Patient demographics and perioperative outcomes
A total of 51 adults underwent aortic root replacement using Tirone’s procedure, and Table 1 lists their preoperative characteristics. The mean age was 47.4±12.5 years, most were men (92.2%), and 6 (11.8%) had BMI ≥30 kg/m². Three presented with a dysmorphic syndrome and one had Marfan’s syndrome. All operations were performed electively for aortic aneurysm associated or not with aortic regurgitation grade 3 or 4 (n=21, 41.2%). The main cardiovascular risk factors were hypertension (n=20, 39.2%) and smoking (n=13, 25.5%), and none of the patients had undergone previous cardiac surgery or had coronary artery disease. The median Euroscore II was 4 [2; 5].
Table 2 shows the intraoperative data. For extracorporeal oxygenation, cannulation involved the brachiocephalic trunk artery in one patient, and in two, hot blood and non-exclusive retrograde cardioplegia were used. The BAVs were classified according to Sievers and were most often type I (n=31, 60.8%), with only one patient having type II. In most cases (n=29, 56.9%), patients had a fusion of the left and right coronary cusps. The diameter of the basal ring varied from 17 mm to 36 mm (mean 25.7±4.2 mm, n=41). Cusp plasty was performed in 50 patients (98.0%), via plication stitch in most cases, and 3 (5.9%) underwent commissure repair, one of them associated with patch repair. No additional aortic procedure or concomitant cardiac procedure was performed. Transesophageal echocardiography was performed for all patients, and mean left ventricular ejection fraction was 63.4±6.2% (n=46), with no grade III or IV aortic regurgitation, and the mean gradient was 6.9±1.5 mmHg (n=8). No second aortic cross-clamp was needed to correct residual aortic insufficiency.
Table 2 also shows the early postoperative outcomes. In-hospital mortality was zero, as was rehospitalization at 30 days. Extubation was performed the first postoperative day for 50 patients (98.0%) and the second day for one, and one patient was reintubated for 13 days for pneumopathy. No permanent neurological deficit was reported.
In the intensive care unit, one patient presented with cardiogenic shock requiring extracorporeal life support and received treatment with two stents in the right coronary with good evolution. At 5 years after surgery, this patient is doing well, and TTE findings show no aortic regurgitation or cardiac insufficiency. The principal arrhythmia in this population was atrial fibrillation, identified in eight patients. No patient had a pacemaker or defibrillator implanted during hospitalization.
One patient required re-exploration for bleeding. Ten (19.6%) patients needed one or more red blood cell infusions, four (7.8%) needed one or more platelet treatments, and four (7.8%) had needed one or more transfusions of fresh-frozen plasma. The median hospital stay was 9 days [8; 12], two of which were in the intensive care unit, and more than half of the population was discharged home after surgery. All patients had TTE before discharge, with a mean ejection fraction of 59.4±9.9%, no grade III or IV aortic regurgitation, and a mean gradient of 8.7±4 mmHg (n=43).