Schematic representation of antegrade and retrograde effects of ascending aorta replacement with non-compliant prosthetic graft. In the pediatric population, one of the most daunting long-term complications of prosthetic aorta replacement regards the development of false aneurysm of the suture line. Troost et al. Additional examples of this tissue incompatibility derive again from pulmonary autograft reinforcement with Dacron prosthesis during Ross operation and from experimental findings demonstrating strong inflammatory responses triggered by prosthetic materials when used to wrap the exterior surface of arterial vessels [ 22 ].
Abnormal and unregulated foreign body reaction might severely impair tissue growth and elastic remodeling and further hemodynamic function of the neo-aorta [ 23 ]. Another well-documented event is represented by the long-term size change of Dacron grafts used in the ascending aorta. A study from Takami et al. Beside the caveat related to the fact that this evaluation was performed in thoracic descending aorta, with a known difference in hemodynamics compared to ascending aorta, the results are in agreement with previous data published by Mattens et al.
Early studies from Berger et al. However, the physical changes in the yarn architecture together with the in vivo material degradation in contact with biological fluids determine loss of elasticity and change in compliance of the graft that is further responsible of the dilation profile shown by these prostheses [ 29 , 30 ] and their functional consequences [ 1 ]. The lack of adequate elastomechanical properties leads to deleterious effects not only at the graft site but also retrogradely with significant reflexes on cardiac function and aortic valve competence as schematized in Fig.
The introduction of a non-distensible graft and the compliance mismatch with the highly elastic native aorta have been shown to determine a significant change in the aortic vascular properties, eventually resulting in increased ventricular afterload [ 31 , 32 ].
Characteristic impedance and pulse wave reflection, parameters describing vascular compliance, are dramatically affected, and the loss of Windkessel effect and alteration of the pulse wave propagation translate in additional workload for the left ventricle eventually inducing adaptive hypertrophy [ 32 , 33 ].
The finding of increased aortic stiffness and augmented aortic pulsed wave velocity PWV have been widely reported in the elderly population in which increased aortic rigidity translates in ventricular hypertrophy and reduced coronary flow because of the loss of diastolic augmentation [ 34 ]. A clinical study comparing age-matched subject bearing a thoracic aortic graft with healthy controls demonstrated under exercise a more marked increase in aortic impedance and an excessive reduction in pulse wave reflection in respect to controls, indicating an higher aorta-graft compliance mismatch when high output flow is required [ 33 ].
In these circumstances, the Dacron graft behaved as a functional stenosis, generating a significant change in impedance at the interface with the native elastic artery and secondarily determining a reduction in ventricular pumping efficiency.
The latter was associated to a higher cardiac energetic cost to maintain a given flow in the less compliant arterial system [ 33 ].
Further studies documented similar consequences after proximal or long bypass procedures with non-compliant grafts, identifying increased characteristic impedance, decreased Windkessel effect of the proximal aorta, and increased systolic wall stress as the main potential factors [ 32 , 38 — 40 ].
More importantly, Kass et al. Also, the group of Toutouzas et al. Translation of these data into the clinical scenario meets the evidence of a natural decrease of arterial compliance with age, with a parallel increase in systolic pressure [ 44 ]. This aspect might further complicate the hemodynamic situation especially considering that aortic reconstructive surgery is often performed on elderly patients, whose aortas are already further up in the degenerative process and might have reduced compliance.
Additionally, increased aortic stiffness has been associated to left ventricular diastolic dysfunction in hypertensive patients [ 45 ]. Introduction of non-compliant grafts in these circumstances, with the consequent further reduction in compliance, might lead to even more relevant hemodynamic changes. Interestingly, one of the first studies demonstrating hemodynamic and ventricular changes in patients undergoing thoracic aorta replacement with prosthetic grafts included a series of subjects with ages ranging between 48 and 60 years [ 37 ].
Therefore, these consequences might not be imputed to original abnormal or deteriorated conditions of the native aorta. Data on the long-term hemodynamic outcomes in even older patients could further elucidate this phenomenon and might be interesting in order to predict eventual outcomes in aged population. The consequences of the compliance mismatch on the aortic valve function might be even more striking in the clinical scenario.
Loss of compliance and augmented stiffness of aortic root determine and increased load of aortic valve cusps, leading to their dysfunction and accelerating their degeneration [ 12 , 46 ].
Interestingly, David et al. These authors showed an acceptable long-term outcome in terms of postoperative aortic insufficiency. The freedom from reoperation on the aortic valve at 1, 5, 10, and 15 years were Therefore, despite the degree of aortic valve dysfunction does not achieve a surgical significance or mandate for reoperation, these data represent an evidence that prosthetic replacement of aortic root might influence the mechanical properties of the aorta and the hemodynamic parameters of the aorta-valve complex, inducing valve malfunctioning.
The above-cited studies presented a mean follow-up of 60 months, showing acceptable performance, but it is still unclear whether the aortic insufficiency induced by the rearrangement of the aortic root or by the simple valve degeneration is able to progress in 10 years up to a level requiring reintervention.
However, as stated by David et al. However, despite that it is difficult to establish a causative effect between the reduced compliance of the neo-aortic root and the general degenerative evolution of the aortic valve, it has been postulated that a rigid aortic root may accelerate degenerative changes in the aortic cusps [ 50 ].
In this context, Zehr et al. The hemodynamic load exerted on an inextensible graft might also reflect in a progressive annular dilation eventually leading to recurrent aortic insufficiency, and this effect might be more pronounced in Marfan syndrome patients, in whom congenital abnormal fibrillin-1 metabolism can render residual aortic tissues even weaker and more prone to dilation [ 51 ].
These points have been stressed by Rama and colleagues in when, taking from the incidence of annulus dilatation and cusp damage and dysfunction, they suggested a new technique of valve-sparing aortic root replacement aiming at preserving and reconstituting anatomical and geometrical features of sinotubular junction and preventing traumatic damage of cusps against inextensible Dacron prosthesis [ 52 ].
Therefore, another important element to be considered in the definition of aortic root compliance and of the dynamics of the valve-aortic root complex is represented by the Valsalva sinuses. A large piece of experimental effort has been spent since the first historical description of Bellhouse and Bellhouse in the early s, which demonstrated the dynamic function of sinuses in the modulation of aortic valve closure [ 53 ].
The majority of in vitro and the in vivo studies, in both native or surgical reconstructed aortic roots, are pointing at the role of the sinuses during the diastolic phase in positively regulating the leaflet dynamics during the cardiac cycle [ 54 , 55 ] and in coronary flow modulation [ 56 ]. The hydrodynamic properties of the aortic root provided by the presence of the sinuses allow for reduced transvalvular gradient and leaflet motion, while their absence reduces the time required for leaflet coaptation, increases the valve closing volume and the maximum transvalvular flow velocity, determining an increase in the working stress on the valve tissue, with eventual premature structural valve deterioration [ 57 ].
In fact, the normal compliance of the root and its sinuses is considered at the basis of the normal leaflet dynamics. The systolic expansion of the aortic root helps the free margins of the leaflet to maintain a distended and flat configuration during opening. Loss of root compliance might determine free margin folding and wrinkling because of reduced excursion from the close to total opening position, eventually leading to accelerated degeneration with valve dysfunction [ 58 ].
As recognized by the same inventor of the reimplantation technique, when reconstructing the aortic root with inextensible anelastic Dacron conduit, leaflet motion will occur inside a stiff and rigid prosthesis with increased risk of valve dysfunction and early degeneration [ 59 ].
The importance of recreate neo-sinuses during the procedure has been discussed and also testified by the last modification of David operation which includes sinotubular ridge reconstruction performed by adapting the graft in the spaces in between commissures in order to resemble pseudosinuses [ 59 , 60 ]. Indeed, the use of a straight Dacron graft abolishes the physiological geometry of the sinuses and sinotubular junction and it has been demonstrated that the velocity of opening and closure of the aortic cusps is greatly increased in this operation [ 61 ], but it can be decreased by creating neo-aortic sinuses [ 62 ] or by using the Valsalva graft [ 63 ].
Simulating an increase of cardiac performance, as per physical exercise, these authors demonstrated that the presence of the sinuses ensured an increase in the valve effective orifice area guaranteeing to maintain the transvalvular gradient unchanged for each increase in the cardiac output. Therefore, preservation of aortic root compliance and adequate shape and dimension of Valsalva sinuses is crucial for the optimal and durable function of the aortic valve as the first allows a normal leaflet dynamics and motion with wrinkle-free cusp opening, while the latter ensures an efficient hemodynamic answer in conditions of increased cardiac output [ 64 ].
This finding acquires particular significance in the clinical scenario, as procedures of valve-sparing aortic root replacement or stentless valve full root implantation are usually performed in young active patients which might undergo important variations in the cardiac performance.
To this extent, a clinical study comparing the hemodynamics in patients, who had undergone aortic root replacement using stentless valves with straight xenopericardial conduits or prosthetic Valsalva grafts, confirmed the importance of the elastic properties of the aortic conduit and demonstrated that the presence of neo-sinuses might improve the compliance of the aortic root determining a more physiologic flow pattern, as indicated by the maximum flow velocity above the aortic valve [ 65 ].
These findings stress the reported importance to use prosthetic conduits provided with neo-sinuses but also induce to consider the compliance of the graft itself for an optimal long-term result at the level of the aortic valve. Despite the overall successful performance of prosthetic Dacron graft in aortic surgery, an increasing amount of evidence is pointing at the discrepancy between the elastomechanical properties of the grafts and of the native aorta as the responsible of worrisome sequelae both locally, at the anastomotic site, and retrogradely, in term of valve dysfunction and ventricular workload.
Concerns on the lack of elasticity of Dacron grafts have been expressed also in the surgical literature especially in regards of their use to reconstruct hemodynamically important structures as Valsalva sinuses because of the progressive loss of compliance in vivo during encapsulation by fibrous tissue [ 11 , 12 ].
The loss of compliance induced by the interposition of an inextensible graft at the level of the aortic root not only might impart excessive stress on the suture line, leading to dangerous anastomotic aneurysm, but also blunt the favorable Windkessel function and hydrodynamic action provided by the root elastic expansion and Valsalva sinuses.
Replacing or bypassing the aorta with non-compliant synthetic prostheses leads to serious changes in arterial wall, aortic leaflets, and ventricular loads [ 1 ], resulting in medium-term functional deterioration and in the need for reintervention in a small percentage of the population [ 66 ]. The optimal function of aortic valve following an aortic root replacement is not primarily determined by the presence and the geometry of Valsalva sinuses, but it is also deeply affected by the neo-root compliance [ 52 , 62 , 64 ].
Full root replacement with Valsalva Dacron conduits might not be sufficient to guarantee an adequate and efficient valve function in the long term because of the presence of an inextensible graft substituting the native aorta [ 11 , 51 ]. Whether these alterations might acquire a stronger clinical significance in the long term, with an increase in the reoperation rate, cannot be deduced yet; longer-term follow-up studies are required for this purpose.
In this extent, it might be hypothesized that full root replacement using the currently available stentless porcine xenografts provided with the native sinuses and ascending aorta might partially preserve the normal compliance of aortic tissue and could be more appropriate for these purposes.
However, the anti-antigenic and anti-calcification chemical treatments used in the preparation of these grafts might be detrimental on the compliance module of the prosthesis itself. Alternatively, new solutions deriving from the rapidly evolving world of regenerative medicine and bioengineering of tissues might be explored at least at the preclinical and translational levels.
With the aim to overcome the current shortcomings of artificial conduits, a significant amount of research has been lavished on the bioengineering front to generate biocompatible grafts able to guarantee an efficient endothelialization and maintenance of vascular patency [ 67 ].
However, in the recent years, scientific efforts have been centered on the realization of biomimetic grafts capable of reproducing when implanted the same hemodynamic and mechanical characteristics of the vascular tree [ 68 ].
Similarly, the combination of type I collagen gel and silk fibroin provided conduits with physiologically relevant compliance and resistance and improved the early response of the material to in vitro cell adhesion and proliferation in virtue of their cytological compatibility [ 70 ].
On the other side, modifications of the existing polyurethanes to improve their mechanical characteristics have been experimented. Addition of a gelatin-based hydrophilic sheath to the hydrophobic core of polyurethane determined significant changes in the core-sheath structures, and consequently in their mechanical properties, leading to the generation of scaffolds with tissue-like viscoelasticity, high compliance, competent tensile modulus and advantageous resistance to burst pressure, and suture retention [ 71 ].
However, the same authors demonstrated the superiority in terms of elastomechanical properties of bioresorbable polymers as polycaprolactone or polylactic acid, which added the benefit of an improved biocompatibility due to the nature of the material and to the nanofibrous extracellular matrix-like ECM architecture in which this polymer can be structured [ 71 ].
The principle of biomimesis of the nanoscale fibrillar features of the native ECM is crucial in vascular tissue engineering to achieve tissue-like mechanical and biological properties [ 67 , 72 , 73 ]. For example, the use of electrospinning technique, a manufacturing approach enabling the generation of scaffolds reproducing the native histoarchitecture of the fibrillar ECM [ 67 , 74 ], has been shown to allow the realization of arterial surrogates with native-like mechanical properties [ 68 , 75 , 76 ].
However, several other tissue engineering methods have been developed for the fabrication of three-dimensional biomimetic scaffolds [ 73 ]. Despite that a complete examination of these approaches is out of the scope of this review, it is important to notice that the general tendency of vascular tissue engineering research is currently inspired by a biomimetic rationale and is focused on the realization of vascular surrogates able to closely simulate the natural biological and physical properties of native vessels and reproduce a similar biomechanical behavior when implanted in vivo settings.
Future researches in this field may provide vascular scaffolds resembling native tissues to be used as aortic substitutes in routine clinical practice, overcoming the limitations associated with current Dacron grafts. In this framework, computational fluid dynamic CFD studies are rapidly emerging in the cardiovascular field providing interesting insights on several hemodynamic aspects, involving vascular prostheses and allowing to evaluate performance and compare the effectiveness of aortic substitutes [ 77 — 79 ].
Blood flow, wall shear stress, and compliance can be accurately evaluated, and this method has been recently introduced to assess the hemodynamic effects of aortic surgery [ 79 , 80 ]. CFD confirmed the importance of Valsalva sinuses in aortic root dynamics and established that stiffness of Dacron conduits still represents a main concern, despite that synthetic grafts share design and many hemodynamic parameters with the native aorta [ 81 ].
Even more interestingly, CFD studies demonstrated that also the surgical technique employed in the aortic replacement might play a role in determining the generation of unfavorable hemodynamic conditions, with consequent reflexes on the formation of aneurysms or pseudoaneurysms.
Indeed, the reestablishment of normal aortic curvature, with a smooth transition between the conduit and native aorta, is crucial to reduce wall stress and potential turbulent retrograde and recirculating flow in the aortic arch [ 81 , 82 ].
CFD may also be used to provide a tailored and patient-specific approach to aorta replacement as able to predict the biomechanical behavior of grafts and native aorta according to the typology of operation performed.
As an example, Heim et al. These findings might have enormous implications in the clinical practice as patient-specific CFD studies could potentially aid the decision on the surgical strategy to be adopted according to the different clinical scenarios. Also, scaffolds produced using tissue engineering approach may be evaluated in vivo using this method in order to individuate the most suitable and biomimicking substitute for aorta replacement.
Far to be provocative, the conclusion of this literature review does not pretend to neglect the uncontested success of synthetic materials as aortic substitutes and the benefit still now provided to millions of patients around the world since their introduction by Dr. Voorhes and soon after Dr. However, early studies already warned about the potential complications above described and found their rationale in the compliance mismatch between the native aorta and the artificial grafts.
The collection of more contemporary experimental and clinical evidences confirms these concerns and might trigger discussion on the long-term consequences of Dacron graft implantation when approaching the surgical workup of aortic root disease. The reconsideration of this apparently neglected problem might on a side prompt the choice of other surgical strategies as the use of xenografts, while on the other might trigger future research activities towards the development alternative conduits mimicking the native biomechanical vascular properties.
In this context, the new advances in tissue engineering of blood vessels using bioresorbable materials able to functionally integrate with the host tissue and induce a natural process of arterialization in vivo might hold a promise for the future.
Would Leonardo Da Vinci, who firstly discovered the importance of aortic root dynamics, have imagined this? All authors declare no conflict of interest related to the material in the manuscript. National Center for Biotechnology Information , U. Such predictors seems to be similar to the findings of Gott et al. In reported study strong predictors for poor early and late survival resulted to be poor NYHA functional class, non-Marfan status, preoperative dissection and male gender [24].
In another study the emergency status and aortic arch replacement were identified as strong predictors for hospital death [23]. At 1 year follow-up, all survivors demonstrated a significant improvement of NYHA functional class.
The echo colour Doppler and computed tomography revealed optimal results of the employed surgical procedures in all patients. All of them did not undergo preoperative coronary angiography. With growing population undergoing cardiac surgery, the CAD is the most frequently found associated pathology in patients with aortic diseases. This strategy will decrease significantly the perioperative mortality due to myocardial infarction and low cardiac output in this group of patients. All seven patients in our series, experiencing perioperative myocardial infarction, did not undergo preoperative coronary angiography.
A postoperative study in four of them who survived demonstrated significant coronary lesions. The high early and late mortality rate in patients with preoperative aortic dissection is closely related to the age, complex type of aortic disease leading to complex surgical procedure, poor perioperative hemodynamic, emergency status, presence of acute myocardial infarction due to dissected coronary sinuses, and repetitive aortic dissection.
This was demonstrated in our study by a significantly lower actuarial survival in patients with preoperative dissection versus patients with non-aortic dissection undergoing ARR with CG. Although the actuarial survival in this subgroup of patients was similar to the non-Marfan population. The overall survival at mean 5 years follow-up resulted to Despite the employment of Ticron sutures with pledgets in our series, the incidence of thromboembolic events remained low.
We may conclude that the ARR with a CG is an alternative technique to the aortic replacement with biological materials, offering acceptable early and long-term outcome. The long-term outcomes demonstrate a low valve prosthesis related morbidity. The predictors for poor overall survival in patients undergoing ARR seems to be preoperative aortic dissection extended into the aortic arch, older age, depressed left ventricular function and associated CAD.
Bentall H. De Bono A. A technique for complete replacement of the ascending aorta Thorax 23 Google Scholar. Cabrol C. Pavie A. Gandjabakhch I. Villemot J. Guiraudon G. Etievent P. Cham B. Complete replacement of the ascending aorta with reimplantation of the coronary arteries J Thorac Cardiovasc Surg 81 Kouchoukos N.
Wareing T. Murphy S. Perrillo J. Sixteen-year experience with aortic root replacement: results of operations Ann Surg David T.
Feindel C. An aortic valve sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta J Thorac Cardiovasc Surg Yacoub M.
Gehle P. Chandrasekaran V. Birks E. Child A. Radley-Smith R. Late results of valve-preservation in patients with aneurysms in the ascending aorta and root J Thorac Cardiovasc Surg Lewis C. Cooley D.
Murphy M. Talledo O. Vega D. Surgical repair of aortic root aneurysms in patients Ann Thorac Surg 53 38 Westaby S. Katsumata T. Vaccari G. Aortic root replacement with coronary button re-implantation: low risk and predictable outcome Eur J Cardiothorac Surg 17 Adams R.
Goldin M. Najafi H. Selectivity in aortic root reconstruction J Card Surg 9 Midulla P. Ergin M. Galla J. Lansman S. Sadeghi A. Levy M. Griepp R. Three faces of the Bentall procedure J Card Surg 9 Mingke D. Dresler C. Stone C. Borst H. Composite graft replacement of the aortic root in patients with aneurysm or dissection Thorac Cardiovasc Surg 46 12 Dossche K.
Schepens M. Morshuis W. Knaepen P. Vermeulen F. A 23 year experience with composite valve graft replacement of the aortic root Ann Thorac Surg 67 Girardi L. Talwalkar N. Coselli J. Aortic root replacement: results using the st. Mesnildrey P. Gandjbakhch I. Bors V. Corcos T. Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries J Thorac Cardiovasc Surg 91 17 Taniguchi K. Nakano S. Matsuda H. Long term survival and complications after composite graft replacement for ascending aortic aneurysms associated with aortic regurgitation Circulation 84 Suppl-III 31 Dougenis D.
Surgery of the thoracic aorta N Engl J Med De Paepe A. Devereux R. Dietz H. Hennekam R. Pyeritz R. Neri E. Massetti M. Capannini G. Carone E. Tucci E. Diciolla F. Prifti E. You may have at least one test each year. This care sheet gives you a general idea about how long it will take for you to recover. But each person recovers at a different pace. Follow the steps below to feel better as quickly as possible.
Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor or nurse call line if you are having problems. It's also a good idea to know your test results and keep a list of the medicines you take.
Call anytime you think you may need emergency care. For example, call if:. Call your doctor or nurse call line now or seek immediate medical care if:. Watch closely for any changes in your health, and be sure to contact your doctor or nurse call line if:. Author: Healthwise Staff. Gilbertson MD - Vascular Surgery. Care instructions adapted under license by your healthcare professional. If you have questions about a medical condition or this instruction, always ask your healthcare professional.
Healthwise, Incorporated disclaims any warranty or liability for your use of this information. Healthwise, Healthwise for every health decision, and the Healthwise logo are trademarks of Healthwise, Incorporated. It looks like your browser does not have JavaScript enabled. Please turn on JavaScript and try again. Important Phone Numbers.
Topic Contents Your Recovery How can you care for yourself at home? When should you call for help? Where can you learn more? Top of the page. Your Recovery Aortic aneurysm repair is surgery to fix a weak and bulging section of the aorta.
How can you care for yourself at home? Rest when you feel tired. Getting enough sleep will help you recover. Try to walk each day.
Start by walking a little more than you did the day before. Bit by bit, increase the amount you walk. Walking boosts blood flow and helps prevent pneumonia and constipation. Avoid strenuous activities, such as bicycle riding, jogging, weight lifting, or aerobic exercise, for up to 3 months. For 6 weeks, avoid lifting anything that would make you strain. This may include a child, heavy grocery bags and milk containers, a heavy briefcase or backpack, cat litter or dog food bags, or a vacuum cleaner.
Hold a pillow over your incision when you cough or take deep breaths. This will support your chest and decrease your pain. Do breathing exercises at home as instructed by your doctor.
This will help prevent pneumonia. Ask your doctor when you can drive again. You will probably need to take at least 4 to 6 weeks off from work. It depends on the type of work you do and how you feel.
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