Midterm Outcome of Valve-Sparing Aortic Root Replacement in Inherited Connective Tissue Disorders

Two-stage surgery for acute type B aortic dissection and aortic root aneurysm in a patient with Turner syndrome: a case report

BACKGROUND

Patients with Turner syndrome are at high risk of aortic dissection and are more likely to present with fatal outcomes. Turner syndrome is classified as a heritable thoracic aortic disease in the latest EACTS/STS guidelines. Herein, we present a case of two-staged surgery for acute type B aortic dissection and aortic root aneurysm in a patient with Turner syndrome.

CASE PRESENTATION

A 29-year-old female patient with Turner syndrome was admitted to our center due to back pain and was diagnosed with acute type B aortic dissection. Echocardiography revealed a dilated aortic root with bicuspid aortic valve. On the 5 th day after admission, the patient presented with a higher level of back pain. Follow-up computed tomography scan revealed changes from two- to three-channel aortic dissection a further aortic dilation. Therefore, descending aorta and partial aortic arch replacement were initially performed. Then, valve-sparing aortic root replacement and residual arch replacement were performed 3 months after the first surgery. Postoperative echocardiography confirmed the absence of aortic regurgitation. The patient was discharged on the 17th postoperative day without any complications.

CONCLUSIONS

Two-stage surgery was successfully performed for the thoracic aorta and aortic root aneurysms in a patient with Turner syndrome. The patient recovered for 3 months after the left thoracotomy surgery and underwent a two-stage surgery through a median sternotomy surgery with good surgical results.

Total arch replacement using frozen elephant trunk and repair of bilateral subclavian artery aneurysms in a patient with type 2 Loeys-Dietz syndrome

Loeys-Dietz syndrome (LDS) is a rare connective tissue disorder. Vessel tortuosity and aneurysms throughout the vasculature are unique to LDS. Aortic root enlargement is ubiquitous, with most patients undergoing root replacement at some point in their lifetime. Multiple vascular procedures are required to prolong life expectancy. We describe a staged hybrid approach to a 17-year-old patient with LDS presenting with ascending aorta, arch, and bilateral subclavian artery aneurysms and prominent tortuosity. Transposition of the left vertebral and subclavian arteries onto the common carotid artery was performed. Total aortic arch replacement with frozen elephant trunk extension into the descending thoracic aorta was performed as a second stage. Bilateral subclavian artery aneurysms were excluded with the use of a four-branched graft.

Decision-making at initial surgery for type A aortic dissection in patients with Marfan syndrome: proximal or extensive repair

Background

Data on outcome of Stanford type A aortic dissection (TAAD) in Marfan syndrome (MFS) patients are limited. We investigated the full spectrum of reoperation and survival after initial surgery in MFS patients who suffered TAAD.

Methods

Retrospective analysis of 85 consecutive MFS patients in one-single center during the past 15 years.

Results

Overall, 85 MFS patients with TAAD underwent surgical repair [74% acute dissections; 80% DeBakey type I; 91% composite valved graft; 70% total arch replacement (TAR); 68% frozen elephant trunk (FET); 7% in-hospital mortality] at Changhai hospital affiliated to the Second Military Medical University over the past 15 years. Five (20.8%) patients in non-TAR group need aortic arch reintervention with resternotomy during follow-up, which is significantly higher than that in TAR group (P=0.001). Freedom from aortic arch reoperation in non-TAR group was all 78.7%±8.5% at 5, 10, and 15 years. No patient required aortic arch reoperation in TAR group (P=0.001). On the other hand, the FET was inserted into false lumen intentionally at initial surgery in 2 cases of chronic TAAD with narrowed true lumen. Scheduled thoracoabdominal aortic replacement was performed 6 months later. Both 2 patients are with well clinical outcomes. At last, we found that Debakey type and TAR at initial surgery were irrelevant to survival and reoperation for descending aorta.

Conclusions

TAR combined with FET is recommended in MFS patients when the aortic arch is dissected or enlarged. The FET could be inserted into the false lumen intentionally in selective case for scheduled 2-staged descending aortic repair.

Aortic treatment in connective tissue disease

Connective tissue disease (CTD) represents a group of genetic conditions characterized by disruptive matrix remodeling. When this process involves aortic and vascular wall, patients with CTD have a high risk of developing arterial aneurysms, dissections and ruptures. Open surgical repair is still the gold standard therapy for patients with CTD with reasonable morbidity and mortality risk. The surgical treatment of CTD often requires multiple operations. In the endovascular era, fenestrated and branched stent grafts may play a role in reducing the complications of multiple open operations. Although the long-term results of endovascular treatment in the setting of CTD are unknown, it is generally accepted that endovascular treatment is restricted to selected patients with high surgical risk. In an emergency setting, endovascular intervention can serve as a lifesaving bridge to elective open aortic repair. Aortic centers performing a large volume of complex open and endovascular aortic repairs have started to combine these two techniques in a staged fashion. The goal is to reduce the morbidity and mortality associated with extensive aortic repairs in CTD patients. For this reason, recommend endovascular therapy when a "graft-to-graft" approach is possible. In this scenario, the surgeon who performs the open repair must take into consideration future interventions. Surgical repair in any aortic segment should allow creation of proximal and distal landing zones over 4 cm to secure the sealing of a future stent graft. Connective tissue disease should be treated with a multidisciplinary approach, in high volume centers. Endovascular treatment represents a potential option in patients at high risk for open repair. Staged hybrid procedures have emerged as a way to reduce spinal cord ischemia and avoid multiple open surgeries. The aim of this article is to discuss the management of aortic diseases in CTD, focusing on to the role of standard open surgery and emerging endovascular treatment, and to give an overview of the few series published regarding this topic with a small number of patients.

Redo Aortic Root Operations in Patients with Marfan Syndrome

Aortic root aneurysm is the most common cardiovascular manifestation requiring surgical intervention in patients with Marfan syndrome (MFS), a heritable thoracic aortic disease. Elective replacement of the aortic root is the treatment of choice for patients with aneurysmal complications of the aortic root and ascending aorta. There are two basic approaches to aortic root replacement: valve-sparing (VS) and valve-replacing (VR) techniques. After successful aortic root replacement surgery, several patients with MFS may develop a late complication related to their aortic disease process, such as developing a pseudoaneurysm of the coronary artery reattachment buttons, aneurysmal expansion, or aortic dissection in the remaining native aorta. These patients may also develop other late complications that are not specifically related to the heritable thoracic aortic disease, such as infections that can lead to dehiscence of some or all of the distal or proximal anastomosis. Because these complications are rare, the clinical volume of reoperations of the aortic root in patients with MFS is low, making it difficult to assess contemporary experiences with these procedures. Only a few published reports have examined reoperative aortic root surgery in patients with MFS, each of which had only a small series of patients. Herein, we describe our contemporary experience with reoperative aortic root replacement in patients with MFS and provide our operative approach for these uncommon procedures.

Impact of connective tissue disease on the surgical outcomes of aortic dissection in patients with cystic medial necrosis

Background

A retrospective analysis was performed to determine the impact of genetically diagnosed connective tissue disease (CTD) on the early and late outcomes of surgical treatment for aortic dissection in patients having aortic pathology associated with cystic medial necrosis (CMN).

Methods

Between 2003 and 2013, a total of 43 patients (37 ± 12.8 years old, 23 men, 20 women) who had undergone surgery for aortic dissection associated with CMN in the aortic wall underwent genetic examinations. Subsequently, there were 30 patients with CTD (CTD group) and 13 without CTD (non-CTD group).

Results

There were no early or late deaths (the follow-up rate was 100% for 57.1 ± 43.0 months). The median age was significantly lower in the CTD group (p = 0.030). The rate of elastic fiber loss was significantly higher in the CTD group (p = 0.014). In the long-term follow-up, there were no significant differences in the incidences of re-dissection (p = 0.332). However, re-operations were required more frequently in the CTD group (p = 0.037).

Conclusions

In patients with CTD as well as CMN, the onset of aortic dissection tends to be earlier, which would result in higher rates of re-operation, compared with the non-CTD group. Closer and stricter follow-up with medication and adequate surgical treatments with appropriate timing are mandatory for such high-risk patients.

Total Aortic Replacement for a 9-Year-Old Boy With Loeys-Dietz Syndrome

Loeys-Dietz syndrome (LDS) is a recently identified rare connective tissue disorder caused by mutations of the transforming growth factor-β receptors and first described in 2005. It is an autosomal dominant syndrome with 2 different phenotypic expressions-LDS I and II. LDS is characterized by the triad of arterial tortuosity and aneurysm, hypertelorism, and a bifid uvula or cleft palate. We present a case of a 9-year-old boy diagnosed with LDS who underwent urgent thoracoabdominal aortic aneurysm repair followed by total arch replacement and aortic valve-sparing root replacement (AVSRR).

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

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.

Valve-sparing aortic root replacement: early and midterm outcomes in 83 patients

BACKGROUND

Valve-sparing aortic root replacement (VSARR) is an alternative to traditional composite valve graft (CVG) root replacement. We examined early and midterm outcomes after VSARR.

METHODS

A combined retrospective/prospective study was performed in 83 patients who underwent VSARR (16%) among 515 patients who underwent aortic root replacement during a nearly 12-year period. Thirty-six patients (43%) had a connective tissue disorder, 3 patients (4%) had acute aortic dissection, and 40 (48%) patients had at least moderate aortic regurgitation (AR). Twenty-eight patients (34%) had left ventricular hypertrophy or dilatation. The reimplantation VSARR technique was used in 82 patients (99%), and the Florida sleeve technique was used in 1 patient. Thirty-two patients (39%) underwent concomitant aortic arch replacement. For early survivors, the median duration of follow-up was 3.5 years (range, 5 days-12.2 years).

RESULTS

One patient had severe AR after VSARR that necessitated intraoperative conversion to a mechanical CVG. The 1 operative death and 1 stroke occurred in a patient with acute dissection. Actuarial survival was 96.4%±2.0% at 2 years and 86.9%±5.6% at 8 years. Six patients (7%) had late valve-related complications: 1 died of endocarditis, 4 underwent reoperation for severe AR and received replacement valves, and 1 had severe AR and is being monitored. Freedom from repair failure (reoperation, endocarditis, or severe AR) was 94.8%±2.6% at 2 years and 87.3%±5.7% at 8 years.

CONCLUSIONS

Valve-sparing aortic root replacement can have excellent early and respectable midterm outcomes, even when combined with arch repair. Further follow-up remains necessary to evaluate the long-term durability of VSARR.

Incidence and progression of mild aortic regurgitation after Tirone David reimplantation valve-sparing aortic root replacement

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.

Systematic review of aortic valve preservation and repair

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.

Aortic valve sparing operations: a review

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.

The year in review: the surgical treatment of valvular disease-2011

This review highlights important advances in techniques, guidelines, outcomes and innovations in valve surgery during 2011.