Remodeling or reimplantation for valve-sparing aortic root surgery?

External aortic annuloplasty with a dedicated expansible ring improves outcomes in remodeling root repair compared with homemade Dacron ring

OBJECTIVES

In remodeling valve-sparing root replacement with external annuloplasty, we compare long-term outcomes of a calibrated expansible extra-aortic ring with a homemade Dacron ring.

METHODS

All patients (2003-2020) operated for root aneurysm with/without aortic insufficiency (AI) were included. The standardized CAVIAAR (conservation aortique valvulaire dans les insuffisances aortiques et anévrysmes de la racine-Valve sparing in aortic insufficiencies and root aneurysms) technique was root remodeling and external annuloplasty ring with the EXTRA-AORTIC Ring or homemade Dacron ring.

RESULTS

Among 486 patients (age 52.3 ± 14.0 years) operated for root aneurysm, 375 (repair rate: 77.1%) underwent root remodeling with annuloplasty (extra-aortic ring, n = 289, vs Dacron ring, n = 86). At 10 years (median follow-up, 4.08 years' interquartile range, 1.95-7.61), unmatched and matched analysis showed that patients with extra-aortic ring had greater survival, similar to the general population (93.3% vs 79.9%, P = .097), lower reoperation incidence (2.0% vs 9.7%, P = .0098), and lower AI grade >2 recurrence (1.9% vs 11.2%, P = .0042), compared with patients with a Dacron ring. Mixed-effect model showed that with extra-aortic ring annuloplasty, annular dilation over time (P = .0033) was prevented and, compared with the homemade Dacron ring, root expansibility was better preserved (3.22% vs 2.12%, P = .002) and mean transvalvular gradient was lower (6.58 mm Hg vs 7.94 mm Hg, P = .001). Tricuspid and bicuspid valves with extra-aortic ring had similar reoperation (4.3% vs 0.85%, P = .65) and AI grade >2 incidence (2.7% vs 1.2%, P = .61), expansibility (P = .29), and diameter (P = .47), whereas mean transvalvular gradient was lower for tricuspid valves (5.58 mm Hg vs 7.60 mm Hg, P = .004).

CONCLUSIONS

Valve-sparing root remodeling with calibrated expansible extra-aortic ring annuloplasty improves the outcomes of reoperation and recurrent AI compared with a homemade Dacron ring. It prevents dilation and maintains physiological root dynamics for durable valve repair.

Aortic Root Remodeling in the Tricuspid Aortic Valve

BACKGROUND

Aortic root remodeling is one of the principal forms of valve-preserving root replacement. Its value has been questioned by some, whereas others have achieved excellent valve durability. The purpose of this review is to summarize the existing information to determine which factors may have contributed both to failures and to successes.

METHODS

Publications on root remodeling for aneurysm or dissection with tricuspid aortic valves with >15 patients were reviewed for specific details of preoperative and intraoperative management.

RESULTS

The series were very heterogeneous. Most operations were performed for root aneurysm, and 10 publications included type A dissection. Connective tissue disease was present in 22% of patients. Mean patient age was 52 years, and 5-year survival varied between 58% and 100%. Most series did not include an annuloplasty. Importantly, no details on quantitative assessment of valve configuration were specified in most series, especially those with suboptimal valve function and durability. The introduction of the effective height concept to control valve configuration was associated with improved results and more frequent correction of cusp prolapse. Late freedom from aortic regurgitation and freedom from reoperation are good in the larger series.

CONCLUSIONS

Root remodeling can lead to excellent valve durability if quantitative intraoperative measurement of valve configuration is performed. The addition of an annuloplasty seems to improve aortic valve competence further, even though its effect on durability is not unequivocally proven. The long-term results of root remodeling are good, also in the second postoperative decade, and it is a valid form of valve-preserving root replacement.

Bicuspid valve repair outcomes are improved with reduction and stabilization of sinotubular junction and annulus with external annuloplasty

OBJECTIVE

We investigated long-term outcomes of bicuspid aortic valve (BAV) repair, with external annuloplasty, according to aorta phenotype.

METHODS

Between 2003 and 2020, all patients with BAV operated on for aortic insufficiency (AI) and/or aneurysm were included. Repairs included isolated AI repair with subvalvular with or without sinotubular junction (STJ) (single or double) annuloplasty, supracoronary aorta replacement (with or without hemiroot remodeling), and root remodeling with external subvalvular ring annuloplasty.

RESULTS

Among 343 patients operated, reparability rate was 81.3% (n = 279; age 46 ± 13.3 years). At 10 years (median follow-up: 3.42 years; interquartile range, 1.1, 5.8), survival was 93.9% (n = 8 deaths, similar to general population), cumulative incidence of reoperation was 6.2% (n = 10), AI grade >2 was 5.8% (n = 9), and grade >1 was 23.0% (n = 30). BAV repair stabilizing both the annulus and STJ with annuloplasty, compared with nonstabilized STJ repair (single annuloplasty), had lower incidence of reoperation (2.6% vs 22.5%, P = .0018) and AI grade >2 (1.2% vs 23.6%, P < .001) at 9 years. Initial commissural angle <160° was not a risk factor for reoperation, compared with angle ≥160° if symmetrical repair was achieved (2.7% and 4.1%, respectively, at 6 years, P = .85). Multivariable model showed that absence of STJ stabilization (odds ratio, 6.7; 95% confidence interval, 2.1-20, P = .001) increased recurrent AI, but not initial commissural angle <160° (odds ratio, 1.01; 95% confidence interval, 0.39-2.63, P = .98). Commissures adjusted symmetrically led to lower transvalvular gradient, compared with nonsymmetrical repair (8.7 mm Hg vs 10.2 mm Hg, P = .029).

CONCLUSIONS

BAV repair, tailored to aorta phenotype, is associated with excellent durable outcomes if both annulus and STJ are reduced and stabilized with external ring annuloplasty. Commissural angle <160° is not associated with reoperation if symmetrical repair is achieved.

Valve-Sparing Aortic Root Replacement With Reimplantation vs Remodeling: A Meta-analysis

BACKGROUND

Long-term outcomes of valve-sparing aortic root replacement (VSARR) with reimplantation vs remodeling in patients undergoing aortic root surgery remains a controversial subject.

METHODS

This study was a pooled meta-analysis of Kaplan-Meier-derived data from comparative studies published by December 31, 2022.

RESULTS

Fifteen studies met our eligibility criteria, comprising 3044 patients (1991 in the reimplantation group and 2018 in the remodeling group). Patients who underwent VSARR with remodeling had a higher risk of all-cause death (hazard ratio [HR], 1.54; 95% CI, 1.16-2.03; P = .002, log-rank test P < .001). Landmark analysis (with 4 years as the landmark time point) demonstrated that survival was lower in patients who underwent VSARR with remodeling (HR, 2.15; 95% CI, 1.43-3.24; P < .001) in the first 4 years. Beyond the 4-year time point, no difference in survival was observed (HR, 1.04; 95% CI, 0.72-1.50; P = .822). The risk for need of aortic valve and/or root reintervention was higher in patients undergoing VSARR with remodeling (HR, 1.49; 95% CI, 1.07-2.07; P = .019, log-rank test P < .001). We did not find statistically significant coefficients for the covariates of age, female sex, connective tissue disorders, bicuspid aortic valve, aortic dissection, coronary bypass surgery, total arch replacement, or annular stabilization, which means that these covariates did not modulate the effects observed in our pooled analyses.

CONCLUSIONS

VSARR with reimplantation is associated with better overall survival and lower risk of need for reintervention over time compared with VSARR with remodeling. Regarding overall survival, we observed a time-varying effect that favored the reimplantation technique up to 4 years of follow-up, but not beyond this time point.

Outcomes of aortic valve-sparing root replacement with cusp repair in connective tissue disease

BACKGROUND

Although, valve sparing is commonly performed in patients with Marfan syndrome, feasibility and results of cusp repair for aortic insufficiency have not been studied.

AIM

To report on the outcomes and durability of aortic cusp repair in valve sparing in patients with Marfan syndrome.

METHODS

All consecutive adult patients with Marfan syndrome who underwent remodelling and annuloplasty with aortic valve repair for aortic insufficiency between May 2005 and December 2020 were included. Patients with Marfan syndrome treated for aortic aneurysm, but without aortic insufficiency, were excluded. Data were collected prospectively and reviewed retrospectively from the Aorticvalve repair International Registry (AVIATOR).

RESULTS

During the study period, 71 patients with Marfan syndrome were referred to surgery. Fifty-five patients with connective tissue disease and aortic insufficiency with aorta aneurysm were treated: 46 underwent aortic valve repair and nine underwent aortic valve replacement (five mechanical aortic valve replacements and four biological aortic valve replacements). The mean age was 42.9±15.4 years, and the mean EuroScore II was 2.5±2.2. No patient died, and no patient had significant aortic insufficiency (grade≥II) at discharge. The 5-year survival rate estimate was 94.4%, which seems statistically similar to that of the age- and sex-matched general population. At 5 years, freedom from reoperation was 94.6%, and the incidence of infective endocarditis was 2.6%. No valve thrombosis, aortic dissection, major bleeding events, thromboembolic events (stroke) or myocardial infarctions were noted during follow-up.

CONCLUSION

Remodelling and aortic valve repair showed excellent durability at 5 years, even in connective tissue disorders.

Comparison of hemodynamics and root configurations between remodeling and reimplantation methods for valve-sparing aortic root replacement: a pulsatile flow study

PURPOSE

To compare the characteristics of reimplantation (RI) using grafts with sinuses and remodeling (RM) with/without external suture annuloplasty using a pulsatile flow simulator.

METHODS

Porcine aortic roots were obtained from an abattoir, and six models of RM and RI with sinuses were prepared. External suture annuloplasty (ESA) was performed in the RM models to decrease the root diameter to 22 mm (RM-AP22) and 18 mm (RM-AP18). Valve models were tested at mean pulsatile flow and aortic pressure of 5.0 L/min and 120/80 (100) mmHg, respectively, at 70 beats/min. The forward flow, regurgitation, leakage, backflow rates, valve-closing time, and mean and peak pressure gradient (p-PG) were evaluated. Root configurations were examined using micro-computed tomography (micro-CT).

RESULTS

The backflow rate was larger in the RM models than in the RI models (RI: 8.56% ± 0.38% vs. RM: 12.64% ± 0.79%; p < 0.01). The RM-AP and RI models were comparable in terms of the forward flow, regurgitation, backflow rates, p-PG, and valve-closing time. The analysis using a micro-CT showed a larger dilatation of the sinus of the Valsalva in the RM groups than in the RI group (Valsalva: RI, 26.55 ± 0.40 mm vs. RM-AP22, 31.22 ± 0.55 mm [p < 0.05]; RM-AP18, 31.05 ± 0.85 mm [p < 0.05]).

CONCLUSIONS

RM with ESA and RI with neo-sinuses showed comparable hemodynamics. ESA to RM reduced regurgitation.

Postoperative imaging of thoracic aortic repairs

Imaging plays a crucial role in the postoperative monitoring of thoracic aortic repairs. With the development of multiple surgical techniques to repair the ascending aorta and aortic arch, it can be a daunting challenge for the radiologist to diagnose potential pathologies in this sea of various techniques, each with their own normal postoperative appearance and potential complications. In this paper, we will provide a comprehensive review of the postoperative imaging in the setting of thoracic aortic repairs, including the role of imaging, components of thoracic aortic repairs, the normal postoperative appearance, and potential complications.

Improved Outcomes of Reimplantation vs Remodeling in Marfan Syndrome: A Propensity-Matched Study

BACKGROUND

Valve-sparing root replacement (VSRR) has excellent outcomes when performed in experienced centers in well-selected patients. It is suggested that reimplantation of the aortic valve may have better durability than remodeling in patients with Marfan syndrome (MFS), although long-term comparative data are limited.

METHODS

Between 1988 and 2018, 194 patients with MFS underwent VSRR at our institution. From these, we derived a propensity-matched cohort of 68 patients (44 who underwent reimplantation and 24 who had remodeling). Early outcomes included death and perioperative complications. Late outcomes were survival, probability of aortic insufficiency, and reintervention up to 20 years of follow-up. Median follow-up was 17.8 years (interquartile range, 12.0-20.6 years) for the entire matched cohort.

RESULTS

Baseline variables were similar between reimplantation and remodeling patients after matching: age (39 ± 12 vs 40 ± 13 years, P = .75) and male sex (28 [64%] vs 15 [63%], P = 1.0). Similar 20-year survival was observed after reimplantation compared with remodeling (82% vs 72%, P = .20), whereas the probability of developing greater than mild aortic insufficiency at 20 years was increased after remodeling (5.8% vs 13%, P = .013). More patients underwent reoperation on the aortic valve after a remodeling procedure than after reimplantation of the aortic valve (18% vs 0%, P = .018).

CONCLUSIONS

VSRR provides excellent long-term survival and freedom from valve-related complications outcomes in patients with MFS. Reimplantation of the aortic valve was associated with a lower risk of aortic valve reoperation and aortic insufficiency than the remodeling procedure after 2 decades of follow-up.

Conventional aortic root vs valve-sparing root replacement surgery in aortic dilatation syndromes: a comparison of mortality and postoperative complications

INTRODUCTION

Conventional aortic root and valve-sparing root replacement surgery are two current surgical treatments for aortic dilatation syndromes. This review article aims to review the current literature surrounding these two established techniques.

AREAS COVERED

This review article will address the current indications for valve-sparing root replacement surgery, technical considerations in surgical planning and a comparison of clinical outcomes between these two surgical techniques.

EXPERT OPINION

Valve-sparing root replacement surgery is a safe and established treatment for aortic syndromes. Valve-sparing surgery procedure avoids the inherent risk of prosthetic valve dysfunction and prosthesis infection by preserving the native aortic valve compared to conventional aortic root surgery. This has been demonstrated in various observational studies and should be considered in clinically and anatomically appropriate patients. Other technical considerations, such as reimplantation versus remodeling technique and aortic cusp repair in select patients, may impact in short-term procedural and long-term clinical success with valve-sparing surgery.

Preliminary results of a simplified aortic valve-sparing technique: A feasibility study

BACKGROUND AND AIM OF THE STUDY

To evaluate whether the simplified valve-sparing technique (SVST) implies clinical outcomes comparable or not with those of established David technique in the surgery of aortic root.

METHODS

We collected the records of patients who had undergone aortic root surgery with the SVST or standard David technique (SDT) at our institution between January 2009 and December 2018. The primary endpoints were the incidence of all-cause death, reoperation for any reason, and postoperative complications. The secondary endpoint was the midterm incidence of reoperation for aortic valve regurgitation.

RESULTS

A total of 169 patients who underwent aortic root surgery were analyzed. SDT and SVST were performed in 48 (28.4%) and in 121 (71.6%) patients, respectively. Thirty-day mortality occurred in 0% and 0.8% of patients in the SDT and SVST groups, respectively. The rate of postoperative new permanent pacemaker implantation was 6.3% (three patients) and 0.8% (one patient) in SDT and SVST cohort, respectively (p = .07). The incidence of postoperative thromboembolic stroke was 6.3% and 2.5% in SDT and SVST groups, respectively (p = .23). The median follow-up time was 29 (23-47) months. During the FU period, no differences were found between two cohorts in terms of all-cause mortality (p = .99), the incidence of reoperation (p = .19), and incidence of aortic valve regurgitation requiring reoperation (p = .58).

CONCLUSIONS

The SVST appears to be safe and feasible showing early clinical results comparable to the SDT. Nevertheless, further studies with larger series and long-term follow-ups are required to demonstrate its safety and efficacy.

Valve-sparing aortic root replacement: a primer for cardiologists

PURPOSE OF REVIEW

The purpose of this article is to review the contemporary evidence supporting valve-sparing aortic root replacement as the best option for patients with aortic root aneurysms and preservable aortic valves as well as to review the technical variations and modern adjuncts of these operations that impact both short and long-term durability.

RECENT FINDINGS

In patients with an aortic root aneurysm, with or without aortic valve regurgitation, valve-sparing aortic root replacement provide excellent clinical outcomes and stable valve function over several decades. Successful execution of this operation depends on careful patient selection and a thorough understanding of the anatomical and physiological relationships between the various components of the aortic root. Echocardiography remains the mainstay of imaging to determine the feasibility of valve-sparing root replacement.

SUMMARY

Valve-sparing aortic root replacement is an excellent alternative to composite valve graft replacement in nonelderly patients with aortic root aneurysms. Dedicated aortic root surgeons perform several technical variations of valve-sparing procedures aimed at matching the specific aortic root disorder with the optimal operation.

Failures of Valve-sparing Aortic Root Replacement using the Root Remodeling Technique

BACKGROUND

Valve failure may occur after valve-sparing aortic root replacement. Little is known about the exact mechanisms of failure. We analyzed our experience with reoperations after aortic root remodeling to determine failure modes, operative risk, and long-term outcome.

METHODS

Between 11/1995 and 12/2019, 1084 patients were treated by root remodeling. Of these, 54 (49 male, 8 to 79 years) underwent reoperation for valve failure (1 week to 16 years postoperatively). The indications for reoperation were aortic regurgitation (n=39), aortic stenosis (n=6), endocarditis (n=7), or ventricular septal defect (n=2). The main causes of valve failure were cusp repair failure (n=29), endocarditis (n=7), and cusp retraction (n=8). The patients were treated by valve replacement (n=40) or cusp repair (n=14). In 6 individuals, combined replacement of valve and root was performed. All 54 patients were followed (mean 69±54 months after reoperation), 1 patient was lost to follow-up.

RESULTS

No patient died in hospital or developed atrioventricular block; twelve patients died late with 10- and 15-year survival of 87%±5.1% and 64%±10.6%. Of the 14 patients who underwent repeat cusp repair, 7 (50%) are still alive with stable valve function, 17 months to 15 years after their reoperation. Eleven patients required a second reoperation leading to a freedom from repeat reintervention of 68%±9.7% at 15 years.

CONCLUSIONS

The main causes of failure of root remodeling are cusp related. Reoperations can be performed with low morbidity and mortality. In selected patients, isolated cusp repair may be an option.

Outcomes in techniques of valve sparing aortic root replacement: A systematic review and meta-analysis

OBJECTIVE

To compare clinical outcomes of reimplantation versus remodeling in patients undergoing valve-sparing aortic root replacement (VSRR) surgery.

METHOD

Electronic database search at PubMed, Scopus, Embase, Ovid, and Google scholar was performed from inception to January 2020. Primary outcomes were aortic valve (AV) reintervention and postoperative grade of aortic insufficiency (AI) while secondary outcomes were 30-day mortality, reoperation for bleeding, and operative times.

RESULTS

A total of 21 articles met the inclusion criteria. A total of 1283 patients had reimplantation while 1150 had remodeling. No difference in preoperative demographics was noted except reimplantation patients were younger (48 ± 16 vs. 56 ± 15 years; p < .00001). The cardiopulmonary bypass and aortic cross-clamp times were shorter in the remodeling cohort (168 ± 38 vs. 150 ± 37 min; p = .0001 and 133 ± 31 vs. 112 ± 30 min; p = .0002, respectively). No difference in concomitant total arch surgery (14% in reimplantation vs. 15% in remodeling; p = .53). Postoperatively, there were similar stroke rates (3% in both cohorts; p = .54), rates of reoperation for bleeding (9% in reimplantation vs. 12% in remodeling; p = .88), and 30-day mortality (3% in reimplantation vs. 4% in remodeling; p = .96). No difference in early AV reintervention (1% in reimplantation vs. 2% in remodeling; p = .07), and late AV reintervention (4% in reimplantation vs. 7% in remodeling; p = .07). The AI of +2 grade was significantly lower in the reimplantation cohort (5% vs. 8%; p = .01).

CONCLUSION

Our study shows comparable clinical outcomes between both techniques. The practice of each technique is largely center and surgeon dependent. Larger sample size cohorts with minimal confounding factors are required to confirm the above findings.

4D flow CMR analysis comparing patients with anatomically shaped aortic sinus prostheses, tube prostheses and healthy subjects introducing the wall shear stress gradient: a case control study

BACKGROUND

Anatomically pre-shaped sinus prostheses (SP) were developed to mimic the aortic sinus with the goal to preserve near physiological hemodynamic conditions after valve-sparing aortic root replacement. Although SP have shown more physiological flow patterns, a comparison to straight tube prosthesis and the analysis of derived quantitative parameters is lacking. Hence, this study sought to analyze differences in aortic wall shear stress (WSS) between anatomically pre-shaped SP, conventional straight tube prostheses (TP), and age-matched healthy subjects) using time-resolved 3-dimensional flow cardiovascular magnetic resonance (4D Flow CMR). Moreover, the WSS gradient was introduced and analyzed regarding its sensitivity to detect changes in hemodynamics and its dependency on the expression of secondary flow patterns.

METHODS

Twelve patients with SP (12 male, 62 ± 9yr), eight patients with TP (6 male, 59 ± 9yr), and twelve healthy subjects (2 male, 55 ± 6yr) were examined at 3 T with a 4D Flow CMR sequence in this case control study. Six analysis planes were placed in the thoracic aorta at reproducible landmarks. The following WSS parameters were recorded: WSSavg (spatially averaged over the contour at peak systole), max. WSSseg (maximum segmental WSS), min. WSSseg (minimum segmental WSS) and the WSS Gradient, calculated as max. WSSseg - min. WSSseg. Kruskal-Wallis- and Mann-Whitney-U-Test were used for statistical comparison of groups. Occurrence and expression of secondary flow patterns were evaluated and correlated to WSS values using Spearman's correlation coefficient.

RESULTS

In the planes bordering the prosthesis all WSS values were significantly lower in the SP compared to the TP, approaching the physiological optimum of the healthy subjects. The WSS gradient showed significantly different values in the four proximally localized contours when comparing both prostheses with healthy subjects. Strong correlations between an elevated WSS gradient and secondary flow patterns were found in the ascending aorta and the aortic arch.

CONCLUSION

Overall, the SP has a positive impact on WSS, most pronounced at the site and adjacent to the prosthesis. The WSS gradient differed most obviously and the correlation of the WSS gradient with the occurrence of secondary flow patterns provides further evidence for linking disturbed flow, which was markedly increased in patients compared to healthy sub jects, to degenerative remodeling of the vascular wall.

A novel device for technical standardization of valve-sparing aortic root reimplantation

Among valve-sparing aortic root replacement techniques developed for the treatment of aortic root aneurysms and aortic insufficiency, the reimplantation technique (the David procedure) has proved to provide excellent outcomes in experienced hands. However, it involves certain challenges in technical standardization, particularly for graft sizing, which is still far from standardization. A novel device was developed to facilitate and provide all the measurements in high precision and accuracy required for the David procedure. The device allows easy, rapid, and accurate acquisition of the patient"s data and appropriate configuration of the aortic valve, irrespective of the surgeon's subjective evaluations. This all-in-one device provides all the major parameters including graft size, effective height, graft preparation, and simulation of the aortic coaptation. The device was successfully tested on a Devotini aortic root simulator and on a bovine heart ex vivo. The device proposed herein to be used for reimplantation has one explicit advantage: all valve geometry to be reconstructed and repaired can be simulated on the device with all its elements, in particular, the commissures and the cusps. Thus, all that is necessary can be clearly visualized in a manner whatever the configuration the surgeon prefers, particularly the creation of the effective height.

Aortic root remodeling in bicuspid and tricuspid aortic valves-long-term results

Background

Root remodeling is one form of valve-preserving root replacement to treat patients with aortic regurgitation (AR) and root aneurysm. We have consistently used it for patients with and without connective tissue disease and different aortic valve morphologies. The objective of this retrospective study was to review 23 years of experience with root remodeling.

Methods and patients

Between 10/95 and 9/2018, 1004 of 1038 root remodeling procedures were performed in patients with tricuspid (n = 589) or bicuspid (n = 414) anatomy of the aortic valve in our institution. Aortic aneurysm was present in 932 cases, 73 procedures were performed for acute aortic dissection type A. The severity of aortic regurgitation ranged from grade I to grade IV (mean 2.5 ± 0.8).

Results

All patients underwent root remodeling, concomitant operations were performed in 433, and cusp repair in 883 instances. Hospital mortality was 2%. Overall freedom from reoperation was 92% at 10 years and 89% at 15 years. It was 94% for tricuspid valves at 10 and 15 years, and 88% for bicuspid aortic valves at 10 years and 80% at 15 years (p = 0.003).

Conclusion

In conclusion, root remodeling is a viable option in valve-preserving root replacement. If combined with careful assessment and, if necessary, correction of aortic valve form reproducible restoration of aortic valve function can be achieved.

Biomechanical characterization and comparison of different aortic root surgical techniques

OBJECTIVES

Understanding the biomechanical impact of aortic valve-sparing techniques is important in an era in which surgical techniques are developing and are increasingly being used based on biomechanical understanding that is essential in the refining of existing techniques. The objective of this study was to describe how the valve-sparing remodelling (Yacoub) and reimplantation (David Type-1) techniques affect the biomechanics of the native aortic root in terms of force distribution and geometrical changes.

METHODS

Two force transducers were implanted into 22 pigs, randomized to 1 of 3 groups (David = 7, native = 7 and Yacoub = 8) along with 11 sonomicrometry crystals and 2 pressure catheters. Force and geometry data were combined to obtain the local structural stiffness in different segments of the aortic root.

RESULTS

The radial structural stiffness was not different between groups (P = 0.064) at the annular level; however, the David technique seemed to stabilize the aortic annulus more than the Yacoub technique. In the sinotubular junction, the native group was more compliant (P = 0.036) with the right-left coronary segment than the intervention groups. Overall, the native aortic root appeared to be more dynamic at both the annular level and the sinotubular junction than both intervention groups.

CONCLUSIONS

In conclusion, the David procedure may stabilize the aortic annulus more than the Yacoub procedure, whereas the leaflet opening area was larger in the latter (P = 0.030). No difference (P = 0.309) was found in valve-opening delay between groups. The 2 interventions show similar characteristics at the sinotubular junction, whereas the David technique seemed more restrictive at the annular level than the Yacoub technique.

Valve Sparing Root Replacement Provides Similar Midterm Outcomes in Bicuspid and Trileaflet Valves

BACKGROUND

Valve-sparing aortic root replacement (VSRR) is an established treatment for aortic root pathology for trileaflet valves. The safety and durability of VSRR in bicuspid aortopathy is unclear. In this study, outcomes of performing VSRR in the setting of bicuspid and trileaflet valves were compared.

METHODS

An institutional database identified 294 patients who underwent VSRR from 2005 to 2017. Of these, 225 had trileaflet valves and 69 had bicuspid valves. Patients were followed prospectively and had annual postoperative echocardiograms. Propensity-matched comparisons were made between trileaflet and bicuspid valve patients.

RESULTS

The average patient age for trileaflet valves was 46.0 ± 13.5 versus 42.7 ± 12.2 years for bicuspid patients (p = 0.07). There was a higher presence of preoperative >2+ aortic insufficiency (AI) present in bicuspid patients (63.8%) compared with trileaflet patients (31.1%) (p < 0.01). Mean follow-up was 39 months and was 98% complete. At 5 years, the cumulative incidence of >2+ AI and aortic valve replacement (AVR) was 2.0% and 4.3% in trileaflet patients and 7.7% (p = 0.75) and 7.7% (p = 0.81) in bicuspid patients. Preoperative >2+ AI was not predictive of >2+ postoperative AI (p = 0.62) nor AVR (p = 0.49). Five-year survival was no different between groups (trileaflet: 98%, bicuspid: 84%, p = 0.24).

CONCLUSIONS

VSRR can be safely and effectively performed in patients with trileaflet and bicuspid valves. Operative outcomes and valve function were equivalent in bicuspid and trileaflet patients in midterm follow-up. Performance of VSRR is a viable term option in the setting bicuspid aortic valve aortopathy.

In vivo assessment of aortic root geometry in normal controls using 3D analysis of computed tomography

Aims

Understanding normal asymmetry in the aortic root could aid in the development of new surgical repair techniques or devices with improved haemodynamic performance. The purpose of this study was to assess geometric asymmetry and age-related changes in the normal aortic root using 3D computed tomography.

Methods and Results

The institutional review board approved this retrospective study of 130 normal subjects (mean age, 51.4 years; 58 men). Specialized 3D software measured individual cusp sinus volumes (CSVs), cusp surface areas (CSAs), and intercommissural distances (ICDs). Age-related aortic root changes were evaluated with simple correlation, ANOVA test among age groups, and multivariable linear regression analyses. The CSV and CSA of left coronary cusp (LCC) were significantly smaller than those of right coronary cusp (RCC) and non-coronary cusp (NCC) (both, P < 0.001) in all age groups. The mean ratios of RCC or NCC-to-LCC were 1.38 and 1.36 for CSV, 1.19 and 1.20 for CSA, and 1.21 and 1.06 for ICD, respectively. The CSV and ICD increased in older age with weak-to-moderate correlation coefficients in both men and women. By multivariable linear regression, CSVs and ICDs of all cusps showed a positive correlation with age (P < 0.05), and the female gender was associated with a smaller size of the CSV and CSA.

Conclusions

The LCC was significantly smaller than the other two cusps, and the aortic root size increased with age.

Bicuspid aortic valve repair in the setting of severe aortic insufficiency

BACKGROUND

Bicuspid aortic valve (BAV) is a common cardiac anomaly that affects 0.5-2% of adults. Valve sparing root replacement (VSRR) in bicuspid aortopathy is gaining popularity. We discuss the technical aspects of the procedure as well as the mid- to long-term results of performing VSRR in the setting of a bicuspid valve.

METHODS

A single institutional database identified 280 patients who underwent VSRR from 2005-2016. Outcomes were analyzed in 60 consecutive patients undergoing a VSRR in the setting of a BAV with aortic regurgitation (AR). Patients were followed prospectively and had annual echocardiograms.

RESULTS

The average age in this series was 42±11 years. Moderate or more AR was present in 50% of patients preoperatively. The incidence of operative death, stroke, and renal failure was 0%. Mean follow-up was 39±30 months. At latest follow-up, 62% of patients had zero AR and 87% of patients had <1+ AR. At 9 years, freedom from >2+ AR was 97% and freedom from aortic valve repair (AVR) was 96%.

CONCLUSIONS

VSRR can be safely and effectively performed in young patients with bicuspid valve anatomy regardless of degree of pre-operative AR. Valve function is durable and the incidence of valve-related complications is low. VSRR is an attractive and potentially superior option to conventional root replacement in appropriately selected patients with bicuspid aortopathy.

Aortic valve insufficiency in aortic root aneurysms: consider every valve for repair

Aortic valve (AV) preservation and repair is emerging as an attractive alternative to AV replacement in younger patients with aortic insufficiency (AI) and aortic root aneurysms. AV repair mitigates some of the risks associated with prosthetic valves. More centers are reporting the safety of AV preservation and repair and favorable short- and long-term outcomes. However, further work is needed to improve long-term repair durability and dissemination of knowledge and technique to make AV repair the gold standard in this patient population.

An Expansible Aortic Ring in Aortic Root Remodeling: Exact Position, Pulsatility, Effectiveness, and Stability in Three-Dimensional CT Study

BACKGROUND

The aim of this study was to assess effectiveness, stability, position, and expansibility of an expansible aortic annuloplasty ring with computed tomography (CT).

METHODS

Ten men (median age 51 years) scheduled for aortic root remodeling with implantation of external annuloplasty ring underwent contrast-enhanced CT of the aortic root preoperatively, postoperatively, and at a median of 21 months after operation. A reconstructed transverse double oblique view of the aortic base (AB) and of the new defined annuloplasty ring base (ARB; plane of the lower edge of the ring) in systole and diastole were obtained. The diameters, perimeter, and area were measured. In addition, the distances between AB and ARB in the nadir of each sinus were measured.

RESULTS

We found 12% reduction of the postoperative AB and 19% of ARB perimeter in both systole (p = 0.004, p < 0.001, respectively) and diastole (p = 0.001, p < 0.001, respectively) compared with preoperative. There was 22% reduction of the postoperative AB area in systole and 24% in diastole (p = 0.002, p = 0.001, respectively) and 33% reduction of the ARB area in systole and 32% in diastole (p < 0.001 for both) compared with the preoperative period. Nearly all measured variables in the follow-up period showed a slight increase compared with the postoperative period; however, they did not reach statistical significance. The postoperative systolic-diastolic differences in the three measured variables at the level of AB and ARB were statistically significant and were maintained throughout the follow-up period. The base of the ring was implanted 2 ± 2 mm at the right, 0 ± 1 mm at the left above the AB, and 2 (-3 to 2) mm at the noncoronary nadir below the AB.

CONCLUSIONS

This study demonstrates imaging evidence of the effectiveness, stability, and pulsatility of the annuloplasty ring in aortic root remodeling in follow-up and describes the exact position of the ring at the base of the aortic root.

Reexamining remodeling

OBJECTIVE

Root remodeling was proposed as valve-preserving root replacement to treat patients with aortic regurgitation and root aneurysm. The objective of this retrospective study was to review 18 years of experience with root remodeling and to identify predictors of valve durability.

METHODS

Between October 1995 and December 2013, root remodeling was performed in 747 patients. The aortic valve anatomy was tricuspid in 431 patients, bicuspid in 290 patients, and unicuspid in 26 patients. Aortic aneurysm was present in 688 patients, and 59 procedures were performed for acute aortic dissection type A. The severity of aortic regurgitation ranged from grade 0 to IV (grade 0, 1%; grade 1, 8%; grade 2, 26%; grade 3, 62%; grade 4, 3%; median, 3). All patients underwent root remodeling, concomitant operations were performed in 352 patients, and cusp repair was used in 690 procedures.

RESULTS

Hospital mortality was 2%. Overall freedom from reoperation was 92% at 10 years and 91% at 15 years. Overall freedom from reoperation was 95% for tricuspid valves at 10 and 15 years, 89% for bicuspid aortic valves at 10 years (P = .006), and 83% for bicuspid aortic valves at 15 years. By multivariate analysis, the strongest risk factors for failure were an aortoventricular junction 28 mm or greater (hazard ratio, 1.43) and the use of a pericardial patch as part of cusp repair (hazard ratio, 6.24).

CONCLUSIONS

Root remodeling continues to be a viable option in valve-preserving root replacement. If combined with careful assessment and, if necessary, correction of aortic valve geometry, reproducible restoration of aortic valve function can be achieved with good long term durability.

The outcome after aortic valve-sparing (David) operation in 179 patients: a single-centre experience

OBJECTIVES

The David aortic valve-sparing reimplantation (AVr-D) operation is increasingly being used in patients with aortic root aneurysmal disease and pliable aortic cusps. The objective of this study was to assess our early and medium-term outcomes with the AVr-D operation.

METHODS

Between 2003 and 2011, a total of 179 patients underwent AVr-D procedures. The mean patient age was 49.7 ± 15.1 years, and 23.5% (n = 42) were females. Marfan syndrome was present in 17.3% of patients (n = 31), and acute Type A aortic dissection in 15.6% (n = 28). Clinical follow-up was 100% complete and was 1.8 ± 1.6 years (0 days to 7.5 years) long. Echocardiographic follow-up was performed 2.2 ± 1.5 years (0 days to 7.5 years) postoperatively and was 77% complete.

RESULTS

Early mortality was 1.1% (n = 2), with both deaths occurring in patients with Type A dissection. Pre-discharge echocardiography revealed no patients with >2+ aortic insufficiency (AI), 19.6% of patients (n = 34) with 1+ or 2+ AI and 80.4% of patients (n = 145) with trace or no AI. Left ventricular end-diastolic diameters decreased significantly from 5.6 ± 0.9 to 5.1 ± 0.8 cm early postoperatively (P < 0.01). Transvalvular maximum gradients were similar before discharge and at last follow-up (10.6 ± 5.4 vs. 10.0 ± 8.2 mmHg, P = 0.4). AI grade increased significantly over time (0.3 ± 0.4 before discharge vs. 0.5 ± 0.6 at follow-up, P = 0.01), but remained less than moderate in 93.6% of patients. Four patients required aortic valve re-replacement during follow-up, two due to early endocarditis and two due to non-coronary leaflet prolapse in Marfan patients. Five-year freedom from aortic valve reoperation was 95.9 ± 2.0%.

CONCLUSIONS

AVr-D is associated with a low mortality and morbidity rate, even in patients with Type A aortic dissection. Although a slightly higher rate of recurrent AI may be present in patients with Marfan syndrome, freedom from recurrent AI and reoperation remains excellent during medium-term follow-up. The David operation should be considered the gold standard for patients with proximal aortic root pathology (aneurysm or dissection) and pliable aortic cusps.

Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection

Acute type A aortic dissection is a lethal condition requiring emergency surgery. It has diverse presentations, and the diagnosis can be missed or delayed. Once diagnosed, decisions with regard to initial management, transfer, appropriateness of surgery, timing of operation, and intervention for malperfusion complications are necessary. The goals of surgery are to save life by prevention of pericardial tamponade or intra-pericardial aortic rupture, to resect the primary entry tear, to correct or prevent any malperfusion and aortic valve regurgitation, and if possible to prevent late dissection-related complications in the proximal and downstream aorta. No randomized trials of treatment or techniques have ever been performed, and novel therapies-particularly with regard to extent of surgery-are being devised and implemented, but their role needs to be defined. Overall, except in highly specialized centers, surgical outcomes might be static, and there is abundant room for improvement. By highlighting difficulties and controversies in diagnosis, patient selection, and surgical therapy, our over-arching goal should be to enfranchise more patients for treatment and improve surgical outcomes.

Preoperative aortic root geometry and postoperative cusp configuration primarily determine long-term outcome after valve-preserving aortic root repair

OBJECTIVE

Technical controversies exist in valve-preserving aortic root replacement. We sought to determine predictors of long-term stability of the aortic valve.

METHODS

A total of 430 patients (aged 57 ± 15 years, 323 male) underwent valve-preserving aortic root surgery (remodeling in 401, reimplantation in 29) between 1995 and 2009 and were followed echocardiographically. Factors influencing late recurrence of aortic valve regurgitation grade II or greater (n = 45) or need for reoperation on the aortic valve (n = 25) were analyzed.

RESULTS

Early mortality was 2.8% (1.9% for elective cases), and actuarial survival at 10 years was 83.5% ± 2.4%. Ten-year freedom from aortic valve regurgitation grade II or greater was 85.0% ± 2.5%. Preoperative aortoventricular junction diameter greater than 28 mm and postoperative effective height of the aortic cusp less than 9 mm were identified as significant predictors for late aortic valve regurgitation grade II or greater in multivariate analysis (both P < .001). Ten-year freedom from reoperation on the aortic valve was 89.3% ± 2.5%. Preoperative aortoventricular junction diameter greater than 28 mm (P < .001), use of pericardial patch (P = .022), and effective height of the aortic cusp less than 9 mm (P = .049) were identified as significant predictors for reoperation in multivariate analysis. Operative technique (remodeling, reimplantation), Marfan syndrome, bicuspid valve anatomy, concomitant central cusp plication, size of prosthesis used, and acute dissection were not associated with an increased risk of late aortic valve regurgitation grade II or greater or reoperation. In patients with preoperative aortoventricular junction diameter greater than 28 mm (n = 94), the addition of central cusp plication significantly improved freedom from aortic valve regurgitation grade II or greater (P = .006) regardless of root procedures (remodeling, P = .011; reimplantation, P = .053).

CONCLUSIONS

Long-term stability of valve-preserving aortic root replacement was influenced not by the technique of root repair but by the preoperative aortic root geometry and postoperative cusp configuration.