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Anzai I, Lawlor M, Hahn R, Takayama H, Kodali S, George I. Reoperation-Sparing Transcatheter Aortic Valve Replacement After Acute Failed Valve-Sparing Aortic Root Replacement. JACC Case Rep 2025; 30:102939. [PMID: 40155124 PMCID: PMC12014291 DOI: 10.1016/j.jaccas.2024.102939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2024] [Revised: 10/01/2024] [Accepted: 10/08/2024] [Indexed: 04/01/2025]
Abstract
Transcatheter aortic valve replacement (TAVR) is rarely performed for pure aortic insufficiency. When aortic insufficiency occurs in the context of a prior valve-sparing aortic root replacement (VSARR), the anatomic complexity of performing TAVR is significantly increased. We report a case of successful TAVR deployment in a patient with severe aortic insufficiency soon after VSARR. TAVR deployment in a prior VSARR graft relies on positioning the valve between the running sinus suture line superiorly and in this case CorKnots inferiorly using an oversized balloon-expandable valve to limit paravalvular leak. This was successfully performed with no residual regurgitation. Nonoperative management using TAVR for high-risk surgical candidates can be safely performed for aortic insufficiency after failed VSARR in the acute setting. Proper sizing, valve selection, and positioning are of utmost importance in this setting although the presence of CorKnots used during VSARR may aid in optimal positioning.
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Affiliation(s)
- Isao Anzai
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA.
| | - Matthew Lawlor
- Division of Cardiology, Department of Medicine, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Rebecca Hahn
- Division of Cardiology, Department of Medicine, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Hiroo Takayama
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Susheel Kodali
- Division of Cardiology, Department of Medicine, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Isaac George
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
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Kim H, Lee OJ, Lee JH, Kim YJ, Chung SR, Park TK, Kim DK, Park PW, Sung K. Impact of the grade and jet-flow direction of residual aortic regurgitation after valve-sparing root replacement. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00840-7. [PMID: 39326729 DOI: 10.1016/j.jtcvs.2024.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 08/20/2024] [Accepted: 09/16/2024] [Indexed: 09/28/2024]
Abstract
OBJECTIVES To investigate the impact of the grade and jet direction of residual aortic regurgitation (rAR) after valve-sparing root replacement (VSRR). METHODS The study enrolled 248 adult patients who underwent VSRR between 1995 and 2021. The patients were divided into groups based on the postoperative rAR. Patients with rAR were further categorized according to rAR grade and jet direction. The primary endpoint was the development of aortic regurgitation of moderate or greater (≥moderate) severity and/or the need for valve replacement during the follow-up, analyzed by a multivariable competing risk analysis. The secondary endpoints included the occurrence of rAR and overall survival. RESULTS The median age of the patients was 36.5 years, and 79.8% had been diagnosed with connective tissue disease. After VSRR, 146 patients did not present with rAR; however, 102 had rAR (77 with minimal central, 18 with minimal eccentric, and 7 with mild rAR). The 5-year and 8-year incidence rates of the primary endpoint were 14.6% and 17.9%, respectively. rAR was a significant risk factor (P = .001), and eccentricity and mild rAR seemed to have important roles. The risk factors for rAR included dilated root, preoperative moderate regurgitation, and redo sternotomy. Overall survival was influenced only by age. CONCLUSIONS rAR after VSRR operation could be a risk factor for AR progression. Minimal central rAR generally has a tolerable clinical course; however, patients with even minimal eccentric AR may develop AR progression, so active surveillance and timely management might be required. Furthermore, early VSRR can help reduce the rAR.
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Affiliation(s)
- Hongsun Kim
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Ok Jeong Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Ho Lee
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Yun Jin Kim
- Department of Medicine, College of Medicine, Hanyang University, Seoul, Korea; Biostatistics Lab, Medical Research Collaborating Center, Hanyang University, Seoul, Korea
| | - Su Ryeun Chung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Duk-Kyung Kim
- Division of Cardiology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Pyo Won Park
- Department of Thoracic and Cardiovascular Surgery, Incheon Sejong Hospital, Incheon, Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Stephens EH, Dearani JA, Pochettino A, Vricella LA, Sundt TM, David TE, Bavaria JE, Cameron DE. Valve-Sparing Aortic Root Replacement State-of-the-Art Review, Part I: Anatomy and Physiology. Ann Thorac Surg 2024; 118:729-735. [PMID: 38360340 DOI: 10.1016/j.athoracsur.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/03/2023] [Accepted: 12/09/2023] [Indexed: 02/17/2024]
Abstract
Aortic valve disease is common, and valve-preserving operations are preferred whenever possible. Valve-sparing aortic root replacement has become an important tool for managing aortic root pathology in children and adults. The learning curve for this operation is challenging, but with increasing experience and technical modifications, early and late outcomes continue to improve. Durable long-term results vary based on the underlying anatomy, pathology, and patient selection, as well as surgeon expertise. The first installment of this Valve-Sparing Aortic Root Replacement State-of-the-Art Review article addresses patient anatomy and physiology as it relates to candidacy for VSRR.
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Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | | | - Luca A Vricella
- Division of Pediatric Cardiovascular Surgery, Department of Surgery, Advocate Children's Heart Institute, Chicago, Illinois
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Tirone E David
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Duke E Cameron
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Zhu Y, Park MH, Wilkerson RJ, Joo HC, Pandya PK, Woo YJ. A 3D-Printed Externally Adjustable Symmetrically Extensible (EASE) Aortic Annuloplasty Ring for Root Repair and Aortic Valve Regurgitation. Cardiovasc Eng Technol 2024; 15:224-231. [PMID: 38238600 DOI: 10.1007/s13239-024-00709-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 01/02/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE The valve-sparing aortic root replacement (VSARR) procedure was developed to preserve the aortic valve apparatus to replace aneurysmal aortic roots with synthetic grafts and to eliminate associated aortic regurgitation (AR). However, residual post-repair AR is not uncommon and has been found to be associated with recurrent AR and future reoperation. METHODS We designed and manufactured a 3D-printed, external adjustable symmetrically extensible (EASE) aortic annuloplasty ring that can symmetrically reduce the aortic annulus diameter via a radial constriction, compliant mechanism. An ex vivo porcine VSARR model with annular dilation and AR was developed (n = 4) and used for hemodynamic, echocardiography, and high-speed videography data collection. RESULTS After ring annuloplasty repair using the EASE aortic ring, the regurgitant fraction decreased from 23.6 ± 6.9% from the VSARR model to 7.4 ± 5.6% (p = 0.05), which was similar to that measured from baseline with a regurgitant fraction of 10.2 ± 3.9% (p = 0.34). The leaflet coaptation height after annuloplasty repair also significantly increased from that measured in VSARR model (0.4 ± 0.1 cm) to 0.9 ± 0.1 cm (p = 0.0004), a level similar to that measured in baseline (1.1 ± 0.1 cm, p = 0.28). CONCLUSION Using an ex vivo VSARR model, the EASE ring successfully reduced AR by reducing the annular diameter and improving leaflet coaptation. With its broad applicability and ease of use, this device has the potential to have a significant impact on patients suffering worldwide from AR due to root aneurysms.
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Affiliation(s)
- Yuanjia Zhu
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, 300 Pasteur Drive, 94305, Stanford, CA, USA
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Matthew H Park
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, 300 Pasteur Drive, 94305, Stanford, CA, USA
- Department of Mechanical Engineering, Stanford University, Stanford, CA, USA
| | - Robert J Wilkerson
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, 300 Pasteur Drive, 94305, Stanford, CA, USA
| | - Hyun-Chel Joo
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, 300 Pasteur Drive, 94305, Stanford, CA, USA
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Pearly K Pandya
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, 300 Pasteur Drive, 94305, Stanford, CA, USA
- Department of Mechanical Engineering, Stanford University, Stanford, CA, USA
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, 300 Pasteur Drive, 94305, Stanford, CA, USA.
- Department of Bioengineering, Stanford University, Stanford, CA, USA.
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Rosinski BF, Hodges K, Vargo PR, Roselli EE, Koprivanac M, Tong M, Rajeswaran J, Blackstone EH, Svensson LG. Outcomes of aortic root replacement with tricuspid aortic valve reimplantation in patients with residual aortic regurgitation. J Thorac Cardiovasc Surg 2024; 167:101-111.e4. [PMID: 37532029 DOI: 10.1016/j.jtcvs.2023.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/22/2023] [Accepted: 07/25/2023] [Indexed: 08/04/2023]
Abstract
OBJECTIVE To characterize residual aortic regurgitation (AR), identify its risk factors, and evaluate outcomes following aortic root replacement with aortic valve reimplantation. METHODS From 2002 to 2020, 756 patients with a tricuspid aortic valve underwent elective reimplantation for aortic root aneurysm. AR on transthoracic echocardiograms before hospital discharge was graded as mild or greater. Machine learning was used to identify risk factors for residual AR and subsequent aortic valve reoperation. RESULTS Sixty-five patients (8.6%) had mild (58 [7.7%]) or moderate (7 [0.93%]) residual postoperative AR. They had more severe preoperative AR (38% vs 12%; P < .0001), thickened cusps (7.7% vs 2.2%; P = .008), aortic valve repair (38% vs 23%; P = .004), and multiple returns to cardiopulmonary bypass for additional repair (11% vs 3.3%; P = .003) than those without AR. Predictors of residual AR were severe preoperative AR, smaller aortic root graft, and concomitant cusp repair. At 10 years, patients with versus without residual AR had more moderate or severe AR (48% vs 7.0%; P < .0001) and freedom from reoperation was worse (89% vs 98%; P < .0001). Residual AR was a risk factor for early reoperation. Concomitant coronary bypass, lower body mass index, and lower ejection fraction were risk factors for late reoperation. Ten-year survival was similar among patients with and without residual AR (97% vs 93%; P = .43). CONCLUSIONS Residual AR after elective reimplantation of a tricuspid aortic valve for aortic root aneurysm is uncommon. Patients with severe preoperative AR and those who undergo valve repair have higher risk for residual AR, which can progress and increase risk of aortic valve reoperation.
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Affiliation(s)
- Brad F Rosinski
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kevin Hodges
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Patrick R Vargo
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Michael Tong
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- The Aorta Center, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio.
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Kubo S, Tanaka A, Omura A, Tsunemi K, Oka T, Okada K, Okita Y. Long-term Results of Valve-Sparing Aortic Root Replacement and Aortic Cusp Repair. Ann Thorac Surg 2024; 117:78-85. [PMID: 37541561 DOI: 10.1016/j.athoracsur.2023.05.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/19/2023] [Accepted: 05/30/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Long-term results of valve-sparing aortic root replacement (VSRR) and aortic cusp repair for aortic regurgitation are unclear. METHODS VSRR by reimplantation was performed in 363 patients. Tricuspid aortic valve (TAV) and bicuspid aortic valve were found in 285 and 71 patients, respectively. RESULTS Aortic cusp repair was performed in 268 patients. Of patients with TAV 129 had central plication of the Arantius node, 36 had free margin resuspension, and 71 had reinforcement. Mean follow-up was 71.4 months. Among TAV patients freedom from aortic valve reoperation at 10 and 15 years was 85.1% and 78.3%, respectively. Freedom from aortic valve reoperation at 10 years was lower in patients with cusp prolapse than without (77.4% vs 93.2%, P = .007). The overall freedom from more than mild aortic regurgitation at 10 and 15 years was 72.4% and 64.0%, respectively. It was also significantly greater in patients without cusp prolapse (78.4% vs 67.7%, P = .02). As for the cusp repair technique the freedom from aortic valve reoperation at 10 years was significantly better in patients who underwent only resuspension or reinforcement techniques compared with patients who underwent only central plication technique (100% vs 72.8%, P = .008). CONCLUSIONS Long-term results of VSRR with aortic cusp repair were satisfactory. The resuspension technique appears to be useful for repairing aortic cusp prolapse in patients with TAV.
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Affiliation(s)
- Sara Kubo
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Aya Tanaka
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Atsushi Omura
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Kotaro Tsunemi
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Takanori Oka
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Kenji Okada
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University, Kobe, Hyogo, Japan
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan.
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7
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Zhu Y, Park MH, Imbrie-Moore A, Wilkerson R, Madira S, Woo YJ. Biomechanical evaluation of aortic regurgitation from cusp prolapse using an ex vivo 3D-printed commissure geometric alignment device. J Cardiothorac Surg 2022; 17:303. [PMID: 36496476 PMCID: PMC9737730 DOI: 10.1186/s13019-022-02049-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 11/27/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Aortic regurgitation (AR) is one of the most common cardiac valvular diseases, and it is frequently caused by cusp prolapse. However, the precise relationship of commissure position and aortic cusp prolapse with AR is not fully understood. In this study, we developed a 3D-printed commissure geometric alignment device to investigate the effect of commissure height and inter-commissure angle on AR and aortic cusp prolapse. METHODS Three porcine aortic valves were explanted from hearts obtained from a meat abattoir and were mounted in the commissure geometric alignment device. Nine commissure configurations were tested for each specimen, exploring independent and concurrent effects of commissure height and inter-commissure angle change on AR and aortic cusp prolapse. Each commissure configuration was tested in our 3D printed ex vivo left heart simulator. Hemodynamics data, echocardiography, and high-speed videography were obtained. RESULTS AR due to aortic cusp prolapse was successfully generated using our commissure geometric alignment device. Mean aortic regurgitation fraction measured for the baseline, high commissure, low commissure, high commissure and wide inter-commissure angle, high commissure and narrow inter-commissure angle, low commissure and wide inter-commissure angle, low commissure and narrow inter-commissure angle, wide commissure, and narrow commissure configurations from all samples were 4.6 ± 1.4%, 9.7 ± 3.7%, 4.2 ± 0.5%, 11.7 ± 5.8%, 13.0 ± 8.5%, 4.8 ± 0.9%, 7.3 ± 1.7%, 5.1 ± 1.2%, and 7.1 ± 3.1%, respectively. CONCLUSIONS AR was most prominent when commissure heights were changed from their native levels with concomitant reduced inter-commissure angle. Findings from this study provide important evidence demonstrating the relationship between commissure position and aortic cusp prolapse and may have a significant impact on patient outcomes after surgical repair of aortic valves.
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Affiliation(s)
- Yuanjia Zhu
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Falk Cardiovascular Research Center, Stanford, CA, 94305, USA
- Department of Bioengineering, Stanford University, Stanford, USA
| | - Matthew H Park
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Falk Cardiovascular Research Center, Stanford, CA, 94305, USA
- Department of Mechanical Engineering, Stanford University, Stanford, USA
| | - Annabel Imbrie-Moore
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Falk Cardiovascular Research Center, Stanford, CA, 94305, USA
- Department of Mechanical Engineering, Stanford University, Stanford, USA
| | - Robert Wilkerson
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Falk Cardiovascular Research Center, Stanford, CA, 94305, USA
| | - Sarah Madira
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Falk Cardiovascular Research Center, Stanford, CA, 94305, USA
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Falk Cardiovascular Research Center, Stanford, CA, 94305, USA.
- Department of Bioengineering, Stanford University, Stanford, USA.
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Patlolla SH, Saran N, Dearani JA, Stulak JM, Schaff HV, Greason KL, Daly RC, King KS, Pochettino AB. Outcomes and risk factors of late failure of valve-sparing aortic root replacement. J Thorac Cardiovasc Surg 2022; 164:493-501.e1. [PMID: 33077178 DOI: 10.1016/j.jtcvs.2020.09.070] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 08/18/2020] [Accepted: 09/09/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Retention of the native aortic valve when performing aortic root surgery for aneurysmal disease has become a more common priority. We reviewed our experience in valve-sparing aortic root replacement (VSARR) to evaluate the long-term outcomes and the risk factors for reoperation. METHODS From January 1994 through June 2017, 342 patients (mean age 47.8 ± 15.5 years, 253 [74%] male) underwent VSARR. The most common etiologies were connective tissue disease (n = 143, 42%) followed by degenerative aortic aneurysm (n = 131, 38%). Aortic regurgitation (moderate or greater) was present in 35% (n = 119). RESULTS Reimplantation technique was used in 90% patients (n = 308). Valsalva graft was used in 38% patients (n = 131) and additional cusp repair was done in 15% (n = 50). Operative mortality was 1% (n = 5). The median follow-up time was 8.79 years (interquartile range, 4.08-13.51). The cumulative incidence of reoperation (while accounting for the competing risk of death) was 8.4%, 12.8%, and 17.1% at 5, 10, and 15 years, respectively. There were no differences in survival and incidence of reoperation between root reimplantation and remodeling. Larger preoperative annulus diameter was associated with greater risk of reoperation (hazard ratio, 1.10; 95% confidence interval, 1.02-1.19, P = .01). The estimated probability of developing severe aortic regurgitation after VSARR was 8% at 10 years postoperatively. Operative mortality, residual aortic regurgitation at dismissal, and survival improved in recent times with more experience. CONCLUSIONS VSARR is a viable and safe option with good long-term outcomes and low rates of late aortic valve replacement. Dilated annulus preoperatively was associated with early repair failure.
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Affiliation(s)
| | - Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Katherine S King
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minn
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Parameswaran S, Ziganshin BA, Zafar M, Elefteriades JA. Progress in surgical interventions for aortic root aneurysms and dissections. Expert Rev Cardiovasc Ther 2022; 20:65-79. [PMID: 35037567 DOI: 10.1080/14779072.2022.2029702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION : The aortic root is a uniquely sensitive region as it anatomically encompasses the aortic valve leaflets and gives origin to the coronary arteries. These associated structures, in addition to the aortic tube, itself, add immensely to the complexity of replacing this segment when it is aneurysmal or dissected. Given this complexity, many contemporary choices for treatment of aortic root aneurysms have evolved over the past few decades. AREAS COVERED The aim of this study was to provide an updated review of the literature regarding various surgical options for management of aortic root aneurysmal disease. A systematic search in Pubmed database was performed for articles related to various aortic root surgeries and outcomes published between 1998 to 2020. EXPERT OPINION : For multiple technical options in aortic root replacement surgery, decades of surgical investigation and development have shown favorable results, which provide a formidable armamentarium to be used at the discretion of the surgeon to suit various patient anatomic patterns and risk profile-while still durably controlling the aortic pathology and protecting from recurrence, valve dysfunction, progressive dilatation, and aortic dissection.
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Affiliation(s)
- Shamini Parameswaran
- Aortic Institute at Yale New-Haven Hospital, Yale University School of Medicine, New Haven, CT.,Department of Surgery, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX
| | - Bulat A Ziganshin
- Aortic Institute at Yale New-Haven Hospital, Yale University School of Medicine, New Haven, CT.,Department of Cardiovascular and Endovascular Surgery, Kazan State Medical University, Kazan, Russia
| | - Mohammad Zafar
- Aortic Institute at Yale New-Haven Hospital, Yale University School of Medicine, New Haven, CT
| | - John A Elefteriades
- Aortic Institute at Yale New-Haven Hospital, Yale University School of Medicine, New Haven, CT
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10
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Tamer S, Mastrobuoni S, Lemaire G, Jahanyar J, Navarra E, Poncelet A, Astarci P, El Khoury G, de Kerchove L. Two decades of valve-sparing root reimplantation in tricuspid aortic valve: impact of aortic regurgitation and cusp repair. Eur J Cardiothorac Surg 2021; 59:1069-1076. [PMID: 33332548 DOI: 10.1093/ejcts/ezaa427] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/05/2020] [Accepted: 10/26/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES Our goal was to analyse the influence of preoperative aortic regurgitation (AR) on the necessity of cusp repair during valve-sparing reimplantation (VSR). We focused on patients with tricuspid aortic valves (TAV) and evaluated the impact of AR and cusp repair on long-term outcomes. METHODS From March 1998 to December 2018, a total of 512 consecutive patients underwent VSR at our institution; of these, 303 had a TAV. The mean age was 53 ± 15 years, and the median follow-up was 6.12 years. The rate and type of cusp repair were analysed based on preoperative AR. Time-to-event analysis was performed, as well as risk of death, reoperation and AR recurrence. RESULTS Cusp repair was necessary in 168 (55.4%) patients; the rate rose significantly as AR grade increased (P < 0.001). In-hospital mortality was 1% (n = 3). At 5 and 10 years, overall survival was 92 ± 2% and 75 ± 5%, respectively. Freedom from valve reoperation was 95 ± 2% and 90 ± 3%. Freedom from AR >2+ and AR >1+ at 10 years was 88 ± 4% and 70.4 ± 4.6%, respectively. Independent predictors of death included age, New York Heart Association functional class and type-A aortic dissection. Predictors of AR greater than mild included previous cardiac surgery and severe preoperative AR. CONCLUSION In patients with TAV receiving VSR, the necessity of cusp repair increased with the degree of preoperative AR. Preoperative AR and cusp repair do not impact long-term survival and aortic valve reoperation, but severe preoperative AR and multiple cusp repair increase the risk of recurrent moderate-to-severe AR. Overall, cusp repair seems to attenuate the negative impact of preoperative AR for at least 1 decade in a majority of patients.
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Affiliation(s)
- Saadallah Tamer
- Cardiovascular and Thoracic Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Stefano Mastrobuoni
- Cardiovascular and Thoracic Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Guillaume Lemaire
- Anesthesiology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jama Jahanyar
- Cardiovascular and Thoracic Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Emiliano Navarra
- Cardiovascular and Thoracic Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Alain Poncelet
- Cardiovascular and Thoracic Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Parla Astarci
- Cardiovascular and Thoracic Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Gebrine El Khoury
- Cardiovascular and Thoracic Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Laurent de Kerchove
- Cardiovascular and Thoracic Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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11
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Izawa Y, Mori S, Tretter JT, Quintessenza JA, Toh H, Toba T, Watanabe Y, Kono AK, Okada K, Hirata KI. Normative Aortic Valvar Measurements in Adults Using Cardiac Computed Tomography - A Potential Guide to Further Sophisticate Aortic Valve-Sparing Surgery. Circ J 2021; 85:1059-1067. [PMID: 33408304 DOI: 10.1253/circj.cj-20-0938] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND A thorough understanding of the anatomy of the aortic valve is necessary for aortic valve-sparing surgery. Normal valvar dimensions and their relationships in the living heart, however, have yet to be fully investigated in a 3-dimensional fashion. METHODS AND RESULTS In total, 123 consecutive patients (66±12 years, Men 63%) who underwent coronary computed tomographic angiography were enrolled. Mid-diastolic morphology of the aortic roots, including height of the interleaflet triangles, geometric height, free margin length of each leaflet, effective height, and coaptation length were measured using multiplanar reconstruction images. Average height of the interleaflet triangle, geometric height, free margin length, effective height, and the coaptation length were 17.3±1.8, 14.7±1.3, 32.6±3.6, 8.6±1.4, and 3.2±0.8 mm, respectively. The right coronary aortic leaflet displayed the longest free margin length and shortest geometric height. Geometric height, free margin length, and effective height showed positive correlations with aortic root dimensions. Coaptation length, however, remained constant regardless of aortic root dimensions. CONCLUSIONS Diversities, as well as characteristic relationships among each value involving the aortic root, were identified using living-heart datasets. The aortic leaflets demonstrated compensatory elongation along with aortic root dilatation to maintain constant coaptation length. These measurements will serve as the standard value for revealing the underlying mechanism of aortic regurgitation to plan optimal aortic valve-sparing surgery.
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Affiliation(s)
- Yu Izawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Shumpei Mori
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Justin T Tretter
- The Heart Institute, Cincinnati Children's Hospital Medical Center
- Department of Pediatrics, University of Cincinnati College of Medicine
| | - James A Quintessenza
- The Heart Institute, Cincinnati Children's Hospital Medical Center
- Kentucky Children's Hospital, University of Kentucky, UK Healthcare
| | - Hiroyuki Toh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Takayoshi Toba
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Yoshiaki Watanabe
- Department of Radiology, Kobe University Graduate School of Medicine
| | - Atsushi K Kono
- Department of Radiology, Kobe University Graduate School of Medicine
| | - Kenji Okada
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
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12
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Yiğit G, Özen A, Çetinkaya F, Ünal EU, İşcan HZ, Birincioğlu CL, Sarıtaş A. Early and Late-Term Follow-Up Results of Patients Diagnosed with Aortic Aneurysm or Aortic Dissection with Aortic Regurgitation Undergoing Aortic Valve Repair or Valve-Sparing Aortic Surgery. Braz J Cardiovasc Surg 2021; 36:192-200. [PMID: 33113319 PMCID: PMC8163274 DOI: 10.21470/1678-9741-2020-0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Valve-reimplantation and remodelling techniques used in aortic reconstruction provide successful early, mid, and long-term results. We present our early and late-term experience with 110 patients with aortic regurgitation (AR) who underwent aortic valve repair (AVr) or valve-sparing aortic root surgeries (VSARS) due to aortic dissection or aortic aneurysm. METHODS Nine hundred eighty-two patients who underwent aneurysm or dissection surgery and aortic valve surgery between April 1997 and January 2017 were analysed using the patient database. A total of 110 patients with AR who underwent AVr or VSARS due to aortic dissection or aortic aneurysm were included in the study. RESULTS In the postoperative period, a decrease was observed in AR compared to the preoperative period (P<0.001); there was an increase in postoperative ejection fraction (EF) compared to the preoperative values (P<0.005) and a significant decrease in postoperative left ventricle diameters compared to the preoperative values (P<0.001). Kaplan-Meier analysis revealed one, two, four, and five-year freedom from moderate-severe AR as 95%, 91%, 87%, and 70%, respectively. Freedom from reoperation in one, two, and five years were 97.9%, 93.6%, and 81%, respectively. Eight patients (7.4%) underwent AVr during follow-up. Out of the remaining 100 patients, 13 (12%) had minimum AR, 52 (48%) had 1st-2nd degree AR, and 35 (32%) had 2nd-3rd degree AR during follow-up. CONCLUSION For the purpose of maintaining the native valve tissue, preserving the EF and the left ventricular end-diastolic diameter, valve-sparing surgeries should be preferred for appropriate patients.
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Affiliation(s)
- Görkem Yiğit
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Anıl Özen
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Ferit Çetinkaya
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Ertekin Utku Ünal
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Hakki Zafer İşcan
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | | | - Ahmet Sarıtaş
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
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13
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Tugulan CI, Bedi R, Jacks D, Parrino EP, Spindel SM. Transcatheter aortic valve replacement after valve-sparing aortic root surgery. J Card Surg 2021; 36:2117-2120. [PMID: 33586247 DOI: 10.1111/jocs.15410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/28/2021] [Accepted: 01/29/2021] [Indexed: 11/29/2022]
Abstract
The use of transcatheter aortic valves for aortic regurgitation presents unique challenges. Although studies describe their successful off-label use, there is a paucity of literature on transcatheter aortic valve replacement after valve-sparing aortic root surgery. We present a patient with severe aortic regurgitation following valve-sparing aortic root replacement that was treated with an oversized transcatheter aortic valve.
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Affiliation(s)
- Carmen I Tugulan
- Division of Cardiothoracic Surgery, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Ryan Bedi
- Division of Cardiothoracic Surgery, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Danielle Jacks
- Division of Cardiothoracic Surgery, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Eugene P Parrino
- Division of Cardiothoracic Surgery, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Stephen M Spindel
- Division of Cardiothoracic Surgery, Ochsner Medical Center, New Orleans, Louisiana, USA
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14
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Yokawa K, Henmi S, Nakai H, Yamanaka K, Omura A, Inoue T, Okita Y, Okada K. Mid-term outcomes of valve-sparing root reimplantation with leaflet repair. Eur J Cardiothorac Surg 2020; 58:138-144. [PMID: 32187353 DOI: 10.1093/ejcts/ezaa058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/27/2020] [Accepted: 01/31/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Valve repair for aortic insufficiency (AI) requires a tailored surgical approach determined by the leaflet and aortic disease. In this study, we used a repair-oriented system for the classification of AI, and we elucidated long-term outcomes of aortic root reimplantation with this classification system. METHODS From 1999 to 2018, a total of 197 patients underwent elective reimplantation (mean age: 52.7 ± 17.7 years; 80% male). The aortic valve was tricuspid in 143 patients, bicuspid in 51 patients and quadricuspid in 3 patients. A total of 93 patients had type I AI (aortic dilatation), 57 patients had type II AI (cusp prolapse) and 47 patients had type III AI (restrictive). In total, 104 of the 264 patients (39%) had more than 1 identified mechanism. RESULTS In-hospital mortality was 0.5% (1/197). Mid-term follow-up (mean follow-up duration: 5.5 years) revealed a late mortality rate of 4.2% (9/197). Aortic valve reoperation was performed on 16 patients (8.0%). Rates of freedom from aortic valve replacement and freedom from aortic valve-related events at 10 years of follow-up were 87.0 ± 4.0% and 60.6 ± 6.0%, respectively; patients with type Ib AI (98.3 ± 1.7%; 80.7 ± 7.5%) had better outcomes than patients with type III AI (59.6 ± 15.6%; 42.2 ± 13.1%, P = 0.01). In patients with types II and III AI who had bicuspid aortic valves, rates of freedom from aortic valve-related events at 5 years of follow-up were 95.2 ± 4.7% and 71.7 ± 9.1%, respectively (P = 0.03). CONCLUSIONS This repair-oriented system for classifying AI could help to predict the durable aortic valve repair techniques. Patient selection according to the classification is particularly important for long-term durability. CLINICAL TRIAL REGISTRATION NUMBER B190050.
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Affiliation(s)
- Koki Yokawa
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Soichiro Henmi
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hidekazu Nakai
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Katsuhiro Yamanaka
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsushi Omura
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takeshi Inoue
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Takatsuki Hospital, Osaka, Japan
| | - Kenji Okada
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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15
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Interdisziplinäre Betreuung von Menschen mit Marfan-Syndrom – Genetik, bildgebende Untersuchung und kardiovaskuläres System. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2020. [DOI: 10.1007/s00398-020-00364-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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16
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Miyahara S, Schneider U, Morgenthaler L, Schäfers HJ. (Almost) All Nonstenotic Bicuspid Aortic Valves Should Be Preserved or Repaired. Semin Thorac Cardiovasc Surg 2019; 31:656-660. [DOI: 10.1053/j.semtcvs.2019.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/18/2019] [Indexed: 11/11/2022]
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17
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Yokawa K, Ikeno Y, Koda Y, Henmi S, Matsueda T, Takahashi H, Nakai H, Yamanaka K, Gotake Y, Tanaka H, Okita Y. Valve-Sparing Root Replacement in Elderly Patients With Annuloaortic Ectasia. Ann Thorac Surg 2018; 107:1342-1347. [PMID: 30529676 DOI: 10.1016/j.athoracsur.2018.10.075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 09/28/2018] [Accepted: 10/29/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND We report early and midterm outcomes of elderly patients who underwent valve-sparing root replacement (VSRR) compared with younger patients and those with Bentall procedure. METHODS From October 1999 to October 2017, 73 patients greater than or equal to 65 years of age who underwent VSRR procedure were assigned as group S. Two hundred thirty-two VSRR patients who were between 15 and 64 years of age were assigned as group Y. Forty-five patients greater than or equal to 65 years of age who underwent Bentall procedure were assigned as group R. Preoperative grades of aortic regurgitation were 3.4 of 4 in group S, 3.1 of 4 in group Y, and 3.3 of 4 in group R (p = 0.07). RESULTS Hospital mortality was found in 1 (1.4%) patient in group S, 3 (6.7%) in group R, and 2 (0.9%) in group Y. Postoperative survival at 5 years was 88.5% in group S, 98.7% in group Y, and 82.4% in group R (p < 0.01). Freedom from more than mild aortic regurgitation at 5 years was 81.0% in group S and 85.4% in group Y. Follow-up echocardiography disclosed an effective aortic valve orifice area of 1.76 cm2 in group R, 2.40 cm2 in group Y, and 2.41 cm2 in group S (p < 0.01), and peak pressure gradient across the aortic valve was 17.7 mm Hg in group R, 13.6 mm Hg in group Y, and 10.8 mm Hg in group S (p < 0.01). CONCLUSIONS Similar early and late outcomes were achieved in elder VSRR patients compared with younger patients. A better postoperative valve performance was demonstrated in VSRR patients than patients undergoing valve-replacement.
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Affiliation(s)
- Koki Yokawa
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuki Ikeno
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yojiro Koda
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Soichiro Henmi
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takashi Matsueda
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroaki Takahashi
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hidekazu Nakai
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Katsuhiro Yamanaka
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yasuko Gotake
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Tanaka
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yutaka Okita
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.
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18
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Yang DH, Kim DH, Handschumacher MD, Levine RA, Kim JB, Sun BJ, Jang JY, Kim N, Baek S, Kang JW, Song JM, Kang DH, Lim TH, Song JK. In vivo assessment of aortic root geometry in normal controls using 3D analysis of computed tomography. Eur Heart J Cardiovasc Imaging 2018; 18:780-786. [PMID: 27461206 DOI: 10.1093/ehjci/jew146] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 06/20/2016] [Indexed: 01/27/2023] Open
Abstract
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.
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Affiliation(s)
- Dong Hyun Yang
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Asanbyeongwon-gil 86, Seoul 138-736, South Korea
| | - Dae-Hee Kim
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Asanbyeongwon-gil 86, Seoul 138-736, South Korea
| | - Mark D Handschumacher
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joon Bum Kim
- Department of Cardiothoracic Surgery, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea
| | - Byung Joo Sun
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Asanbyeongwon-gil 86, Seoul 138-736, South Korea
| | - Jeong Yoon Jang
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Asanbyeongwon-gil 86, Seoul 138-736, South Korea
| | - Namkug Kim
- Department of Convergence Medicine, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seunghee Baek
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea
| | - Joon-Won Kang
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Asanbyeongwon-gil 86, Seoul 138-736, South Korea
| | - Jong-Min Song
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Asanbyeongwon-gil 86, Seoul 138-736, South Korea
| | - Duk-Hyun Kang
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Asanbyeongwon-gil 86, Seoul 138-736, South Korea
| | - Tae-Hwan Lim
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Asanbyeongwon-gil 86, Seoul 138-736, South Korea
| | - Jae-Kwan Song
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Asanbyeongwon-gil 86, Seoul 138-736, South Korea
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19
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Tanaka H, Takahashi H, Inoue T, Matsueda T, Oda T, Abe N, Nomura Y, Gotake Y, Okita Y. Which technique of cusp repair is durable in reimplantation procedure? Eur J Cardiothorac Surg 2018; 52:112-117. [PMID: 28498897 DOI: 10.1093/ejcts/ezx034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 01/18/2017] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES We aimed to ascertain the durability of cusp repair techniques used in reimplantation procedures. METHODS Between 2000 and 2015, 249 patients (mean age, 49 ± 17 years) with aortic insufficiency underwent the reimplantation procedure. The pathology was acute aortic dissection in 24 and non-dissection in 225 patients. Preoperative aortic regurgitation (AR) was absent in 9, 1+ in 19, 2+ in 20, 3+ in 71 and 4+ in 120 patients. The mean aortic root and ascending aortic diameters were 47 ± 9 mm and 38 ± 7 mm, respectively. The following techniques of cusp repair were used: none (83), central plication (130), free margin reinforcement (57) and patch repair (19). Annual echocardiography was performed. Freedom from moderate aortic insufficiency and aortic valve reoperation were calculated by the Kaplan-Meier method. Factors influencing the freedom from moderate or severe AR were calculated by proportional hazard analysis. RESULTS Mean follow-up period was 56 ± 44 months. Freedom from moderate or severe AR was 82%±3% and 77% ± 4% at 5 and 8 years, respectively, whereas freedom from aortic valve reoperation was 93%±8% and 87% ± 3% at 5 and 8 years, respectively. Recurrent AR and infection were causes of reoperation in 13 and 3 patients, respectively. Preoperative cusp prolapse, technique of free margin reinforcement used and patch repair were significant factors for recurrent AR by proportional hazard analysis. Central plication was not a significant factor for recurrent AR. CONCLUSIONS Preoperative cusp prolapse was a risk factor, whereas central plication was not a risk factor for recurrent AR. Free margin reinforcement had a positive effect, whereas patch repair had a negative effect on aortic valve durability.
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Affiliation(s)
- Hiroshi Tanaka
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Hiroaki Takahashi
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Takeshi Inoue
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Takashi Matsueda
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Tatsuya Oda
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Noriyuki Abe
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Yoshikatsu Nomura
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Yasuko Gotake
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
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20
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Choo SJ. Seeing is believing. J Thorac Cardiovasc Surg 2017; 154:30-31. [PMID: 28389012 DOI: 10.1016/j.jtcvs.2017.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 03/06/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University School of Medicine, Seoul, Republic of Korea.
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21
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Huang F, Li L, Qin W, Su C, Wang L, Xiao L, Chen X. Partial aortic root remodeling for root reconstruction in patients with acute type A dissection. J Biomed Res 2016; 30:411-418. [PMID: 27845304 PMCID: PMC5044713 DOI: 10.7555/jbr.30.20150097] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 10/05/2015] [Accepted: 12/25/2015] [Indexed: 11/07/2022] Open
Abstract
In the present study, we reported our experience with partial aortic root remodeling for root reconstruction in patients with acute type A dissection, which involves in non-coronary sinus and/or the right coronary sinus with just one trimmed Dacron graft. Between February 2001 and May 2010, we performed partial aortic root remodeling in 40 patients, who underwent emergency surgical intervention. The dissected sinuses were excised leaving a 3-5 mm rim of the aortic wall from the attached aortic valve cusps. A short piece (4-5 cm) of collagen coated woven polyester vascular prosthesis was trimmed with one or two “tongues” to reconstruct the non-coronary sinus and/or the right coronary sinus, but without using separated patches. Additional procedures were including hemi-arch replacement in 11 patients, and total arch replacement plus stent-elephant trunk in 20 patients. The mean follow-up time was 36.4±3.6 months. In-hospital mortality was only 5.0% (2/40); furthermore, 3 (8.6%) patients underwent re-operation of the aortic valve and 2 (5.7%) patients died during follow-up. At the end of follow-up, trivial or no aortic regurgitation was found in 33 patients, but mild aortic regurgitation was found in 2 patients. Our data suggest that the early and mid-term results of partial aortic root remodeling were favorable, and it restored valve durability and function. Thus, the use of technique for root reconstruction in patients with acute type A dissection should be vigorously encouraged.
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Affiliation(s)
- Fuhua Huang
- Department of Thoracic and Cardiovascular Surgery, Nanjing Hospital affiliated to Nanjing Medical University, Nanjing Cardiovascular Disease Research Institute, Nanjing, Jiangsu 210006, China
| | - Liangpeng Li
- Department of Thoracic and Cardiovascular Surgery, Nanjing Hospital affiliated to Nanjing Medical University, Nanjing Cardiovascular Disease Research Institute, Nanjing, Jiangsu 210006, China
| | - Wei Qin
- Department of Thoracic and Cardiovascular Surgery, Nanjing Hospital affiliated to Nanjing Medical University, Nanjing Cardiovascular Disease Research Institute, Nanjing, Jiangsu 210006, China
| | - Cunhua Su
- Department of Thoracic and Cardiovascular Surgery, Nanjing Hospital affiliated to Nanjing Medical University, Nanjing Cardiovascular Disease Research Institute, Nanjing, Jiangsu 210006, China
| | - Liming Wang
- Department of Thoracic and Cardiovascular Surgery, Nanjing Hospital affiliated to Nanjing Medical University, Nanjing Cardiovascular Disease Research Institute, Nanjing, Jiangsu 210006, China
| | - Liqiong Xiao
- Department of Thoracic and Cardiovascular Surgery, Nanjing Hospital affiliated to Nanjing Medical University, Nanjing Cardiovascular Disease Research Institute, Nanjing, Jiangsu 210006, China
| | - Xin Chen
- Department of Thoracic and Cardiovascular Surgery, Nanjing Hospital affiliated to Nanjing Medical University, Nanjing Cardiovascular Disease Research Institute, Nanjing, Jiangsu 210006, China;
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22
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Baumbach H, Wachter K, Nagib R, Ahad S, Yadav R, Ursulescu A, Hansen M, Franke U. Complex Cusp Repair in Patients Undergoing the David Procedure: Is It Worth It? Ann Thorac Surg 2016; 102:483-8. [PMID: 27112645 DOI: 10.1016/j.athoracsur.2016.01.094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Revised: 01/28/2016] [Accepted: 01/28/2016] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Hardy Baumbach
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany.
| | - Kristina Wachter
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Ragi Nagib
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Samir Ahad
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Rashmi Yadav
- Department of Cardiac Surgery, Royal Brompton Hospital, London, United Kingdom
| | - Adrian Ursulescu
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Matthias Hansen
- Department of Anaesthesiology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Ulrich Franke
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
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Settepani F, Cappai A, Raffa GM, Basciu A, Barbone A, Berwick D, Citterio E, Ornaghi D, Tarelli G, Malvindi PG. Cusp repair during aortic valve-sparing operation: technical aspects and impact on results. J Cardiovasc Med (Hagerstown) 2016; 16:310-7. [PMID: 24978873 DOI: 10.2459/jcm.0000000000000031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Aortic valve-sparing operations are nowadays considered safe and reliable procedures in terms of mid-term and long-term results. Although surgical techniques regarding the modality of grafts' implantation have been properly addressed, the modality of cusp repair, when needed, is still open to debate. We sought to review the literature to try to shed light on when the cusp repair is required and how it should be performed. METHODS We searched the PubMed database using the keywords aortic valve-sparing operation, aortic valve-sparing reimplantation, valve-sparing aortic root replacement, aortic valve repair, and aortic cusp repair. Only studies that included and described in detail the technique of cusp repairs in adjunct to aortic valve-sparing operation were considered. RESULTS Bicuspid aortic valve more often requires correction when compared with tricuspid valve. The range of the techniques varies from the 'simple' free margin plication to the more complex triangular resection with patch repair. Results in the literature seem to be encouraging, showing that, in most of the cases, cusp repair does not affect valve competence in the mid-term and long-term. CONCLUSION Correction of the cusp is a delicate balance between undercorrection that could lead to residual prolapse and overcorrection that could lead to cusp restriction. Although complex repair of the aortic valve in addition to root replacement provided satisfactory results, it should be reserved for experienced centers with a large volume of patients.
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Affiliation(s)
- Fabrizio Settepani
- Department of Cardiac Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
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Wendt D, Raweh A, Knipp S, El Gabry M, Eißmann M, Dohle DS, Tsagakis K, Thielmann M, Jakob H, Benedik J. Comparison of mid-term haemodynamic performance between the BioValsalva and the BioIntegral valved conduits after aortic root replacement. Interact Cardiovasc Thorac Surg 2016; 23:112-7. [PMID: 27048273 DOI: 10.1093/icvts/ivw066] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 02/03/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We retrospectively compared the haemodynamic performance of the BioValsalva (BV) and BioIntegral (BI) biological aortic-valved conduits in the aortic root position. METHODS Between July 2008 and June 2014, a total of 55 patients underwent aortic root replacement using the BV conduit (n = 27) or the BI conduit (n = 28). The primary study endpoints were haemodynamic performance during follow-up, including mean pressure gradients (MPGs) and effective orifice areas (EOAs). Secondary study endpoints were early postoperative outcomes within 30 days and survival. RESULTS Both groups did not differ in regard to demographics (BV: median age 71 years, 70.4% female; BI: median age 66 years, 85.7% female, P = 0.15 and P = 0.17) and risk profile (median EuroSCORE-II BV: 3.8 vs 5.3% for BI, P = 0.38). A total of 20% of the total patients (BV 5/27, 18.5% vs BI 6/28, 21.4%) presented with acute type-A aortic dissection. During follow-up, both groups showed no difference in MPGs for all valve sizes [BV, 11.0 mmHg (8.3-14.8 mmHg) vs BI, 11.5 mmHg (9.0-13.0), P = 0.82]. Similar results were achieved for EOAs for all valve sizes [BV, 1.85 cm(2) (1.55-2.21) vs BI, 1.80 cm(2) (1.64-1.83), P = 0.24]. Moreover, there was no statistically significant difference in aortic regurgitation (AR) with none/trace AR in (21/23) 91.3% in BV patients versus (16/21) 76.2% in BI patients (P = 0.23) at follow-up. Both groups showed a high rate of concomitant procedures (BV: 59.3% vs BI: 71.4%, P = 0.40) and emergency indication (BV: 18.5% vs BI: 21.4%, P = 0.79), resulting in an overall 30-day mortality rate of 7.3% (4/55 patients). CONCLUSIONS The present small single-centre study is one of the first to evaluate and compare the BioValsalva and BioIntegral biological aortic-valved conduit in the aortic root position. Both conduits showed optimal haemodynamic results with a low incidence of aortic regurgitation.
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Affiliation(s)
- Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Ayman Raweh
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Stephan Knipp
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Mohammed El Gabry
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Mareike Eißmann
- Department of Cardiology, West-German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Daniel Sebastian Dohle
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Jaroslav Benedik
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
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Aortic cusp extension valvuloplasty: repair with an extracellular patch. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2015; 12:314-7. [PMID: 26855646 PMCID: PMC4735531 DOI: 10.5114/kitp.2015.56780] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 12/01/2015] [Indexed: 12/19/2022]
Abstract
Introduction The proportion of valve repair procedures is increasing in experienced centers. The aim of the study was to assess the clinical and echocardiographic outcomes after aortic valve reconstruction with a novel surgical technique. Material and methods The study group consisted of 30 patients (23 male and 7 female) at a mean age of 35 ± 14 years. In patients with aortic root aneurysm the reimplantation or Florida sleeve technique was used. A sub-commissural annuloplasty, plication of the free edge of the cusp, shaving, and commissurotomy were performed. At this stage of surgery aortic repair was then attempted by cusp extension. Since 2013 the strips have been tailored from extracellular matrix. Results The mean aortic cross-clamp time was 90 ± 32 min. The mean cardiopulmonary bypass time was 126 ± 38 min. There was no in-hospital death. Re-exploration for bleeding was required in 1 patient. During follow-up, 1 patient needed reoperation at 1 year due to endocarditis. All patients remained alive in New York Heart Association (NYHA) functional class I. The echocardiographic findings remained unchanged in all cases during follow-up. Conclusions Our modification of aortic valve repair results in a good outcome.
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Reported Outcome After Valve-Sparing Aortic Root Replacement for Aortic Root Aneurysm: A Systematic Review and Meta-Analysis. Ann Thorac Surg 2015; 100:1126-31. [DOI: 10.1016/j.athoracsur.2015.05.093] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 04/20/2015] [Accepted: 05/14/2015] [Indexed: 11/17/2022]
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Miyahara S, Matsueda T, Izawa N, Yamanaka K, Sakamoto T, Nomura Y, Morimoto N, Inoue T, Matsumori M, Okada K, Okita Y. Mid-Term Results of Valve-Sparing Aortic Root Replacement in Patients With Expanded Indications. Ann Thorac Surg 2015; 100:845-51; discussion 852. [DOI: 10.1016/j.athoracsur.2014.09.091] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Revised: 08/31/2014] [Accepted: 09/09/2014] [Indexed: 10/23/2022]
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Lee H, Cho YH, Sung K, Kim WS, Park KH, Park PW, Lee YT. Clinical outcomes of valve-sparing root replacement in acute type A aortic dissection. SCAND CARDIOVASC J 2015; 49:331-6. [DOI: 10.3109/14017431.2015.1072236] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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A Simple Device for Morphofunctional Evaluation During Aortic Valve-Sparing Surgery. Ann Thorac Surg 2015; 100:331-3. [PMID: 26140788 DOI: 10.1016/j.athoracsur.2015.02.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 02/14/2015] [Accepted: 02/18/2015] [Indexed: 11/19/2022]
Abstract
Valve-sparing operations for the treatment of aortic root disease with a structurally normal aortic valve are increasingly performed as they avoid prosthesis-related complications. Short- and long-term results are critically dependent on perfect intraoperative restoration of valve anatomy and function. Residual aortic regurgitation is the main cause of early failure, and it is the most common motive for reoperation. However, intraoperative morphofunctional valve assessment requires expertise, and only transesophageal echocardiography can provide reliable information. We describe a simple, economic, reproducible hydrostatic test to intraoperatively evaluate valve competency under direct visualization.
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Aortic Root Replacement With Biological Valved Conduits. Ann Thorac Surg 2015; 100:337-53. [DOI: 10.1016/j.athoracsur.2015.02.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 02/06/2015] [Accepted: 02/12/2015] [Indexed: 11/24/2022]
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Kaku Y, Aomi S, Tomioka H, Yamazaki K. Surgery for aortic regurgitation and aortic root dilatation in Takayasu arteritis. Asian Cardiovasc Thorac Ann 2015; 23:901-6. [PMID: 26089524 DOI: 10.1177/0218492315591291] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Special consideration may be required for surgical treatment in Takayasu arteritis because inflammation may cause serious complications such as valve detachment or dilatation of the residual aorta. We evaluated our surgical outcome of treatment for aortic regurgitation and aortic root dilatation in Takayasu arteritis. METHODS Between December 1983 and January 2013, 22 cardiac operations were performed in 20 patients with aortic regurgitation due to Takayasu arteritis. Aortic valve replacement was carried out in 6 patients, and aortic root replacement in 16. Of these 16 patients, composite graft replacement was undertaken in 6, composite graft replacement plus coronary artery bypass grafting in 2, composite graft replacement plus total or partial arch replacement in 7, and valve-sparing aortic root replacement with hemiarch replacement in one. RESULTS The operative mortality (within 30 days) was 4.5% and the 5-year survival rate was 90.9%. Early surgical reintervention was not required in any patient. Neither valve detachment nor composite graft detachment was noted. Two patients required redo aortic root replacement due to pseudoaneurysm formation and severe aortic regurgitation during follow-up. Late dilatation of the residual thoracoabdominal or abdominal aorta was observed in 2 patients, and both were treated surgically. CONCLUSIONS The early surgical outcome was acceptable but surgical reintervention was required because of late dilatation of the residual aorta or recurrent aortic regurgitation due to annular dilatation, and longstanding careful follow-up will be needed.
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Affiliation(s)
- Yuji Kaku
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Shigeyuki Aomi
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Hideyuki Tomioka
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Kenji Yamazaki
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, Tokyo, Japan
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Ando M, Yamauchi H, Morota T, Taketani T, Shimada S, Nawata K, Umeki A, Ono M. Long-term outcome after the original and simple modified technique of valve-sparing aortic root reimplantation in Marfan-based population, David V University of Tokyo modification. J Cardiol 2015; 67:86-91. [PMID: 25920727 DOI: 10.1016/j.jjcc.2015.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 02/10/2015] [Accepted: 03/16/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND In valve-sparing aortic root replacement (VSARR), how to reproduce Valsalva sinus has been an issue. In the original David V procedure, they put plication stitches at sinotubular junction level, although the reefing effect is limited and distal graft remains larger than native. Other modified techniques are two-grafts technique and ready-made Valsalva graft. However, the former needs graft-graft anastomosis and may not be cost-effective, while in the latter, the shape of sinus is fixed and minor adjustment is difficult. David V University of Tokyo modification (David V-UT) is our original solution to that, creating pseudosinus with one straight graft by longitudinal size-reduction running sutures above each pseudosinus. The purpose of the present study is to investigate long-term outcome of David V-UT. METHODS We analyzed 59 David V-UT patients from February 2004 to February 2013 and long-term outcomes were investigated by Kaplan-Meier methods. Risk factors for adverse events "death or recurrent aortic insufficiency (AI) with or without aortic valve reoperation" were analyzed by using Cox proportional hazard models. RESULTS Mean age was 33.1±14.5 years, and 38 patients (64%) were male. Marfan syndrome (MFS) accounts for 47 patients (80%). Only one patient was with bicuspid aortic valve. No in-hospital mortality was observed. Mean follow-up was 4.9±2.4 years. Estimated survival was 94.0±3.4% at 5 years. Freedoms from aortic valve reoperation and recurrent AI greater than mild were 95.7±3.0% and 88.9±4.7% at 5 years, respectively. In Cox proportional hazard analysis, preoperative AI greater than mild and Z score of annular diameter were significant risks for adverse events (p=0.027 and 0.045, hazard ratio 6.084 and 1.432, 95% C.I. 1.225-30.21 and 1.008-2.035, respectively). CONCLUSIONS Even in Marfan-characterized population, David V-UT provided satisfactory long-term outcome, comparable to other VSARR modifications. It is simple but can freely reproduce trilobed sinus with one straight graft.
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Affiliation(s)
- Masahiko Ando
- The University of Tokyo, Department of Cardiac Surgery, Tokyo, Japan.
| | - Haruo Yamauchi
- The University of Tokyo, Department of Cardiac Surgery, Tokyo, Japan
| | - Tetsuro Morota
- Nippon Medical School Hospital, Department of Cardiovascular Surgery, Tokyo, Japan
| | - Tsuyoshi Taketani
- Mitsui Memorial Hospital, Department of Cardiovascular Surgery, Tokyo, Japan
| | - Shogo Shimada
- The University of Tokyo, Department of Cardiac Surgery, Tokyo, Japan
| | - Kan Nawata
- The University of Tokyo, Department of Cardiac Surgery, Tokyo, Japan
| | - Akihide Umeki
- The University of Tokyo, Department of Cardiac Surgery, Tokyo, Japan
| | - Minoru Ono
- The University of Tokyo, Department of Cardiac Surgery, Tokyo, Japan
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Bavaria JE, Desai N, Szeto WY, Komlo C, Rhode T, Wallen T, Vallabhajosyula P. Valve-sparing root reimplantation and leaflet repair in a bicuspid aortic valve: Comparison with the 3-cusp David procedure. J Thorac Cardiovasc Surg 2015; 149:S22-8. [DOI: 10.1016/j.jtcvs.2014.10.103] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 10/22/2014] [Accepted: 10/26/2014] [Indexed: 11/16/2022]
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David TE. Current readings: Aortic valve-sparing operations. Semin Thorac Cardiovasc Surg 2014; 26:231-8. [PMID: 25527017 DOI: 10.1053/j.semtcvs.2014.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2014] [Indexed: 11/11/2022]
Abstract
It has been more than 2 decades since aortic valve-sparing operations were introduced to preserve the aortic valve in patients with aortic root aneurysm. Remodeling of the aortic root is physiologically superior to reimplantation of the aortic valve, mostly because it preserves the aortic annulus movement during the cardiac cycle. However, several comparative studies have shown that reimplantation of the aortic valve has provided more stable aortic valve function than remodeling of the aortic root. This difference in outcomes is largely because of patients׳ selection. Remodeling of the aortic root has been associated with high failure rates in patients with aneurysms associated with genetic syndromes and bicuspid aortic valves with dilated aortic annulus, but it has provided excellent long-term results in older patients with aortic root aneurysms secondary to ascending aortic aneurysms and normal aortic annulus. Thus, both techniques are useful in preserving the aortic valve. With either technique, restoration of normal aortic annulus and cusp geometry is the single most important technical aspect of these operations. In addition to having a competent valve with no or trivial aortic insufficiency at the end of the operation, there must be no cusp prolapse and the coaptation level of the cusps has to be well above the level of the nadir of the aortic annulus.
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Affiliation(s)
- Tirone E David
- Division of Cardiovascular Surgery of Peter Munk Cardiac Centre at Toronto, General Hospital; Department of Surgery, University of Toronto, Toronto, Ontario, Canada..
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Minami H, Miyahara S, Okada K, Matsumori M, Kano H, Inoue T, Sakamoto T, Okita Y. Clinical outcomes of combined aortic root reimplantation technique and total arch replacement. Eur J Cardiothorac Surg 2014; 48:152-7. [PMID: 25354747 DOI: 10.1093/ejcts/ezu387] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 09/04/2014] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES The goal of this study was to evaluate early and late outcomes of combined valve-sparing aortic root replacement and total arch replacement (TAR). METHODS From October 1999 to May 2014, 195 patients underwent valve-sparing operations using the David reimplantation technique. Thirty-one patients underwent combined TAR for aortic regurgitation (AR) with extended aortic aneurysm from the aortic root to the aortic arch. Aetiologies included acute type A aortic dissection in 12 cases, chronic aortic dissection in 8 cases and non-dissecting aneurysm in 11 cases. There were 9 patients with Marfan syndrome. The preoperative severity of AR was mild in 4, moderate in 16 and severe in 11. Even though half of those were emergent operations for acute aortic dissection, preoperative haemodynamic conditions were stable in all patients. RESULTS No hospital deaths occurred. Postoperative complications included prolonged mechanical ventilation (>48 h) in 1 case and re-exploration for bleeding in 2 cases. Other complications, such as neurological dysfunction or low cardiac output syndrome, were not observed. At hospital discharge, 2 patients had mild AR, 22 had trace AR and 7 had no AR. During follow-up, 2 patients had moderate AR, 7 had mild AR, 18 had trace AR and 3 had no AR. Follow-up was completed in 95.1% of patients, and the mean follow-up period was 60.5 ± 9.1 months. No late death and thromboembolic complication occurred during follow-up. One patient required reoperation for AR. Freedom from reoperation at 5 and 10 years was 100 ± 0 and 83.3 ± 3.5%, respectively. Freedom from moderate or severe AR at 3 and 5 years was 83.3 ± 3.5 and 83.3 ± 3.5%, respectively. CONCLUSIONS Early outcomes of combined aortic root reimplantation and TAR were satisfactory and provided excellent freedom from thromboembolic complication. The rate of freedom from reoperation during long-term follow-up was acceptable. Further follow-up is required to evaluate this procedure.
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Affiliation(s)
- Hitoshi Minami
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shunsuke Miyahara
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masamichi Matsumori
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroya Kano
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takeshi Inoue
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Toshihito Sakamoto
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Midterm follow-up of the reimplantation technique in patients with relatively normal annulus: Is David I still a clinically valid option? J Thorac Cardiovasc Surg 2014; 148:1334-40. [DOI: 10.1016/j.jtcvs.2013.11.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 11/18/2013] [Accepted: 11/29/2013] [Indexed: 11/15/2022]
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Ariyaratnam P, Loubani M, Griffin SC, Cowen ME, Vijayan A, Jarvis MA, Cale AR. Complex aortic surgery in a regional center in the United Kingdom. Should the United Kingdom now adopt a United States–style supercenter model? J Thorac Cardiovasc Surg 2014; 148:1428-1434.e1. [DOI: 10.1016/j.jtcvs.2014.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/14/2013] [Accepted: 01/10/2014] [Indexed: 11/16/2022]
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A quarter of a century of experience with aortic valve-sparing operations. J Thorac Cardiovasc Surg 2014; 148:872-9; discussion 879-80. [DOI: 10.1016/j.jtcvs.2014.04.048] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 03/29/2014] [Accepted: 04/02/2014] [Indexed: 11/19/2022]
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Di Eusanio M, Murana G, Cefarelli M, Mazzola A, Di Bartolomeo R. The Bentall procedure with a biological valved conduit: substitute options and techniques. Multimed Man Cardiothorac Surg 2014; 2014:mmu010. [PMID: 24925908 DOI: 10.1093/mmcts/mmu010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
As originally described by Bentall and De Bono, aortic root replacement with reimplantation of the coronary arteries using a composite valved conduit represents the gold standard intervention in patients with aneurysmal disease or dissection involving the aortic root. Over the last decade, the number of Bentall procedures performed using biological valved conduit has dramatically expanded mainly due to the increased incidence of aortic disease in the aging population. Here, we sought to describe the commercially available biological composite grafts and the techniques that, to the best of our knowledge, are most frequently used in this setting.
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Affiliation(s)
- Marco Di Eusanio
- Cardiovascular Surgery Department, Sant'Orsola-Malpighi Hospital, Bologna University, Bologna, Italy
| | - Giacomo Murana
- Cardiovascular Surgery Department, Sant'Orsola-Malpighi Hospital, Bologna University, Bologna, Italy
| | - Mariano Cefarelli
- Cardiovascular Surgery Department, Sant'Orsola-Malpighi Hospital, Bologna University, Bologna, Italy
| | - Alessandro Mazzola
- Division of Cardiothoracic Surgery, Research Hospital Foundation San Matteo, Pavia, Italy
| | - Roberto Di Bartolomeo
- Cardiovascular Surgery Department, Sant'Orsola-Malpighi Hospital, Bologna University, Bologna, Italy
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Stephens EH, Liang DH, Kvitting JPE, Kari FA, Fischbein MP, Mitchell RS, Miller DC. Incidence and progression of mild aortic regurgitation after Tirone David reimplantation valve-sparing aortic root replacement. J Thorac Cardiovasc Surg 2013; 147:169-77, 178.e1-178.e3. [PMID: 24176278 DOI: 10.1016/j.jtcvs.2013.09.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 08/24/2013] [Accepted: 09/04/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The study objective was to determine whether recurrent or residual mild aortic regurgitation, which occurs after valve-sparing aortic root replacement, progresses over time. METHODS Between 2003 and 2008, 154 patients underwent Tirone David-V valve-sparing aortic root replacement; 96 patients (62%) had both 1-year (median, 12 ± 4 months) and mid-term (62 ± 22 months) transthoracic echocardiograms available for analysis. Age of patients averaged 38 ± 13 years, 71% were male, 31% had a bicuspid aortic valve, 41% had Marfan syndrome, and 51% underwent aortic valve repair, predominantly cusp free margin shortening. RESULTS Forty-one patients (43%) had mild aortic regurgitation on 1-year echocardiogram. In 85% of patients (n = 35), mild aortic regurgitation remained stable on the most recent echocardiogram (median, 57 ± 20 months); progression to moderate aortic regurgitation occurred in 5 patients (12%) at a median of 28 ± 18 months and remained stable thereafter; severe aortic regurgitation developed in 1 patient, eventually requiring reoperation. Five patients (5%) had moderate aortic regurgitation at 1 year, which did not progress subsequently. Two patients (2%) had more than moderate aortic regurgitation at 1 year, and both ultimately required reoperation. CONCLUSIONS Although mild aortic regurgitation occurs frequently after valve-sparing aortic root replacement, it is unlikely to progress over the next 5 years and should not be interpreted as failure of the valve-preservation concept. Further, we suggest that mild aortic regurgitation should not be considered nonstructural valve dysfunction, as the 2008 valve reporting guidelines would indicate. We need 10- to 15-year follow-up to learn the long-term clinical consequences of mild aortic regurgitation early after valve-sparing aortic root replacement.
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Affiliation(s)
- Elizabeth H Stephens
- Department of Cardiovascular and Thoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - David H Liang
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, Calif
| | | | - Fabian A Kari
- Department of Cardiovascular and Thoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Michael P Fischbein
- Department of Cardiovascular and Thoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - R Scott Mitchell
- Department of Cardiovascular and Thoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - D Craig Miller
- Department of Cardiovascular and Thoracic Surgery, Stanford University School of Medicine, Stanford, Calif.
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Saczkowski R, Malas T, de Kerchove L, El Khoury G, Boodhwani M. Systematic review of aortic valve preservation and repair. Ann Cardiothorac Surg 2013; 2:3-9. [PMID: 23977553 DOI: 10.3978/j.issn.2225-319x.2013.01.07] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 01/16/2013] [Indexed: 11/14/2022]
Abstract
BACKGROUND Aortic valve repair has emerged as a feasible alternative to replacement in the surgical treatment of selected patients with aortic valve (AV) pathology. In order to provide a synopsis of the current literature, we preformed a systematic review with a focus on valve-related events following AV repair. METHODS Structured keyword searches of Embase and PubMed were performed in January 2012. A study was eligible for inclusion if it reported early mortality, late mortality, or valve-related morbidity in the adult population. RESULTS Initial search results identified 3,507 unique studies. After applying inclusion and exclusion criteria, 111 studies remained for full-text review. Of these, 17 studies involving 2,891 patients were included for quantitative assessment. No randomized trials were identified. Tricuspid and bicuspid AV pathologies were present in 65% (range, 21-100%) and 13.5% (range, 5-100%) of the population, respectively. Cusp repair techniques were applied in a median of 46% (range, 5-100%) of patients. The median requirement for early reoperation for post-operative bleeding and early reintervention for primary AV repair failure was 3% (range, 0-10%) and 2% (range, 0-16%), respectively. Pooled early mortality was 2.6% (95% CI: 1.4-4.4%, I(2) =0%). Late mortality and valve-related events were linearized [(number of events/number of patient-years) ×100] (%/pt-yr) for each study. Late operated valve endocarditis was reported at median event rate of 0.23%/pt-yr (range, 0-0.78%/pt-yr), while a composite outcome of neurological events and thromboembolism occurred at a median rate of 0.52%/pt-yr (0-0.95%/pt-yr). Late AV re-intervention requiring AV replacement or re-repair occurred at a rate of 2.4%/pt-yr (range, 0-4.2%/pt-yr). The median 5-year freedom from AV re-intervention and late recurrent aortic insufficiency >2+ estimated from survival curves was 92% (range, 87-98%) and 88% (range, 87-100%), respectively. Pooled late mortality produced summary estimate of 1.3%/pt-yr (95% CI: 0.9-2.1%, I(2) =0%). CONCLUSIONS The present systematic review confirmed the low operative risk of patients who underwent aortic valve preservation and repair. There is a need for long-term follow-up studies with meticulous reporting of outcomes following AV repair, as well as comparative studies with aortic valve replacement.
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Affiliation(s)
- Richard Saczkowski
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Canada
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David TE. Aortic valve sparing operations: outcomes at 20 years. Ann Cardiothorac Surg 2013; 2:24-9. [PMID: 23977555 DOI: 10.3978/j.issn.2225-319x.2012.11.15] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Accepted: 11/29/2012] [Indexed: 11/14/2022]
Affiliation(s)
- Tirone E David
- The Division of Cardiovascular Surgery of Peter Munk Cardiac Centre at Toronto General Hospital, University Health Network, and University of Toronto, Toronto, Canada
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Aicher D, Schäfers HJ. Aortic valve repair--current status, indications, and outcomes. Semin Thorac Cardiovasc Surg 2013. [PMID: 23200074 DOI: 10.1053/j.semtcvs.2012.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Aortic valve repair is a new development with old roots. In the past 20 years, marked progress has been made in understanding the normal anatomy of the aortic valve and the interrelation between cusps and root. Aortic dilatation is the single most frequent pathogenetic factor in aortic regurgitation, accompanied by cusp pathology, that is, prolapse or congenital anomaly in most industrialized countries. Frequently, aortic and cusp pathology coexist. Different operative techniques have been established for correction of aortic and cusp pathology. Experience has shown that the combined application of repair procedures will lead to good results if normal valve and cusp configuration is achieved. Some congenital anomalies may require design alteration of the aortic valve. Low-operative mortality rates have been reported consistently. When adequate repair durability is achieved, the incidence of valve-related complications is lower than what has been reported for valve replacement. Aortic valve repair is currently in transition from surgical improvisation to a reproducible operation and an option for many patients with aortic regurgitation. Current research focuses on some special aspects, such as stabilization of the basal ring, ideal material and technique for cusp replacement, and more objective information on ideal valve configuration.
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Affiliation(s)
- Diana Aicher
- Department of Thoracic and Cardiovascular Surgery, University of Saarland Medical Center, Homburg/Saar, Germany
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Subramanian S, Leontyev S, Borger MA, Trommer C, Misfeld M, Mohr FW. Valve-Sparing Root Reconstruction Does Not Compromise Survival in Acute Type A Aortic Dissection. Ann Thorac Surg 2012; 94:1230-4. [DOI: 10.1016/j.athoracsur.2012.04.094] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 04/25/2012] [Accepted: 04/26/2012] [Indexed: 10/28/2022]
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David TE. Aortic valve sparing operations: a review. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2012; 45:205-12. [PMID: 22880164 PMCID: PMC3413824 DOI: 10.5090/kjtcs.2012.45.4.205] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 07/25/2012] [Accepted: 07/26/2012] [Indexed: 11/16/2022]
Abstract
Aortic valve sparing operations were developed to preserve the native aortic valve during surgery for aortic root aneurysm as well as surgery for ascending aortic aneurysms with associated aortic insufficiency. There are basically two types of aortic valve sparing oprations: remodeling of the aortic root and reimplantation of the aortic valve. These operations have been performed for over two decades and the clinical outcomes have been excellent in experienced hands. Although remodeling of the aortic root is physiologically superior to reimplantation of the aortic valve, long-term follow-up suggests that the latter is associated with lower risk of developing aortic insufficiency. Failure of remodeling of the aortic root is often due to dilatation of the aortic annulus. Thus, this type of aortic valve sparing should be reserved for older patients with ascending aortic aneurysm and normal aortic annulus whereas reimplantation of the aortic valve is more appropriate for young patients with inherited disorders that cause aortic root aneurysms. This article summarizes the published experience with these two operations. They are no longer experimental procedures and should be part of the surgical armamentarium to treat patients with aortic root aneurysm and ascending aortic aneurysms with associated aortic insufficiency.
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Affiliation(s)
- Tirone E David
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Canada
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DiMario C, Pepper J, Golesworthy T, Treasure T. External aortic root support for the Marfan aorta: anatomically normal coronary orifices imaged seven years after surgery. Interact Cardiovasc Thorac Surg 2012; 15:528-30. [PMID: 22695514 DOI: 10.1093/icvts/ivs237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The occurrence of angina necessitated investigation of a patient seven years after an operation to protect his dilated Marfan aorta. The customized support, manufactured by a process of computer-aided design, had been fitted in May 2004 when the aortic root measured 49 mm. The magnetic resonance imaging appearances of the aorta remained unchanged over a postoperative period of 7 years and he remained completely well until he began to experience exercise-related angina in 2011. Coronary angiography showed the cause of angina to be an atherosclerotic left anterior descending coronary artery stenosis which was successfully stented. Aortography and coronary angiography performed at that time showed widely patent coronary orifices with no sign of impingement of the external support on the smooth lumen of his coronary arteries. The soft pliant nature of the textile from which the support was made, its intimate fit to the aorta and porous nature allowing incorporation into the aortic adventitia were deliberately built into the design. Nevertheless it was affirming to see these features realized on imaging seven years later. The patient is again completely well and angina free. He is one of a consecutive series of 30 patients who have had this device. There have been no device-related events in over 100 patient/years of follow-up, and all the patients remain alive and well.
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Malvindi PG, Raffa GM, Basciu A, Citterio E, Cappai A, Ornaghi D, Tarelli G, Settepani F. Bicuspidy does not affect reoperation risk following aortic valve reimplantation. Interact Cardiovasc Thorac Surg 2012; 14:717-20. [PMID: 22389000 DOI: 10.1093/icvts/ivs059] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Aortic valve reimplantation has been shown to be a safe procedure. However, evidences of durability in bicuspid aortic valves (BAVs) are limited in the literature. Between 2002 and 2011, 132 patients (mean age 61 ± 12 years) underwent aortic valve reimplantation. In 24 patients (18%), aortic valve was bicuspid. Mean follow-up was 50 ± 26 months (range 1-102 months) and was 99% complete. In-hospital mortality was 0.8% (1 patient). Survival at 1 and 5 years was 99 and 94%, respectively. Overall freedom from aortic valve reoperation at 1 and 5 years was 96 and 90%, respectively, without significant difference between patients with bicuspid and tricuspid aortic valve. Freedom from aortic valve regurgitation >2+/4+, excluding patients reoperated, was at 1 and 5 years of 100 and 99%, respectively. Patients with valve cusp repair showed a higher rate of aortic valve reoperation; however, only postoperative aortic regurgitation >2+/4+ was significant risk factor for redo procedure at multivariate analysis. Aortic valve reimplantation in BAV without cusp repair provides excellent mid-term results. Further observations and longer follow-up are necessary to determine if BAV sparing, even in the presence of cusps alterations, could allow satisfying durability.
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Invited commentary. Ann Thorac Surg 2011; 92:1644-5. [PMID: 22051260 DOI: 10.1016/j.athoracsur.2011.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2011] [Revised: 07/17/2011] [Accepted: 07/19/2011] [Indexed: 11/21/2022]
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