¼ 312)
Women (n ¼ 86)
Age (y) Risk factors Hypertension History of smoking Diabetes COPD Hyperlipidemia Genetic disorder Logistic EuroSCORE Indication for root replacement Type A dissection Aneurysm Other Acute infective endocarditis Preoperative valve function Normal Significant AR Significant AS AR plus AS LVEF (%) BSA (Mosteller)
53 12 (18-88)
52 12 (18-88)
56 12 (29-83)
228 (57) 106 (27) 24 (6) 11 (3) 98 (25)
181 (58) 92 (29) 20 (6) 7 (2) 85 (27)
14.1 11.6
13.5 11.5
51 (13) 330 (83) 7 (2) 10 (3)
36 (12) 259 (83) 7 (2) 10 (3)
3 (1) 225 (57) 43 (11) 127 (32) 59 15 1.99 0.59
3 (1) 172 (55) 30 (10) 107 (34) 58 15 2.04 0.66
47 (55) 14 (16) 4 (5) 4 (5) 13 (15) 16.1 11.9 15 (17) 71 (83) 0 (0) 0 (0) 0 (0) 53 (62) 13 (15) 20 (23) 61 17 1.81 0.19
P value .01 .54 .38 .80 .26 .02 .01 .15 1.00 .35 .12 1.00 .33 .17 .07 .07
Acquired Cardiovascular Disease
Longevity after mechanical aortic root replacement—do men live longer? Felix Girrbach, MD, Christian D. Etz, MD, PhD, Pascal M. Dohmen, MD, PhD, Konstantin von Aspern, MD, Maximilian Luehr, MD, Michael A. Borger, MD, PhD, Martin Misfeld, MD, PhD, Sandra Eifert, MD, PhD, and Friedrich-Wilhelm Mohr, MD, PhD Objective: To investigate whether longevity after mechanical aortic root replacement is influenced by the patient’s gender. Methods: From February 1998 to June 2011, 476 patients (376 men, 100 women, mean age, 53 12 years; range, 18-88) underwent composite aortic root replacement. Of these patients, 398 (312 men) were included in the present analysis. The indications for root replacement were aortic valve dysfunction (mostly stenosis) and concomitant aneurysmal disease in 334 (83.9%), acute type A aortic dissection in 51 (12.8%), and infective endocarditis in 10 (2.5%). Other indications were technical or anatomic considerations (0.8%).
ACD
Results: The women who presented for surgery were significantly older (men, 52 12 years vs women, 56 12 years; P ¼ .01). However, no significant differences were found with regard to previous cardiac surgery (5.3%, 20 men [6.4%] vs 1 woman [1.2%]; P ¼ .06), concomitant procedures (38%; 117 men [37.5%] vs 35 women [40.7%]; P ¼ .62), or additive EuroSCORE (men, 5.1 2.2; women, 5.2 2.2; P ¼ .55). The mean diameter of the ascending aorta was not significantly different between the 2 groups (men, 54 9 mm; women, 56 14 mm; P ¼ .97). The median follow-up period was 7.4 years (range, 0-13; 2366 cumulative patient-years), with no significant difference in hospital mortality (men, 6.7% vs women, 10.5%; P ¼ .25). Overall, men enjoyed significantly better longevity than did women. After 10 years, 73% 3% of the men and only 60% 6% of the women were alive (P ¼ .03). Although no long-term survival benefit for either gender was found in an age-matched subgroup among young patients (P ¼ .66), men experienced much more favorable longevity after 55 years of age (P ¼ .04). Consequently, the longevity in men—but not in women—was equal to an age-matched normal population. Conclusions: Overall, long-term survival after mechanical aortic root replacement was significantly better among men. However, comparing age-matched subgroups 55 years old, no significantly different life expectancy was found after mechanical root replacement. (J Thorac Cardiovasc Surg 2014;-:1-9)
A variety of surgical options have become available for the treatment of aortic root disease. With the incentive to avoid long-term anticoagulation, valve-sparing aortic root procedures—such as the David or Yacoub procedure—have been progressively promoted during the previous 2 decades.1,2 However, these techniques require preservable valve leaflets and have therefore been mainly limited to mild or moderate aortic regurgitation.3 Aortic root replacement—offering versatility in terms of the valve dysfunction treated and reliability in terms of
From the Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany. Disclosures: Authors have nothing to disclose with regard to commercial support. Drs F.G. and C.D.E. contributed equally to the present report. Received for publication Oct 14, 2013; revisions received March 12, 2014; accepted for publication March 21, 2014. Address for reprints: Felix Girrbach, MD, Department of Cardiac Surgery, Heart Centre Leipzig, University of Leipzig, Struempellstrasse 39, Leipzig D-04289, Germany (E-mail: [email protected]). 0022-5223/$36.00 Copyright Ó 2014 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2014.03.042
longevity—remains the reference standard for various aortic pathologic entities affecting the aortic valve and root.4 Since its invention in 1968 and after the initial experience,5,6 many modifications of the Bentall procedure have been developed until, in the early 1990s, the ‘‘biologic Bentall’’ was introduced—a ‘‘homemade’’ composite graft manufactured intraoperatively using stented bioprostheses. For the first time, it enabled root reconstruction in patients deemed unable to take anticoagulants.7 The biologic Bentall offered excellent long-term survival, very low rates of thrombembolic and bleeding complications in the long term, with only 1 late reoperation for structural failure in a series of 275 consecutive patients. That series for the first time revealed a less favorable outcome after aortic root replacement in women.7 However, whether men also experience better longevity after mechanical aortic root replacement remains unclear. Therefore, we investigated the potential gender-dependent outcome differences in a large cohort of mechanical aortic root replacements with the classic Bentall technique.
The Journal of Thoracic and Cardiovascular Surgery c Volume -, Number -
1
Acquired Cardiovascular Disease
Girrbach et al
Abbreviations and Acronyms CPB ¼ cardiopulmonary bypass PPM ¼ patient–prosthesis mismatch
METHODS
ACD
In a review of our institutional database, including >1200 patients treated for aortic root disease, we found 476 consecutive patients (376 men [79%] and 100 women [21%]) who had undergone aortic root replacement with a mechanical conduit (ATS Medical, Minneapolis, Minn) from February 1998 to June 2011. A total of 78 patients were excluded because the valve morphology had not been clearly specified (5%, n ¼ 25), because of previous aortic valve replacement (9%, n ¼ 41), or because of Marfan syndrome (2.5%, n ¼ 12). Specification of the valve morphology was required because the gender distribution among patients with bicuspid aortic valves might be distinct from that of those with tricuspid aortic valves. A total of 398 patients with primary composite root replacement (312 men [78.4%]; 86 women [21.6%]) were included in the statistical analysis. Additional patient characteristics and preoperative data are listed in Table 1. The indication for aortic root replacement was aortic valve pathologic features and an aneurysm of the aortic root and/or ascending aorta in 330 patients (82.9%) and acute type A aortic dissection in 51 patients (12.8%). Concomitant procedures were performed in 152 patients (117 of 312 men [37.5%] and 35 of 86 women [40.7%]; P ¼ .62). Concomitant total aortic arch (n ¼ 22) or partial arch replacement (n ¼ 56) was performed in 78 patients. Of the 56 patients receiving partial arch replacement, 43 were men (13.8% of 312) and 13 were women (15.1% of 86). Of the 22 patients receiving total arch replacement, 14 were men (4.5% of 312) and 8 were women (9.3% of 86). Additional operative data are listed in Table 2. The clinical data were completely drawn from our institutional database and patient records. All patients had provided written informed consent for their patient records and follow-up data to be used in an anonymized form
for retrospective studies. Thus, additional patient consent was not required by the local ethics committee.
Surgical Technique The modified button Bentall operation described by Kouchoukos and colleagues8 was performed in all cases. The native aortic valve and the diseased part of the ascending aorta were resected after preparing 2 buttons from the native aorta, including the coronary ostia. However, it has been our institutional policy to avoid the use of felt strips to prevent adhesions from developing and facilitate downstream repair or reoperation, if necessary. All patients received an ATS aortic valved graft conduit (ATS Medical). If concomitant procedures were performed, mitral valve repair (n ¼ 18 of 29) or replacement (n ¼ 11 of 29) were done after aortic valve excision. If coronary bypass grafting (n ¼ 51) was performed, the distal anastomoses were completed before the Bentall procedure. Arterial cannulation for cardiopulmonary bypass (CPB) depended on the extension of the diseased part of the aorta. The ascending aorta or proximal aortic arch were directly cannulated in most cases (303 of 398 patients [76%]). Cannulation of the right or left femoral artery was mostly used when emergency cannulation was performed in hemodynamically unstable patients with type A dissection or if the aneurysm was in close proximity to the sternum (n ¼ 41 of 398 [10%]). Cannulation of the right axillary artery (n ¼ 54 [13.6%]) was used if partial or complete arch replacement was anticipated (ie, in the case of acute type A dissection). Venous cannulation was usually performed through a 2-stage catheter in the right atrium. Cannulation of the femoral vein was performed as an alternative cannulation site, mostly with cannulation of the femoral artery. In accordance with the current guidelines, replacement of the ascending aorta was performed if the diameter exceeded 4.0 to 4.5 cm in bicuspid valve disease and >5.0 cm in tricuspid aortic valve disease or rapid progression was documented on computed tomography scan or magnetic resonance imaging. In most patients, intermittent cold antegrade crystalloid cardioplegia was used for myocardial protection (253 men [81%] and 77 women [90%]; P ¼ .08), mostly Bretschneider HTK solution (K€ohler Chemie,
TABLE 1. Preoperative patient characteristics Variable
All patients (n ¼ 398)
Men (n ¼ 312)
Women (n ¼ 86)
Age (y) Risk factors Hypertension History of smoking Diabetes COPD Hyperlipidemia Genetic disorder Logistic EuroSCORE Indication for root replacement Type A dissection Aneurysm Other Acute infective endocarditis Preoperative valve function Normal Significant AR Significant AS AR plus AS LVEF (%) BSA (Mosteller)
53 12 (18-88)
52 12 (18-88)
56 12 (29-83)
228 (57) 106 (27) 24 (6) 11 (3) 98 (25)
181 (58) 92 (29) 20 (6) 7 (2) 85 (27)
14.1 11.6
13.5 11.5
51 (13) 330 (83) 7 (2) 10 (3)
36 (12) 259 (83) 7 (2) 10 (3)
3 (1) 225 (57) 43 (11) 127 (32) 59 15 1.99 0.59
3 (1) 172 (55) 30 (10) 107 (34) 58 15 2.04 0.66
47 (55) 14 (16) 4 (5) 4 (5) 13 (15) 16.1 11.9 15 (17) 71 (83) 0 (0) 0 (0) 0 (0) 53 (62) 13 (15) 20 (23) 61 17 1.81 0.19
P value .01 .54 .38 .80 .26 .02 .01 .15 1.00 .35 .12 1.00 .33 .17 .07 .07
