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).