Quality of life after aortic root surgery: reimplantation technique versus composite replacement

Long-term outcomes comparison of Bentall-De Bono-versus valve-sparing aortic root replacement: An updated systematic review and reconstructed time-to-event meta-analysis

BACKGROUND

For patients with aortic root dilatation and a structurally normal aortic valve (AV) undergoing composite aortic valve-graft (Bentall-De Bono) versus valve-sparing aortic root replacement (VSARR) procedures there are conflicting data regarding early and long-term benefits. We undertook a study-level meta-analysis to compare the results of both procedures.

METHODS

Three databases were assessed, and both randomized trials and observational studies were considered eligible. Kaplan-Meier curves of long-term survival and reoperation risk were reconstructed and compared with Cox linear regression and incidence rate ratios (IRR) with 95 % confidence intervals (CI). Landmark analysis and time-varying hazard ratio (HR) were analyzed. Odds ratios (OR) were calculated for early mortality, postoperative stroke, and re-exploration for postoperative bleeding. A random effects model was used. Sensitivity analyses included leave-one-out-analysis, meta-regression and subgroups analysis.

RESULTS

1456 articles were identified, including 39 observational studies, totaling 14,651 patients (Bentall-De Bono = 9557 and VSARR = 5094). Twelve studies were adjusted. The mean weighted follow-up was 5.05 ± 3.7 years. VSARR was associated with significantly greater survival (HR = 0.50; 95 % CI, 0.45-0.57; p < 0.0001) at 15-year follow-up. The reoperation risk was higher following VSARR (HR = 1.30; 95 % CI, 1.03-1.63; p = 0.02.), although time-varying HR model and landmark analysis reported an increased risk of reoperation within 5 years after VSARR (HR = 1.57; 95 % CI, 1.23-2.01; p < 0.001), after which the difference disappeared. Subgroups analysis of studies excluding aortic dissection showed a comparable rate of late reoperation.

CONCLUSIONS

VSARR is associated with improved long-term survival compared to Bentall-De Bono. The risk of late reoperation is higher within 5 years following VSARR, after which the two procedures are comparable.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

The Long-Term Outcome and Quality of Life after Replacement of the Ascending Aorta

(1) Background: Despite optimal surgical therapy, replacement of the ascending aorta leads to a significant reduction in the quality of life (QoL). However, an optimal result includes maintaining and improving the QoL. The aim of our study was to evaluate the long-term outcome and the QoL in patients with aneurysms in the ascending aorta; (2) Methods: Between 2014 and 2020, 121 consecutive patients who underwent replacement of the ascending aorta were included in this study. Acute aortic pathologies were excluded. A standard short form (SF)-36 questionnaire was sent to the 112 survivors. According to the surgical procedure, patients were divided into two groups (A: supracoronary replacement of the aorta, n = 35 and B: Wheat-, David- or Bentall-procedures, n = 86). The QoL was compared within these groups and to the normal population, including myocardial infarction (MI), coronary artery disease (CAD) and cancer (CAN) patients; (3) Results: 83 patients were males (68.6%) with a mean age of 62.0 ± 12.5 years. Early postoperative outcomes showed comparable results between groups A and B, with a higher re-thoracotomy rate in B (A: 0.0% vs. B: 22.1%, p = 0.002). The 30-day mortality was zero. Overall, mortality during the follow-up was 7.4%. The SF-36 showed a significant decay in both the Physical (PCS) and Mental Component Summary (MCS) in comparison to the normal population (PCS: 41.1 vs. 48.4, p < 0.001; MCS: 42.1 vs. 50.9, p < 0.001) but without significant difference between both groups. Compared to the MI and CAD patients, significantly higher PCS but lower MCS scores were detected (p < 0.05); (4) Conclusions: Replacement of the ascending aorta shows low risk regarding the operative and postoperative outcomes with satisfying long-term results in the QoL. The extent of the surgical procedure does not influence the postoperative QoL.

Is valve-sparing aortic root replacement better than total aortic root replacement? An overview of reviews

Background

Total aortic root replacement (TRR) is certainly beneficial for aortic root disease, but does it still have an advantageous prognosis for patients compared to valve-sparing aortic root replacement (VSRR)? An overview of reviews was conducted to assess each of their clinical efficacy/effectiveness.

Review methods

Systematic reviews (SRs)/Meta-analyses comparing the prognosis of TRR and VSRR in aortic root surgery were collected from 4 databases, all searched from the time of database creation to October 2022. Two evaluators independently screened the literature, extracted information and applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2) tool, Grading of Recommendations, Assessment, Development and Evaluations (GRADE), and Risk of Bias in Systematic Reviews (ROBIS) to evaluate the quality of reporting, methodological quality, risk of bias, and level of evidence of the included studies.

Main results

A total of 9 SRs/Meta-analyses were ultimately included. In terms of the reporting quality of the included studies, PRISMA scores ranged from 14 to 22.5, with issues mainly in reporting bias assessment, risk of study bias, credibility of evidence, protocol and registration, and funding sources. The methodological quality of the included SRs/Meta-analyses was generally low, with key items 2, 7, and 13 having major flaws and non-key items 10, 12, and 16. In terms of risk of bias assessment, the overall assessment of the included 9 studies was high-risk. The quality of the evidence was rated as low to very low quality for the three outcome indicators selected for the GRADE quality of evidence rating: early (within 30 days postoperatively or during hospitalization) mortality, late mortality, and valve reintervention rate.

Conclusions

VSRR has many benefits including reduced early and late mortality after aortic root surgery and reduced rates of valve-related adverse events, but the methodological quality of the relevant studies is low, and there is a lack of high-quality evidence to support this.

Systematic Review Registration

https://www.PROSPERO, identifier: CRD42022381330.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Long-term outcomes after aortic root repair using selective sinus replacement

OBJECTIVES

The study aim was to evaluate long-term results after anatomic restoration of the aortic root.

METHODS

During an 18-year period, a total of 669 patients underwent valve-sparing root repair (aneurysm 554, dissection 115) using selective sinus replacement. None/trivial, mild, moderate, and severe (grades 3+ and 4+) insufficiency were present in 57, 146, 204, and 262 patients, respectively.

RESULTS

The anatomic repair was adjusted to the existing aortic annulus diameter, which was 27.0 ± 3.0 mm on average. Replacement of 1, 2, or 3 sinuses of Valsalva was performed in 209, 234, and 226 patients, respectively. Altogether, 454 additional procedures on the cusps were performed, mostly as cusp patch plasty with pericardium (210). Thirty-day mortality was 0.6%. The mean follow-up duration was 7.1 ± 4.1 years (range, 0.01-19.1 years). The estimated freedom from relevant aortic insufficiency grade 3+ or greater (15 events) was 98% ± 1%, 97% ± 1%, and 94% ± 3% at 5, 10, and 15 years, respectively. On echocardiogram, no patient revealed a considerable change of the form or size of the repaired root, which was confirmed radiologically in 160 patients who received computed tomography angiography for any reason. Multivariate logistic regression analysis identified cusp prolapse/pseudo-prolapse as the only independent risk factor for the development of recurrent insufficiency grade 2+ or greater (41 occurrences), with a hazard ratio of 3.258 (95% confidence interval, 1.658-6.403; P = .001). An association between aortic annulus size and functional results could not be demonstrated.

CONCLUSIONS

Patient-tailored root repair using isolated sinus replacement offers excellent functional long-term results regardless of underlying root pathology or annulus size. Aortic cusp pathology was decisive for long-term valve function.

Regurgitant Bicuspid Aortopathy: Is Valve-Sparing Root Replacement Equivalent to Bentall Procedure?

BACKGROUND

Repair of aortic root aneurysms with nonstenotic bicuspid valves (NS-BAVs) is achieved either with valve-sparing root replacement (VSRR) or conventional Bentall procedure (ROOT). Procedural and long-term outcomes comparing these 2 techniques are sparse and need investigation.

METHODS

From March 2004 to January 2019, 158 patients with an aortic root aneurysm and NS-BAV underwent VSRR (n = 78, 49.3%) or ROOT (n = 80, 50.6%). VSRR involved optional aortic valve repair (n = 47, 60%), and ROOT was performed with bioprosthetic (81.3%) or mechanical valve replacement (18.7%). Procedural and postoperative outcomes were obtained, and univariate and Kaplan-Meier analyses were performed.

RESULTS

VSRR patients were younger (42.7 ± 12.0 years of age) than ROOT (54.8 ± 13.6 years of age) (P < .001). Cardiopulmonary bypass (CPB) and cross-clamp duration were longer in VSRR (CPB: 228.0 ± 39.1 minutes; cross-clamp: 200.1 ± 36.2 minutes) compared with ROOT (CPB: 199.5 ± 55 minutes; cross-clamp: 170.3 ± 39.5 minutes) (P < .001). Postoperative stroke, renal failure, pneumonia, and reoperation for bleeding were similar, but postoperative atrial and ventricular arrhythmias was lower in VSRR (15% vs 42%; P < .001). Length of stay and 30-day mortality were similar. At discharge, none had greater than trivial aortic insufficiency. Long-term 10-year survival and incidence of moderate-severe aortic insufficiency, aortic stenosis, and reoperation were equivalent between groups.

CONCLUSIONS

Surgery for aortopathy associated with NS-BAV is safe and effective with either VSRR or ROOT. Despite its complexity, VSRR should be considered in the surgical treatment of this population.

Clinical outcomes and quality of life in patients with acute and subacute type B aortic dissection after thoracic endovascular aortic repair

OBJECTIVE

Thoracic endovascular aortic repair (TEVAR) is considered the mini-invasive treatment of choice for patients with Stanford type B aortic dissection (TBAD). This study aimed to investigate the clinical outcomes and quality of life (QoL) in patients with acute and subacute TBAD after TEVAR.

METHODS

From January 2014 until July 2016, 22 acute patients (Group A) and 18 subacute patients received TEVAR (Group B), and 13 patients were managed non-operatively (Group C). The Medical Outcomes Study Short Form-36 was used to assess QoL preoperatively and after TEVAR. Operative techniques and complications were retrospectively analyzed.

RESULTS

The role emotion, vitality, and mental health domains scored well preoperatively. Except for role emotion, vitality, and mental health, the remaining domains significantly improved after TEVAR. There was no significant difference in QoL metrics between Groups A and B. In Group C, bodily pain and social functioning domains were improved, and role emotion was decreased, with no improvement in the remaining domains. The 3-year survival rates were 95.5%, 100%, and 85.7% for Groups A, B, and C, respectively.

CONCLUSIONS

TEVAR may be safe and effective in patients with acute and subacute TBAD with similar and favorable clinical and QoL metrics.

Valve-Sparing Root Replacement Versus Composite Valve Grafting in Aortic Root Dilation: A Meta-Analysis

BACKGROUND

Aortic valve-sparing operations theoretically have fewer stroke and bleeding complications but may increase late reoperation risk versus composite valve grafts.

METHODS

We meta-analyzed all studies comparing aortic valve-sparing (reimplantation and remodelling) and composite valve-grafting (bioprosthetic and mechanical) procedures. Early outcomes were all-cause mortality, reoperation for bleeding, myocardial infarction, and thromboembolism/stroke. Long-term outcomes included all-cause mortality, reintervention, bleeding, and thromboembolism/stroke. Studies exclusively investigating dissection or pediatric populations were excluded.

RESULTS

A total of 3794 patients who underwent composite valve grafting and 2424 who underwent aortic valve-sparing procedures were included from 9 adjusted and 17 unadjusted observational studies. Mean follow-up was 5.8 ± 3.0 years. Aortic valve sparing was not associated with any difference in early mortality, bleeding, myocardial infarction, or thromboembolic complications. Late mortality was significantly lower after valve sparing (incident risk ratio, 0.68; 95% confidence interval [CI], 0.54-0.87; P < .01). Late thromboembolism/stroke (incident rate ratio, 0.36; 95% CI, 0.22-0.60; P < .01) and bleeding (incident rate ratio, 0.21; 95% CI, 0.11-0.42; P < .01) risks were lower after valve sparing. Procedure type did not affect late reintervention.

CONCLUSIONS

Aortic valve sparing appears to be safe and associated with reduced late mortality, thromboembolism/stroke, and bleeding compared with composite valve grafting. Late durability is equivalent. Aortic valve sparing should be considered in patients with favorable aortic valve morphology.

Clinical and quality of life outcomes after aortic valve replacement and aortic root surgery in adult patients <65 years old

Selecting the optimal surgical treatment strategy in patients below the age of 65 years (i.e., non-elderly patients) with aortic valve or aortic root disease remains challenging. The objective of the current study is to summarize contemporary research on clinical and quality of life outcomes after aortic valve replacement (AVR) and aortic root surgery in non-elderly patients. Recent systematic reviews on clinical outcome after biological and mechanical AVR, the Ross procedure and aortic root surgery show that event occurrence is considerable after any type of AVR or aortic root surgery and-with the exception of the Ross procedure-survival is suboptimal. Although thromboembolism and bleeding events are more common after mechanical AVR and root surgery, these events are also considerably present after biological AVR, the Ross procedure and valve-sparing aortic root surgery (VSRR). Similarly, reoperation is more common after biological AVR, the Ross procedure and VSRR, but also occurs frequently after mechanical AVR and root replacement. Published evidence in AVR patients points to the direction of better health-related quality of life (HRQoL) outcomes with a biological solutions, while the HRQoL after aortic root surgery is limited and contradictory. This review illustrates that treatment for non-elderly aortic valve and aortic root disease patients needs to be tailored to the individual patient, considering both clinical and HRQoL outcomes as crucial factors to reach a treatment decision that best reflects the patient's values and goals in life.

Valve-sparing root replacement and composite valve graft replacement in patients with aortic regurgitation: From the Japan Cardiovascular Surgery Database

OBJECTIVES

The advantage of valve-sparing root replacement (VSRR) over aortic root replacement with a composite valve graft (CVG) remains unclear. We compared these 2 procedures with regard to early outcomes with propensity score matching using the Japan Cardiovascular Surgery Database.

METHODS

Of 5303 patients from the Japan Cardiovascular Surgery Database who had undergone aortic root replacement in 2008 to 2017, emergent/urgent or redo cases and those with infective endocarditis or aortic stenosis were excluded (included n = 3841). Two propensity score-matched groups treated with VSRR or CVG replacement (n = 1164 each) were established.

RESULTS

Overall, VSRR was more frequently performed for younger patients with Marfan syndrome with lower operative risk and aortic regurgitation grade compared with CVG replacement. After matching, a weaker but similar trend still existed in baseline characteristics. Although more concomitant procedures were performed in the CVG group, myocardial ischemia and cardiopulmonary bypass time was significantly longer in the VSRR group (median, 193 and 245 minutes) than the CVG group (172 and 223 minutes, both P < .01). The CVG group was associated with a significantly greater incidence of postoperative stroke (2.5% vs 1.1%, P = .01) and prolonged ventilation >72 hours (7.0% vs 4.6%, P = .02). In-hospital mortality rates were significantly greater in the CVG group (1.8%) than the VSRR group (0.8%, P = .02).

CONCLUSIONS

In overall Japanese institutions, VSRR was more frequently performed for patients at low risk and was associated with better morbidity and mortality rates than CVG replacement. After matching, VSRR was also associated with better morbidity and mortality rates despite longer procedure time.

Measuring what matters to the patient: health related quality of life after aortic valve and thoracic aortic surgery

With improved outcomes following cardiac surgery, health related quality of life (HRQoL) gains increasing importance for the better judgement of choosing the preferred treatment strategy in the individual patient. The physician perception of patient preferences can differ considerably from actual patient preferences, underlining the importance of gathering evidence of actual patient preferences before and quality of life after cardiac surgery. The objective of the current review is to provide an overview of current insights into the quality of life measurements after aortic valve and thoracic aortic surgery and to provide starting points for the application of HRQoL measurements toward the future. The amount and level of evidence on HRQoL outcomes after aortic valve and thoracic aortic surgery seems to be insufficient. Little has been investigated about the natural course of HRQoL after cardiac surgery, HRQoL outcomes between different surgical strategies, HRQoL outcomes between surgical patients and the general population, the different factors influencing HRQoL after cardiac surgery, and the effect of HRQoL on healthcare costs. More prospective studies should be performed, taking into account the knowledge gaps that need to be filled. Computerized adaptive testing methods through open source programs can be implemented to keep the burden to the patient as low as possible and catalyze the use of these tools. Our cardiovascular surgery community has the responsibility to deliberate how it can proceed to effectively fill in these knowledge gaps, and use this newfound knowledge to improve shared treatment decision making, patient outcomes, and ultimately optimize health care efficiency.

Predictors of Outcome for Aortic Valve Reimplantation Including the Surgeon-A Single-Center Experience

INTRODUCTION

Aortic valve reimplantation is considered technically demanding. We searched for predictors of long-term outcome including the surgeon as risk factor.

METHODS

We selected all aortic valve reimplantations performed in our department between December 1999 and January 2017 and obtained a complete follow-up. The main indications were combined aortic aneurysm plus aortic valve regurgitation (AR), 69% and aortic dissections (15%). In 14%, valves were bicuspid. Cusp repair was performed in 27% of patients. One-third received additional procedures (coronary artery bypass grafting, mitral, or arch surgery). We performed multivariable analyses for independent risk factors of short- and long-term outcomes, including "surgeon" as variable. Twelve different surgeons operated on 193 patients. We created three groups: surgeons A and B with 84 and 64 procedures, respectively, and surgeon C (10 surgeons for 45 patients).

RESULTS

Cardiopulmonary bypass and clamp times were 176 ± 45 and 130 ± 24 minutes, respectively. In-hospital mortality was 2%. Postoperatively, 5% had mild and 0.5% had moderate AR. Kaplan-Meier's survival estimates, freedom from reoperation, and freedom from severe AR at 12 years were 97 ± 1, 93 ± 2, and 91 ± 3%, respectively. Age and chronic obstructive pulmonary disease appeared as risk factors for perioperative complications by univariate analysis. Age, coronary artery disease, and duration of cardiopulmonary bypass, but not surgeon, presented as risk factors by multivariable analysis.

CONCLUSION

The results suggest that if a David procedure is performed successfully, long-term durability may be excellent. They also suggest that good and durable results are possible even with limited experience of the operating surgeon.

Valve-sparing aortic root replacement-midterm outcomes and quality of life

Background

This study evaluated the midterm outcomes, the valve related events and quality of life of patients treated by valve-sparing aortic root replacement (VSRR).

Methods

From January 2003 to December 2014, 88 consecutive patients diagnosed with an aortic root aneurysm or ascending aortic aneurysms underwent VSRR surgery. The mean age was 55±14 (range 19-77) years. A total of 84% of the patients were male; 89% were in New York Heart Association functional class I or II, 55% had aortic regurgitation (AR) grade III or IV. Twenty-four patients (27.3%) had bicuspid aortic valve. The mean left ventricular ejection fraction (LVEF) was 61%±9% (range 29-78%). Patients were yearly followed by family doctors and referent cardiologists. Doppler echocardiographic examinations were obtained annually in all patients. The midterm clinical, echocardiographic results and quality of life were analyzed. The mean follow-up was 5.3±3 (range 1-12) years.

Results

Hospital mortality was 1%. There were 10 late deaths (11%) including 5 cardiac cases. Two patients (2%) required an aortic valve or graft prosthesis reoperation. Aortic valve endocarditis occurred in two patients. Thromboembolic events were reported in three patients. None of the following morbidity has been observed: structural valve deterioration, nonstructural dysfunction, valve thrombosis, bleeding event. The 5- and 8-year survival were 92% and 88%, respectively. The 8-year survival free from cardiac death was 88%. The mean of EuroQoL visual analogue scale (EQ VAS) and EQ index were respectively 83±15 (range 30-100) and 0.94±0.12 (range 0.5-1).

Conclusions

Eight-year clinical improvement, function of the spared aortic valve and quality of life after valve sparing aortic root surgery appear excellent.

Surgical Treatment of Annuloaortic Ectasia - Replace or Repair?

Background

Patients with annuloaortic ectasia may be surgically treated with modified Bentall or David I valve-sparing procedures. Here, we compared the long-term results of these procedures.

Methods

A total of 181 patients with annuloaortic ectasia underwent modified Bentall (102 patients, Group 1) or David I (79 patients, Group 2) procedures from 1994 to 2015. Mean age was 62 ± 11 years in Group 1 and 64 ± 16 years in Group 2. Group 1 patients were in poorer health, with a lower ejection fraction and higher functional class.

Results

Early mortality was 3% in Group 1 and 2.5% in Group 2. Patients undergoing a modified Bentall procedure had a higher incidence of thromboembolism and hemorrhage, whereas those undergoing a David I procedure had a higher incidence of endocarditis. Actuarial survival was 70 ± 6% at 15 years in Group 1 and 84 ± 7% at 10 years in Group 2. Actuarial freedom from reoperation was 97 ± 2% at 15 years in Group 1 and 84 ± 7% at 10 years in Group 2. In Group 2, freedom from procedure-related reoperations was 98 ± 2% at 10 years. At last follow-up, no cases of moderate or severe aortic regurgitation were observed.

Conclusions

The modified Bentall and David I procedures showed excellent early and late results. The modified Bentall procedure with a mechanical conduit was associated with thromboembolic and hemorrhagic complications, whereas the David I procedure was associated with unexplained occurrences of endocarditis. Thus, the David I procedure appears to be safe, reproducible, and capable of achieving stable aortic valve repair and is therefore our currently preferred solution for patients with annuloaortic ectasia. However, the much shorter follow-up for David I patients limits the strength of our comparison between the two techniques.

Complex Cusp Repair in Patients Undergoing the David Procedure: Is It Worth It?

BACKGROUND

Valve-sparing aortic root replacement has already proven its excellent long-term results, with low valve-related complications comparable with conventional aortic valve replacement. The aim of this study was to investigate whether additional expanded cusp repair is an alternative with comparable results.

METHODS

Data of 192 elective patients undergoing valve-sparing aortic root replacement were prospectively recorded: 58 patients (30.2%) received an isolated aortic root replacement (group I, isolated David), and 134 patients (69.8%) received additional cusp repair (group II, complex David), such as plication of the free margin (n = 77), decalcification (n = 45), or pericardial patch (n = 39). Cumulative follow-up was 480 patient-years, with a mean of 2.5 ± 1.5 years.

RESULTS

Mean age was 60 years, and 76.6% were men. In hospital mortality was 3.4% in group I and 0.0% in group II. Freedom from cardiac death at 5 years (by Kaplan-Meier estimation) was 83% vs 98% (p = 0.058). Freedom from moderate or severe aortic insufficiency at 5 years was 100% in group I vs 93% (95% confidence interval, 86% to 97%) in group II (p = 0.110). Seven patients required reoperation for aortic insufficiency or stenosis: repeat repair (n = 3), Ross procedure (n = 2), and biologicical aortic valve replacement (n = 2). Freedom from reoperation at 5 years was 96% (95% confidence interval, 76% to 99%) in group I vs 89% (95% confidence interval, 71% to 96%) in group II (p = 0.305).

CONCLUSIONS

Overall survival and freedom from reoperation after valve-sparing aortic root replacement, even with additional complex cusp repair, provides excellent midterm results. Low risk of valve-related complications and absence of anticoagulation therapy are distinctive advantages of this complex procedure.

Quality of life after aortic valve repair is similar to Ross patients and superior to mechanical valve replacement: a cross-sectional study

Background

In patients after aortic valve surgery, the quality of life is hypothesized to be influenced by the type of the valve procedure. A cross-sectional study on the postoperative quality of life was carried out in patients after aortic valve-sparing surgery (with regards to the age of the patient), Ross procedure and mechanical aortic valve replacement.

Methods

Quality of life was studied in 139 patients after aortic valve surgery divided into four study groups (Y – aortic valve-sparing procedure at the age below 50 years, mean age 36.2 years; O – aortic valve-sparing procedure at the age 50 years and over, mean age 59.2 years; R – Ross procedure, mean age 37.8 years and M – mechanical aortic valve replacement at the age below 50 years, mean age 39.2 years). SF-36 Short Form and valve-specific questionnaires were mailed to the patients after 6 months or later following surgery (median 26.9 months).

Results

In SF-36, the younger aortic valve repair patients and the Ross patients scored significantly better in 4 of 4 physical subscales and in 2 of 4 mental subscales than the older aortic valve repair and mechanical valve replacement patients. In the valve-specific questionnaire; however, all 3 groups free of anticoagulation (Y, O, and R) displayed greater freedom from negative valve-related concerns.

Conclusions

Postoperative quality of life is influenced by the type of aortic valve procedure and is negatively linked with mechanical prosthesis implantation and long-term anticoagulation. Aortic valve-sparing strategy should be considered in cases with suitable valve morphology due to favorable clinical results and beneficial impact on the long-term quality of life.

Standardized approach to valve repair using an expansible aortic ring versus mechanical Bentall: early outcomes of the CAVIAAR multicentric prospective cohort study

OBJECTIVE

The study objective was to compare the 30-day outcomes of a standardized aortic valve repair technique (REPAIR group) associating root remodeling with an expansible aortic ring annuloplasty versus mechanical composite valve and graft (CVG group) replacement in treating aortic root aneurysms.

METHODS

A total of 261 consecutive patients with aortic root aneurysm were enrolled in this multicentric prospective cohort (131 in the CVG group, 130 in the REPAIR group) in 20 centers. The main end point is a composite criterion including mortality; reoperation; thromboembolic, hemorrhagic, or infectious events; and heart failure. Secondary end points were major adverse valve-related events. Crude and propensity score adjusted estimates are provided.

RESULTS

The mean age was 56.1 years, and the valve was bicuspid in 115 patients (44.7%). The median (interquartile range) preoperative aortic insufficiency grade was 2.0 (1.0-3.0) in the REPAIR group and 3.0 (2.0-3.0) in the CVG group (P = .0002). Thirty-day mortality was 3.8% (n = 5) in both groups (P = 1.00). Despite a learning curve and longer crossclamp times for valve repair (147.7 vs 99.8 minutes, P < .0001), the 2 groups did not differ significantly for the main criterion (odds ratio, 1.31; 95% confidence interval, 0.72-2.40; P = .38) or 30-day mortality (odds ratio, 0.99; 95% confidence interval, 0.28-3053; P = .99), with a trend toward more frequent major adverse valve-related events in the CVG group (odds ratio, 2.52; 95% confidence interval, 0.86-7.40; P = .09). At discharge, 121 patients (96.8%) in the REPAIR group had grade 0 or 1 aortic insufficiency.

CONCLUSIONS

A new standardized approach to valve repair, combining an expansible aortic annuloplasty ring with the remodeling technique, presented similar 30-day results to mechanical CVG with a trend toward reducing major adverse valve-related events. Analysis of late outcomes is in process for 3- and 10-year follow-ups.

Health-Related Quality of Life in Thoracic Aortic Disease: Part II. After Surgery on the Proximal (Root, Ascending, Arch) Aorta

BACKGROUND

Health-related quality of life (HRQOL) has been reported to be near-to-normal after operations on the proximal aorta. However, a thorough evaluation of variables related to postoperative HRQOL is lacking. We report HRQOL after surgery on the proximal aorta acknowledging current symptoms and conditions. If modifiable factors affect HRQOL, surgical treatment could be tailored to optimize outcomes.

METHODS

The short form 36 item (SF-36) questionnaire was used to measure HRQOL in eight domains and a physical component summary (PCS) and mental component summary (MCS) score. Median differences (Δ) between the component summary scores and a sex- and age-matched reference group from the general population were the primary outcome measures, along with comparisons of patient subgroups according to pathology (aneurysm versus dissection), aortic valve procedure, and circulatory arrest.

RESULTS

In 207 patients operated on the proximal aorta, after a mean of three years, there were no significant differences in median PCS (Δ = -0.3 [95% confidence limits -2.6, 2.0]) and MCS (Δ = 1.7 [-0.4, 2.9]) scores compared to the reference group, but median scores for the physical functioning, general health, and mental health domains were significantly lower. There were no statistically significant differences in PCS, MCS, or domain scores for patients with aneurysm versus dissection, for patients undergoing aortic valve procedures or not, or for patients managed with circulatory arrest or not. In multivariable analysis, exertional dyspnea was independently related to both ΔPCS (-6.5 [-13, -0.44]) and ΔMCS (-7.5 [-13, -1.6]), whereas age, exertional calf pain, and myocardial infarction were related only to ΔPCS.

CONCLUSIONS

Overall HRQOL after surgery on the proximal aorta is encouraging, which remains important when benchmarking against novel therapeutic procedures. At follow-up, HRQOL appears related to current symptoms and conditions, but not to operative procedures. To better understand their impact on HRQOL, prospective studies comparing pre- and postoperative scores are needed.