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

Long-term outcomes of aortic root procedures for heterogenous ascending aneurysm disease in bicuspid aortic valve syndrome

OBJECTIVE

Surgery for ascending aneurysms in bicuspid aortic valve syndrome primarily includes Bentall root replacement, aortic valve replacement with supracoronary ascending aorta replacement (AVRSCAAR), and valve-sparing root reimplantation (VSRR). Comparative analysis of long-term clinical and functional outcomes of these procedures is detailed.

METHODS

From 1997 to 2017, 635 patients with bicuspid aortic valve undergoing root complex-focused procedures electively were stratified by valvulopathy (ie, aortic stenosis vs aortic insufficiency) and substratified into ascending or root aneurysm phenotype. Inverse probability weights were calculated to adjust for baseline differences.

RESULTS

Kaplan-Meier curves for all-cause mortality demonstrated no difference between Bentall versus AVRSCAAR for aortic stenosis and aortic insufficiency presentations (log-rank P > .05). In patients with aortic stenosis, multivariable Cox regression showed significantly decreased risk of stroke for biologic AVRSCAAR (hazard ratio, 0.04; P = .013). Aortic reoperation rates were similar for biologic versus mechanical valves (P = .353). In patients with aortic insufficiency, similar long-term mortality (hazard ratio, 0.95; P = .93), but lower stroke risk in biologic AVRSCAAR group by Cox regression, and lower aortic reoperation rate was noted (coefficient < 0.01; P < .001). Comparing Bentall to VSRR, mortality (hazard ratio, 0.12; P = .022) was significantly improved in patients undergoing VSRR, but recurrence of moderate or greater aortic insufficiency was higher in VSRR by multistate model (beta coefficient 2.63; P < .001).

CONCLUSIONS

A tailored approach to heterogeneous ascending aneurysm pathologies in bicuspid aortic valve syndrome utilizing Bentall, AVRSCAAR, and VSRR procedures renders excellent long-term clinical and functional outcomes, with biologic conduits showing equivalent to improved clinical outcomes.

Minimally Invasive versus Conventional Aortic Root Surgery: Results of an Intermediate-Volume Center

BACKGROUND

 We evaluate the outcome of aortic root surgery via an upper J: -shaped mini-sternotomy (MS) versus full sternotomy (FS) in an intermediate-volume center.

METHODS

 Between November 2011 and February 2019, 94 consecutive patients underwent aortic root surgery: 62 (66%) patients were operated via a J: -shaped MS (group A) and 32 (34%) patients via FS (group B). The primary endpoints were mortality, major adverse cardiac and cerebral events (MACCE), and reoperation in a 2-year follow-up. The secondary endpoints were perioperative complications and patient's satisfaction with the procedural results.

RESULTS

 Valve sparing root replacement (David procedure) was performed in 13 (21%) of the MS and 7 (22%) of the FS patients. The Bentall procedure in MS versus FS was 49 (79%) versus 25 (78%), respectively. Both groups presented similar mean operation, cardiopulmonary bypass, and cross-clamp times. Postoperative bleeding was 534 ± 300 and 755 ± 402 mL (p = 0.01) in MS and FS, respectively, erythrocyte concentrate substitution was 3 ± 3 and 5.3 ± 4.8 (p = 0.018) in MS and FS, respectively, and pneumonia rates were 0 and 9.4% (p = 0.03) in MS and FS, respectively. The 30-day mortality was 0% in both groups, whereas MACCE was 1.6 and 3% (p = 0.45) in MS and FS, respectively. After 2 years, the mortality and MACCE were 4.6 and 9.5% (p = 0.11) and 4.6 and 0% (p = 0.66) in MS and FS, respectively. The number of patients who were satisfied with the surgical cosmetic results in groups A and B was 53 (85.4%) and 26 (81%), respectively.

CONCLUSION

 Aortic root surgery via MS is a safe alternative to FS even in an intermediate-volume center. It offers a shorter recovery time and similar midterm results.

Short and mid-term outcomes of valve-sparing, aortic root reimplantation (David's procedure)

BACKGROUND

In the current study, we aimed to report the short- and mid-term outcomes of patients undergoing valve-sparing aortic root reimplantation (VSARR) and our center's experience with the procedure.

METHODS

Forty patients with aortic root aneurysms underwent VSARR at our center from 2010 until 2022. We retrospectively reviewed the medical records of these patients and extracted the relevant data. After carefully examining the aortic valve, the surgeon decided to perform Bentall or David's procedure during the operation.

RESULTS

The study population comprised 31 (77.5%) men and nine (22.5%) women, with a mean age of 55.35 ± 15.40. One patient developed hemodynamic instability post-surgery in the hospital and died from multi-organ failure. Another patient had severe AI in the intraoperative echocardiography, and aortic valve replacement with a prosthetic graft was performed during the same operation. In pre-operation echocardiography, 25 (62.5%) patients had severe, nine (22.5%) had moderate, and six (15%) had mild AI. In the in-hospital post-operation follow-up echo, AI was improved, and no patients had severe AI (P < 0.001). Only eight patients had moderate AI in post-one-year follow-up echo exams, while the rest had mild AI.

CONCLUSION

David's procedure showed excellent mid-term results in our center, with only one in-hospital mortality.

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

AIM

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

METHODS

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

STRUCTURE

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

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

AIM

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

METHODS

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

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

AIM

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

METHODS

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

STRUCTURE

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

Biomechanical evaluation of aortic regurgitation from cusp prolapse using an ex vivo 3D-printed commissure geometric alignment device

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.

Valve-Preserving Root Reimplantation Combined with Arch Procedure: Optimizing Patient Selection

OBJECTIVE

Patients with thoracic aortic disease commonly present with concomitant multisegment pathology. We describe the patient population, analyze outcomes, and define the patient selection strategy for valve-preserving aortic root reimplantation (VPARR) combined with the arch procedure. Methods: From 2008 to 2018, 98 patients underwent VPARR combined with the aortic arch procedure (hemi-arch, 50% [n = 49, limited repair]; total arch, 50% [n = 49, complete repair] including 39 with elephant trunk). Indications for surgery were aneurysmal disease (61%) and aortic dissection (39%). The median follow-up was 17 months (IQR, 8 to 60 months). Results: There were no operative deaths or paraplegia, and 5 patients underwent re-exploration for bleeding. During follow-up, 2 patients required aortic valve replacement for severe aortic insufficiency at 1 and 5 years, and 4 patients died. In the limited repair group, 1 patient underwent reintervention for aortic arch replacement, whereas 4 patients underwent planned intervention (1 endovascular and 3 open thoracoabdominal aortic repair). In the complete repair group, 23 patients underwent planned intervention (15 endovascular and 8 open thoracoabdominal repair). Conclusions: Single-stage, complete, proximal aortic repair including VPARR combined with total aortic arch replacement is as safe and feasible to perform as limited arch repair and facilitates further intervention in carefully selected patients with diffuse aortic pathology at centers of expertise.

Transcatheter valve-in-valve implantation for degenerated stentless aortic bioroots

Background

Open surgical repair of a failed valve-sparing aortic root replacement (VSARR) or stentless bioroot aortic root replacement (bio-ARR) entails significant operative risks. Whether valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) is feasible in patients with a previous VSARR or stentless bio-ARR remains unclear, given lingering concerns about the ill-defined aortic annulus in these patients and the potential for coronary obstruction. We present our experience with patients who had a previous VSARR or stentless bio-ARR and underwent ViV-TAVR to repair a degenerated aortic valve with combined valvular disease, aortic insufficiency and aortic stenosis.

Methods

In this retrospective data review, we identified and analyzed consecutive patients with a previous VSARR or stentless bio-ARR who underwent ViV-TAVR between December 1, 2014 and August 31, 2019.

Results

ViV-TAVR was performed in twelve high-risk patients with previous VSARR or bio-ARR during the study period. Of these, seven received Medtronic Freestyle porcine stentless bioprosthetic aortic roots, three received homograft aortic roots, one underwent a Ross procedure and one underwent VSARR. ViV-TAVR restored satisfactory valve function in all patients, and technical success was 100%. No patient had more than mild regurgitation after implantation. No thirty-day mortality was seen. One patient had major bleeding after transapical access, one patient had a transient ischemic stroke, and one patient needed permanent pacemaker implantation. At a median last follow-up of 21.5 months (interquartile range, 9.0-69.0 months), all patients remained alive and had satisfactory valve function.

Conclusions

In this study, ViV-TAVR was a clinically effective option for treating patients with a failed stentless bio-ARR or previous VSARR. Short-term and intermediate-term results after these procedures were favorable. These findings may have important implications for treating high-risk patients with structural aortic root deterioration and call for better transcatheter heart valves that are suitable for treating aortic insufficiency.

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

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.

Impact of Aortic Valve Function and the Need for Aortic Valve Repair on Long-Term Outcomes of Valve-Sparing Aortic Root Replacement: 13-Year Experience of David Operation

BACKGROUND

The best approach for aortic root disease remains controversial. Composite valve-graft conduit (CVG) replacement offers good results at short-term and long-term follow-up; on the other hand, valve-sparing aortic root replacement (VSARR) has proven to be an excellent treatment alternative. This study aimed to analyse the outcomes after VSARR and compare whether preoperative moderate or severe aortic regurgitation (AR) and or the need for aortic valve repair (AVR) during this procedure influenced survival and freedom from reoperation rates.

METHODS

From September 2005 to June 2018, 104 patients underwent VSARR using the reimplantation technique: 64% presented with preoperative moderate or severe AR, concomitant AVR was performed in 43.3%, Marfan syndrome was present in 16.3%, and 12.5% had a bicuspid aortic valve. Complete follow-up was obtained in 91% of the sample, echocardiographic results were available for 86% and the mean follow-up time was 1,893 days.

RESULTS

In-hospital mortality was 2.9% and one death occurred 42 days after hospital discharge. In the latest echocardiographic assessment, 88.3% presented with mild AR or better. Freedom from reoperation at 8 years was 95.4%. There was no case of endocarditis and one patient had a stroke 2 years after the operation. There were no between-group differences in morbidity, mortality and complications during the follow-up.

CONCLUSION

VSARR can be performed with low mortality rates and reasonable durability of the aortic valve. Neither moderate or severe AR nor the need for aortic valve repair during the procedure altered survival and freedom from reoperation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Incidence of cardiovascular events and risk markers in a prospective study of children diagnosed with Marfan syndrome

BACKGROUND

Little is known about the incidence of cardiovascular events (CVEs) and their associated risk markers in children with Marfan syndrome (MFS).

AIMS

To assess the incidence of CVEs and determine risk markers in a cohort diagnosed with Marfan syndrome during childhood and followed for several years.

METHODS

From a French multicentre nationwide database, 462 patients with MFS diagnosed during childhood were included prospectively. Patients' files were screened for a period of 20 years (1993-2013). CVEs (e.g. death, aortic dissection, cardiac valve or aortic root surgery) were assessed during the prospective follow-up.

RESULTS

Median (interquartile range) age at the end of follow-up was 17.2 (11.1-21.3) years. CVEs were reported for 35 participants (7.6%; 95% confidence interval [CI] 5.3-10.4%). First CVEs were prophylactic aortic root surgery (n=29), aortic dissection (n=4; two aged <18 years) and death (n=2). Kaplan-Meier cumulative incidence of CVEs was 5.3% (95% CI 3.3-8.7%) during childhood (aged≤18 years) and 19.4% (95% CI 13.3-27.9%) at 25years of age. The cumulative rate of CVEs was higher in case of Valsalva sinus Z-score increase of≥0.1 per year (P=0.0003), maximal Valsalva sinus diameter growth speed ≥5mm per year (P=0.03), aortic regurgitation≥2 (P=0.0005) and maximal Valsalva sinus Z-score≥3 before 16 years of age (P<0.0001). In a multivariable Cox proportional analysis, the Valsalva sinus Z-score remained significantly related to outcome. Considering aortic root evolution, aortic regurgitation, age at diagnosis and beta-blocker therapy were related to Valsalva sinus Z-score evolution during follow-up.

CONCLUSIONS

CVEs in children with MFS are mainly related to prophylactic aortic root surgery. Aortic dissections are rarely observed in children. The Valsalva sinus Z-score is a strong indicator of subsequent CVEs in children with MFS. Attention to follow-up and beta-blocker observance may be warranted in high-risk children.

The Florida Sleeve Procedure Is Durable and Improves Aortic Valve Function

Background  The Florida (FL) Sleeve procedure was introduced as a simplified approach for valve-sparing correction of functional Type I aortic insufficiency (AI) associated with aortic root aneurysms. In this study, short- and long-term outcomes after the FL Sleeve procedure were investigated.

Methods  From May 2002 to January 2016, 177 patients underwent the FL Sleeve procedure. Left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter, left ventricular ejection fraction, and degree of AI (none = 0, minimal = 1, mild = 2, moderate = 3, severe = 4) were evaluated by echocardiography.

Results  Mean ± standard deviation of age was 49.41 ± 15.37 years. Survival rate was 98% at 1 year, 97% at 5 years, and 93% at 8 years. Freedom from reoperation was 99% at 1 year and 98% at 2 to 8 years. Three patients (1.69%) died during hospitalization. Three patients (1.69%) developed periprocedural stroke. Postoperative follow-up echocardiography was available in 140 patients at 30 days, and 31 patients at 5 years. AI grade significantly improved from baseline at 30 days (2.18 ± 1.26 vs. 1.1 ± 0.93, p  < 0.001) and at 5 years (2.0 ± 1.23 vs. 1.45 ± 0.88, p  = 0.04). Preoperative mean LVEDD significantly decreased from 52.20 ± 6.73 to 46.87 ± 8.40 ( p  < 0.001) at 30 days, and from 53.22 ± 7.07 to 46.61 ± 10.51 ( p  = 0.01) at 5 years.

Conclusions  The FL Sleeve procedure is a safe, effective, and durable treatment of aortic root aneurysm and Type I AI. Long-term survival and freedom from reoperation rates are encouraging.

Early and Midterm Outcomes of Valve-Sparing Aortic Root Replacement-Reimplantation Technique

Background  Valve-sparing aortic root replacement (VSARR) is an increasingly popular alternative to traditional aortic root replacement for aortic root aneurysm disease with a normal aortic valve. We evaluated the early and midterm outcomes of VSARR—reimplantation technique (VSARR-RT) done at a single institution over a decade.

Materials and Methods  We performed a retrospective study of all patients who underwent VSARR-RT between January 2004 and July 2014.

Results A total of 85 patients underwent VSARR-RT. Median time to latest echocardiographic follow-up was 4 years (range: 15–72 months). Total observation time was 491 patient years. Mean age was 44.6 ± 14.3 years, and 13 (15%) were women. Thirty-nine (46%) patients had a connective tissue disorder and 6 (7%) had a bicuspid aortic valve. Thirty-three (39%) patients underwent concomitant procedures, including coronary artery bypass grafting ( n  = 9, 11%), mitral valve repair ( n  = 8, 9%), and aortic hemi-arch replacement ( n  = 7, 8%). There were no operative deaths or in-house mortality and no postoperative strokes. Kaplan-Meier analysis demonstrated survival of 99% (95% confidence interval [CI]: 97–100%) at 2 years and 98% (95% CI: 97–100%) at 8 years. Freedom from reoperation was 95.8% (95% CI: 91.2–100%) at 8 years. Freedom from endocarditis was 100% at 8 years. At the last echocardiographic follow-up, 95% of patients were free of severe aortic regurgitation (AR) and 82% free of moderate AR. Of the four patients who had severe AR, three underwent reoperations and received prosthetic valves and one is being clinically monitored.

Conclusion  This study reports early and midterm outcomes after VSARR-RT at our institution, including those patients who underwent a VSARR-RT procedure combined with other procedures. Further follow-up remains necessary to determine long-term outcomes.

Early and long-term results of aortic valve sparing aortic root reimplantation surgery for bicuspid and tricuspid aortic valves

Introduction:

To evaluate early and long-term clinical outcomes following aortic valve sparing aortic root reimplantation surgery in patients with leaking bicuspid and tricuspid aortic valves.

Methods:

The study consisted of 92 consecutive adult patients (tricuspid aortic valve group = 63 and bicuspid aortic valve group = 29) who underwent aortic valve sparing aortic root reimplantation surgery with or without aortic cusp repair for dilatation of the aortic root and/or aortic valve regurgitation at our institution from April 2004 to October 2016. Clinical outcomes were investigated using Kaplan–Meier and log-rank tests between groups.

Results:

The follow-up was 100% complete with a mean time of 5.3 ± 3.3 years. The 30-day in-hospital mortality was 3.1% in tricuspid aortic valve group and 3.4% in bicuspid aortic valve group patients. The overall survival rates at 10 years did not differ between bicuspid aortic valve and tricuspid aortic valve patient groups (96.6 ± 3.3% vs. 90.3 ± 4.2%, p = 0.3). Freedom from recurrent aortic valve regurgitation (>2+) at 10 years was 90.5 ± 4.1% in tricuspid aortic valve group and 75.7 ± 8.7% in bicuspid aortic valve group (p = 0.06). Freedom from aortic valve reoperation at 10 years was 100% in tricuspid aortic valve group and 83.9 ± 7.4% in bicuspid aortic valve group (p = 0.002).

Conclusion:

Aortic valve sparing aortic root reimplantation surgery is a safe and efficient technique, providing acceptable long-term survival with low rates of valve-related complications in both tricuspid aortic valve and bicuspid aortic valve patient groups. However, aortic valve reoperation rates at 10 years follow-up were higher in bicuspid aortic valve group patients compared to tricuspid aortic valve group patients.

Short-term results of flanged Bentall de Bono and valve-sparing David V procedures for the treatment of aortic root aneurysms

Aim

Even though the Bentall de Bono procedure is widely used for the treatment of aortic root aneurysms, the procedure is under scrutiny nowadays because of complications due to mechanical prosthetic valves and the need for life-long anticoagulation. Due to these complications, aortic valvesparing operations are being researched. In this study we compared the short-term morbidity and mortality rates of both Bentall de Bono and valve-sparing David V procedures.

Methods

We retrospectively evaluated data from 70 patients who had undergone surgery for aortic root aneurysm between April 2009 and June 2013. We had performed the Bentall de Bono procedure on 46 patients and the David V procedure on 24 patients. Mortality rates, cardpulmonary bypass (CPB) and aortic cross-clamp durations, postoperative arrhythmias, and prolonged intensive care unit (ICU) and hospital stays were compared in this study.

Results

There was no statistical difference for mortality rate (p = 0.57), while the CPB time and cross-clamp duration were shorter in the Bentall group. When we compared the length of ICU and hospital stay, we observed that the David group stayed longer in ICU (p = 0.003) but the duration of hospital stay was shorter (p = 0.007).

Conclusion

Despite Bentall de Bono being the most commonly used procedure, the short-, mid- and long-term results of both procedures were similar. Spared native aortic valve and lack of anticoagulation usage are notable advantages of the David V procedure.

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

Background

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

Methods

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

Results

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

Conclusions

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

Aortic root surgery with circulatory arrest: Predictors of prolonged postoperative hospital stay

OBJECTIVE

Little is known about the outcomes of aortic root operations that involve inducing hypothermic circulatory arrest for relatively extensive proximal aortic surgery. We attempted to identify predictors of postoperative hospital length of stay (LOS) and factors that affect postoperative recovery.

METHODS

During 2006-2014, 247 of 265 patients (93.2%) with disease extending into the aortic arch survived aortic root operations (206 elective, 41 urgent/emergent) in which hypothermic circulatory arrest with moderate hypothermia was used. Stepwise multivariate regression analysis was performed to identify predictors of LOS (as a continuous variable) and prolonged LOS (defined as LOS >9 days, the median for the cohort). By this definition, 111 patients (45%) had prolonged LOS and 136 (55%) did not.

RESULTS

Preoperative factors that independently predicted longer LOS in the entire cohort included age (P = .0014), redo sternotomy (P = .0047), and intraoperative packed red blood cell (PRBC) transfusion (P = .0007). Redo sternotomy and intraoperative PRBC transfusion also predicted longer LOS in 3 subgroup analyses: one of elective cases, one from which total arch replacement procedures were excluded, and one limited to patients who were discharged home. Age predicted longer LOS in the non-total arch (hemiarch) replacement patients. Ventilator support >48 hours (P < .0001) was associated with longer LOS. Elective aortic valve-sparing root replacement predicted a shorter LOS than valve replacement in multivariate regression analysis (P = .028).

CONCLUSIONS

In patients undergoing aortic root surgery with hypothermic circulatory arrest for disease extending into the aortic arch, reducing intraoperative PRBC transfusion except when absolutely necessary may reduce postoperative LOS and expedite recovery. Performing aortic valve-sparing root replacement, when feasible, may also reduce LOS.

Elective primary aortic root replacement with and without hemiarch repair in patients with no previous cardiac surgery

OBJECTIVE

Excellent outcomes have been established for elective aortic root replacement (ARR). It is less clear whether extending the repair into the proximal aortic arch with hypothermic circulatory arrest increases risk. We examined the early outcomes of elective, primary ARR, with and without hemiarch replacement, in patients without previous cardiac surgery.

METHODS

Over a 4-year period, 140 non-redo patients (median age, 54 years) underwent elective, primary ARR for root aneurysms; 119 patients (85%) had hemiarch replacement, and 21 (15%) had only ascending aortic replacement. Valve-sparing ARR was performed in 41 cases (29.3%) and valve-replacing ARR in 99 (70.7%). Moderate hypothermic circulatory arrest and antegrade cerebral perfusion were used in 118 (99%) hemiarch repairs.

RESULTS

There were no operative deaths or permanent strokes. Complications included temporary renal dialysis (n = 1; 4.8%), transient neurologic deficit (n = 2; 9.5%), and tracheostomy (n = 2; 9.5%) after ascending aortic repair and bleeding requiring reoperation (n = 4; 3.4%), pericardial effusion requiring drainage (n = 9; 7.6%), and tracheostomy (n = 2; 1.7%) after hemiarch replacement. No stroke was observed in the hemiarch group (P = .022; univariate analysis). The extent of the repair into the proximal arch did not appear to be associated with any adverse effect.

CONCLUSIONS

In non-redo patients, elective primary ARR has excellent early outcomes, regardless of whether repair extends into the proximal arch. Additional elective hemiarch replacement with moderate hypothermic circulatory arrest and antegrade cerebral perfusion has a low risk of neurologic complications and should be performed if necessary. Long-term data are needed to compare the rates of reintervention in the aortic arch in patients with or without proximal arch replacement.

Surgery of the aortic root: should we go for the valve-sparing root reconstruction or the composite graft-valve replacement is still the first choice of treatment for these patients?

Objective

To compare the results of the root reconstruction with the aortic valve-sparing operation versus composite graftvalve replacement.

Methods

From January 2002 to October 2013, 324 patients underwent aortic root reconstruction. They were 263 composite graft-valve replacement and 61 aortic valve-sparing operation (43 reimplantation and 18 remodeling). Twenty-six percent of the patients were NYHA functional class III and IV; 9.6% had Marfan syndrome, and 12% had bicuspid aortic valve. There was a predominance of aneurysms over dissections (81% vs. 19%), with 7% being acute dissections. The complete follow-up of 100% of the patients was performed with median follow-up time of 902 days for patients undergoing composite graft-valve replacement and 1492 for those undergoing aortic valve-sparing operation.

Results

In-hospital mortality was 6.7% and 4.9%, respectively for composite graft-valve replacement and aortic valve-sparing operation (ns). During the late follow-up period, there was 0% moderate and 15.4% severe aortic regurgitation, and NYHA functional class I and II were 89.4% and 94%, respectively for composite graft-valve replacement and aortic valve-sparing operation (ns). Root reconstruction with aortic valve-sparing operation showed lower late mortality (P=0.001) and lower bleeding complications (P=0.006). There was no difference for thromboembolism, endocarditis, and need of reoperation.

Conclusion

The aortic root reconstruction with preservation of the valve should be the operation being performed for presenting lower late mortality and survival free of bleeding events.