Concomitant Wrapping of a Moderately Dilated Ascending Aorta during Aortic Valve Replacement: Postoperative Remodeling of a Distinctive Aorta

Abstract

Purpose: The long-term outcomes of aortic wrapping in patients with ascending aortic aneurysms, which are rare, but can be fatal, remain poorly understood. This retrospective study analyzed the outcomes of aortic diameter, including aortic root, ascending aorta, and proximal arch diameters, after aortic wrapping during aortic valve replacement surgery.

Materials and methods: Ninety-six patients with ascending aortic dilation of 40-55 mm who underwent aortic wrapping during aortic valve replacement were selected for this study. Aortic diameter was measured at three levels perioperatively and at follow-up (median time of 9.1±4.2 years). A linear mixed-effects model was used to analyze aortic diameter expansion.

Results: Freedom from adverse aortic events (aortic dissection or rupture, reoperation, or sudden death) at 10 years was 97.9%. No significant dilation at the level of the sinuses of Valsalva (0.069 mm/year, p=0.524) or ascending aorta (0.152 mm/year, p=0.124) was observed. Significant dilation occurred at the proximal aortic arch (0.343 mm/year, p=0.006). Subgroup analysis with a multivariable linear mixed model identified initial ascending aortic diameter to be a significant predictor of proximal arch dilation (p=0.032). Receiver operating characteristic curve analysis revealed that the cut-off for the prediction of proximal arch redilation was an initial mid-ascending aortic diameter of 47.0 mm (area under the curve 0.747, 90% confidence interval 0.613-0.881, p=0.023).

Conclusion: Aortic wrapping could be considered as a safe and long-term therapeutic option. Redilation of the proximal arch should be carefully observed during long-term follow-up.

Keywords: Aortic aneurysm; aorta; aortic valve.

Fig. 1. Illustration of aortic wrapping carried out with (A) polytetrafluoroethylene felt and (B) double-velour vascular grafts.

Fig. 2. Spaghetti plot of aortic growth rate over time after aortic wrapping for individual patients. Aortic diameters were measured at the level of (A) the aortic root, (B) the ascending aorta, and (C) the proximal arch. Red lines indicate the overall growth rate calculated using the univariable linear mixed model.

Fig. 3. Receiver-operating characteristic curve analysis of initial ascending aortic diameter affecting redilation of the proximal aortic arch after wrapping. AUC, area under the curve; CI, confidence interval.

Fig. 4. Freedom from redilation of the proximal aortic arch and overall survival after wrapping by Kaplan-Meier analysis.