Download PDF
Thorac Cardiovasc Surg 2000; 48(6): 342-346
DOI: 10.1055/s-2000-8346
Original Cardiovascular
Original Paper
© Georg Thieme Verlag Stuttgart · New York

Proximal Aortic Dissection Late After Aortic Valve Surgery: 119 Cases of a Distinct Clinical Entity[*]

Y. von Kodolitsch1 , R. Loose4 ,  J. Ostermeyer2 , A. Aydin1 , D. H. Koschyk1 , A. Haverich3 , C. A. Nienaber1 , Y. von Kodolitsch1 , R. Loose4 ,  J. Ostermeyer2 , A. Aydin1 , D. H. Koschyk1 , A. Haverich3 , C. A. Nienaber1
  • 1Department of Internal Medicine, Division of Cardiology at the University Hospital Eppendorf, Hamburg, 2Department of Cardiovascular Surgery, St. Georg Hospital, Hamburg, 3Department of Cardiovascular Surgery of the Hannover Medical School, Hannover, 4Department of Cardiovascular Surgery, Christian-Albrechts-University, Kiel, Germany[1]
Further Information

Publication History

Publication Date:
31 December 2000 (online)

    Permissions and Reprints All articles of this category

Background: Besides systemic hypertension and Marfan syndrome, only previous aortic valve replacement (AVR) is independently associated with proximal (type A) aortic dissection. Little, however, is known to date about the characteristic features of this clinical entity. Methods: Clinical, prognostic and predisposing profiles in 119 cases of dissection and/or aneurysm occuring 1 month to 16 years after routine AVR were analyzed comprising 62 cases from our database and 57 reported cases. Results: Dissection after AVR has been observed in 0.6 % of all routine AVR procedures in the past four decades. With clinical signs, symptoms and anatomical features different from classic aortic dissection post-AVR dissection is a distinct clinical entity with a high intraoperative mortality of 44 % and a 30-day and 5-year survival of 62 % and 43 %, respectively. Aortic regurgitation and a thin and/or fragile aortic wall at AVR, however, predict late dissection. Using a prediction model, the risk of late dissection can be stratified based on information obtained during AVR surgery. Conclusions: Aortic dissection following AVR is likely to represent a distinct clinical entity which can be predicted and possibly prevented at AVR.

Key words:

Aneurysm - Aorta - Risk factors - Surgery - Valves

1 The material of this manuscript was presented at the International Congress on “Risk Stratification in Cardiac and Thoracic Surgery”, October 15/16, 1999, Cologne, Germany.

References

  • 1 von Kodolitsch Y, Simic O, Dresler C, Haverich, Nienaber C A. Aortic valve replacement: An independent predisposing factor for late aortic dissection?.  Circulation. 1997;  96 I-507 (A)
    PubMedSearch in Google Scholar
  • 2 von Kodolitsch Y, Simic O, Bregenzer T, Dresler C, Haverich, Nienaber C A. Der Aortenklappenersatz als unabhängiger prädiktiver Faktor für die Entstehung einer späten Aortendissektion.  Z Kardiol. 1998;  87 604-612
    CrossrefPubMedSearch in Google Scholar
  • 3 von Kodolitsch Y, Simic O, Schwartz A G, Dresler C, Loose R, Staudt M, Ostermeyer J, Haverich A, Nienaber C A. Predictors of proximal aortic dissection at the time of aortic valve replacement.  Circulation. 1999;  100 II-287-II-294
    PubMedSearch in Google Scholar
  • 4 Muna W F, Spray T L, Morrow A G, Roberts W C. Aortic dissection after aortic valve replacement in patients with valvular aortic stenosis.  J Thorac Cardiovasc Surg. 1977;  74 65-69
    PubMedSearch in Google Scholar
  • 5 Bachet J, Mesnildrey P, Goudot B, Tawil N, Dubois C, Brodaty D, Schlumberger S, Guilmet D. Dissection de l'aorte ascendante apres remplacement valvulaire aortique.   Presse Med. 1984;  13 2253-2256
    PubMedSearch in Google Scholar
  • 6 Burckhardt D, Striebel D, Vogt S, Hoffmann A, Roth J, Weiss P, Kiowski W, Pfisterer M, Burkart F, Althaus U, Goy J J, Sadeghi H, Grädel E. Heart valve replacement with St. Jude Medical valve prothesis. Long-term experience in 743 patients in Switzerland.  Circulation. 1988;  78 I-18-I-24
    PubMedSearch in Google Scholar
  • 7 Cohn L H, Allred E N, DiSesa V J, Sawtelle K, Shemin R J, Collins J J. Early and late risk of aortic valve replacement. A 12 year concomitant comparison of the porcine bioprosthetic and tilting disc prosthelic aortic valves.  J Thorac Cardiovasc Surg. 1984;  88 695-705
    PubMedSearch in Google Scholar
  • 8 Douglas P S, Hirshfeld J W, Edie R N, Harken A H, Stephenson L W, Edmunds L H. Clinical comparison of St. Jude and porcine aortic valve prostheses.  Circulation. 1985;  72 II-135-II-139
    PubMedSearch in Google Scholar
  • 9 Lytle B W, Cosgrove D M, Taylor P C, Goormastic M, Stewart R W, Golding L A R, Gill C C, Loop F D. Primary isolated aortic valve replacement. Early and late results.  J Thorac Cardiovasc Surg. 1989;  97 675-694
    PubMedSearch in Google Scholar
  • 10 Hedoire F, Grollier G, Maragnes P, Valette B, Lognone T, Breut C, Scanu P, Bonnefoy L, Khayat A, Potier J C. Dissections de I'aorte apres remplacement valvulaire aortique.  Arch Mal Coeur Vaiss. 1991;  84 967-974
    PubMedSearch in Google Scholar
  • 11 Carrel T, von Segasser L, Jenni R, Gallino A, Egloff L, Laske A, Turina M. Dealing with dilated ascending aorta during aortic valve replacement: advantages of conservative surgical approach.  Eur J Cardio-thorac Surg. 1991;  5 137-143
    CrossrefPubMedSearch in Google Scholar
  • 12 Presbitero P, Aruta E, Rabajoli F, Agaccio G, Donegani E, Orzan F, Malara D, Di Summa M, Morea M. Aortic dissection after aortic valve replacement: clinical and anatomic features.  G Ital Cardiol. 1993;  22 941-947
    PubMedSearch in Google Scholar
  • 13 Aris A, Padró J M, Cámara M L, Lapiedra O, Caralps J M, Borrás Y, Carreras F, Pons-Lladó G. The monostrut Bjork-Shiley valve. Seven years' experience.  J Thorac Cardiovasc Surg. 1992;  103 1074-1082
    PubMedSearch in Google Scholar
  • 14 David T E, Armstrong S, Sun Z. Clinical and hemodynamic assessment of the Hancock II bioprosthesis.  Ann Thorac Surg. 1992;  54 661-668
    PubMedSearch in Google Scholar
  • 15 Prenger K, Pieters F, Cheriex E. Aortic dissection after aortic valve replacement; Incidence and consequences for strategy.  J Card Surg. 1994;  9 495-499
    PubMedSearch in Google Scholar
  • 16 Miller D C, Mitchell R S, Oyer P E, Stinson E B, Jamieson S W, Shumway N E. Independent determinations of operative mortality for patients with aortic dissectios.  Circulation. 1984;  70 I-153-I-164
    PubMedSearch in Google Scholar
  • 17 Crawford E S, Svensson L G, Coselli J S, Safi H J, Hess K R. Aortic dissection and dissecting aortic aneurysms.  Ann Surg. 1988;  208 254-272
    CrossrefPubMedSearch in Google Scholar
  • 18 Epperlein S, Mohr-Kahaly S, Erbel R, Kearney P, Meyer J. Aorta and aortic valve morphologies predisposing to aortic dissection. An in vivo assessment with transesophageal echocardiography.  Eur J Cardiol. 1994;  15 1520-1527
    PubMedSearch in Google Scholar
  • 19 Derkac W, Laks H, Cohn L H, Collins J J. Dissecting aneurysm after aortic valve replacement.  Ann Surg. 1974;  109 388-390
    PubMedSearch in Google Scholar
  • 20 Spitzer S, Blanco G, Adam A, Spyrou P G, Mason D. Superior vena cava obstruction and dissecting aortic aneurysm.  JAMA. 1975;  233 164-165
    CrossrefPubMedSearch in Google Scholar
  • 21 Fukuda T, Tadavarthy S M, Edwards J E. Dissecting aneurysm of aorta complicating aortic valvular stenosis.  Circulation. 1976;  53 169-175
    PubMedSearch in Google Scholar
  • 22 Charnsangarvej C. Occlusion of right pulmonary artery by acute dissecting aortic aneurysm.  AJR. 1979;  132 274-276
    PubMedSearch in Google Scholar
  • 23 Gooch A S. Downward displacement of competent aortic valve prosthesis without left ventricular enlargement: A new sign of ascending aortic root dissection in absence of valvular regurgitation.  Am Heart J. 1982;  103 920-922
    CrossrefPubMedSearch in Google Scholar
  • 24 Orszulak T A, Pluth J R, Schaff H V, Piehler J M, Smith H C, McGoon D C. Results of surgical treatment of ascending aortic dissections occuring late after cardiac operation.  J Thorac Cardiovasc Surg. 1982;  83 538-545
    PubMedSearch in Google Scholar
  • 25 Le Heuzey J Y, Guize L, Guerinon J, Forman J, Sellier P, Maurice P. Dissection de I'aorte ascendante apres replacement valvulaire aortique.  Arch Mal Coeur. 1983;  11 1349-1356
    PubMedSearch in Google Scholar
  • 26 Stone D L, Petch M C, Verney G I, Dixon A K. Superior mediastinal obstruction with aortic dissection after aortic valve replacement. Diagnosis by computed tomography.  Br Heart J. 1984;  51 565-567
    PubMedSearch in Google Scholar
  • 27 Morin D, Sadeghi H. Dissection de l'aorte apres chirurgie cardiaque.  Schweiz med Wschr. 1984;  114 1530-1534
    PubMedSearch in Google Scholar
  • 28 Nancarrow R A, Higgins C B. Progressive aortic dilatation after aortic valve replacement.  Am J Roentgenol. 1984;  142 669-672
    PubMedSearch in Google Scholar
  • 29 Schofield P M, Bray C L, Brooks N. Dissecting aneurysm of the thoracic aorta presenting as right attial obstruction.  Br Heart J. 1986;  55 302-304
    PubMedSearch in Google Scholar
  • 30 Hirao D, Ishikura Y, Odagiri S, Shimazu A, Yano K, Shirakusa T. A case report of type II dissecting aneurysm after aortic valve replacement, successful repair by the modified Cabrol's method.  J Jpn Assoc Thorac Surg. 1991;  39 1940-1944
    PubMedSearch in Google Scholar
  • 31 Albat B, Thevenet A. Dissecting aneurysms of the ascending aorta occuring late after aortic valve replacement.  J Cardiovasc Surg. 1992;  33 272-275
    PubMedSearch in Google Scholar
  • 32 Osada T, Nagae T, Hirayama T, Ishimura S, Furukawa K. A case of ascending aortic dissection after aortic valve replacement in congenital bicuspide aortic valve.  J Jpn Assoc Thorac Surg. 1992;  40 1928-1932
    PubMedSearch in Google Scholar
  • 33 Tayama K, Aoyagi S, Akashi H, Oryoji A, Higa Y, Hiromatsu S, Yamana K, Kosuga K, Ohishi K. Aortic dissection after aortic valve replacement. Report of a case with an aortocameral fistula.  Thorac Cardiovasc Surgeon. 1995;  43 299-301
    PubMedSearch in Google Scholar
  • 34 Anderson R P, Bonchek L I. The analysis and presentation of surgical results by actuarial methods.  J Surg Res. 1974;  16 224-228
    CrossrefPubMedSearch in Google Scholar
  • 35 Nunley D L, Grunkemeier G L, Starr A. Aortic valve replacement with coronary bypass grafting. Significant determinants of ten-year survival.  J Thorac Cardiovasc Surg. 1983;  85 705-711
    PubMedSearch in Google Scholar
  • 36 Stone P H, Clark R D, Goldschlager N, Selzer A, Cohn K. Determinants of prognosis of patients with aortic regurgitation who undergo aortic valve replacement.  JACC. 1984;  3 1118-1126
    PubMedSearch in Google Scholar
  • 37 Czer L S C, Gray R J, Stewart M E, De Robertis M, Chaux A, Matloff J M. Reduction in sudden late death by concomitant revascularization with aortic valve replacement.  J Thorac Cardiovasc Surg. 1988;  95 390-401
    PubMedSearch in Google Scholar
  • 38 von Kodolitsch Y, Nienaber C A. Die intramurale Hamorrhagie der thorakalen Aorta: Diagnostik, Therapie und Prognose bei 209 in vivo diagnostizierten Fallen.  Z Kardiol. 1998;  87 797-807
    CrossrefPubMedSearch in Google Scholar
  • 39 Nienaber C A, von Kodolitsch Y. Meta-analysis of changing mortaliy pattern in thoracic aortic dissection.  Herz. 1992;  17 398-416
    PubMedSearch in Google Scholar
  • 40 Pieters F A A, Widdershoven J W, Gerardy A-C, Geskes G, Cheriex E C, Wellens H J. Risk of aortic dissection after aortic valve replacement.  Am JCardiol. 1993;  72 1043-1047
    PubMedSearch in Google Scholar
  • 41 Litchford B, Okies J E, Sugimura S, Starr A. Acute aortic dissection from cross-clamp injury.  J Thorac Cardiovasc Surg. 1976;  72 709-713
    PubMedSearch in Google Scholar

2 Y. von Kodalitsch is supported by grants of the Deutsche Forschungsgemeinschaft (KO 1828/1 and KO 1828/ 1-2)

1 The material of this manuscript was presented at the International Congress on “Risk Stratification in Cardiac and Thoracic Surgery”, October 15/16, 1999, Cologne, Germany.

Dr. Y. von Kodolitsch

Department of Internal Medicine Division of Cardiology University Hospital Eppendorf

Martinistrasse 52, 20246 Hamburg, Germany

Phone: ++4940 42803 4308

Fax: ++4940 42803 8015

Email: kodolitsch@uke.uni-hamburg.de