Clinical Outcomes of the David V Valve-Sparing Root Replacement Compared With Bioprosthetic Valve-Conduits for Aortic Root Aneurysms

Reintervention after valve-sparing aortic root replacement: A comprehensive analysis of 781 David V procedures

OBJECTIVE

Studies of reintervention after valve-sparing aortic root replacement (VSRR) are limited by sample size and failure to evaluate all types of reinterventions, including distal aorta and transcatheter interventions. In this report, reintervention after VSRR using a large patient cohort was comprehensively analyzed.

METHODS

In a series involving 2 academic aortic centers, 781 consecutive patients from 2005 to 2020 undergoing David V VSRR for aortic aneurysm (91%) or dissection (9%) were included. Median age was 50 years, and 23% had a bicuspid aortic valve (AV). Median follow-up was 7.0 years. Open or transcatheter reintervention on the AV, proximal, or distal thoracic aorta was identified. Cumulative incidence was calculated, and subdistribution hazard models identified factors associated with reintervention. Time-dependent incidence of reintervention was plotted using risk-hazard functions.

RESULTS

Sixty-eight reinterventions (57 open, 11 transcatheter) were performed. Reinterventions were divided by indication into degenerative AV (n = 26, including 1 transcatheter aortic valve replacement), endocarditis (n = 11), proximal aorta (n = 8), and distal aorta (n = 23, including 10 thoracic endovascular aortic repairs). Risk of reintervention for endocarditis peaked 1 to 3 years after VSRR, whereas other indications had stable, low rates of occurrence throughout the follow-up period. The cumulative incidence of reintervention was 12.5% whereas the cumulative incidence of AV reintervention was 7.0% at 10 years and was associated with residual postoperative aortic insufficiency. In-hospital mortality after reintervention was 3%.

CONCLUSIONS

Reintervention rates after VSRR are relatively low in long-term follow-up and can be performed with acceptable operative risk. The majority of reinterventions are performed for indications other than AV degeneration, with the timing of reintervention varying by the specific clinical indication.

Current controversies in aortic valve-preserving surgery

The clinical outcome of severe aortic regurgitation (AR) remains suboptimal, but surgery has been shown to have survival benefit over medical therapy. Postoperative survival is inferior in patients with reduced left ventricular function, and therefore early surgical intervention is recommended. Aortic valvuloplasty (AVP) is an attractive option to avoid the major drawbacks of prosthetic valves but has not been widely adopted. The etiology of AR is classified functionally into three groups: normal leaflet motion (type I), cusp prolapse (type II), and restriction (type III). Type I with dilatation of the sinus of Valsalva (type Ib) can be repaired by aortic valve reimplantation or aortic root remodeling with similar valve stability. Type I with dilatation of the aortic annulus (type Ic) can be managed by annuloplasty. Type II can be corrected by plication or resuspension techniques. Pericardial patch is necessary in AVP for type Id (perforation/fenestration) and type III but is associated with risk of recurrence. Bicuspid aortic valve is classified according to commissure angle: symmetrical, asymmetrical, and very asymmetrical. Tricuspidization is recommended for repair of very asymmetrical valves to avoid postoperative stenosis. Recent progress has achieved similar reoperation rates between bicuspid and tricuspid aortic valve repair. For Marfan syndrome, valve-sparing root replacement is advantageous compared to Bentall operation regarding late survival, thromboembolic and hemorrhagic events, and endocarditis. Similar findings have been reported in acute aortic dissection. Both remodeling and reimplantation procedures provide similar favorable outcomes in these settings. Recent advances in AVP are summarized by quantitative assessment of cusp configuration (effective height and geometric height), graft size decision, use of template to cut the graft, and videoscopic assessment of post-repair cusp configuration. Due to these advances, AVP shows superior results to replacement surgery. Further concrete evidence with larger case volumes and longer observation periods are necessary to popularize AVP.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Valve-sparing versus valve-replacing aortic root replacement in patients with aortic root aneurysm

BACKGROUND

Valve-sparing aortic root replacement (VSARR) is an alternative to valve-replacing aortic root replacement (VRARR) with valved-conduits based on recent guidelines for clinical practice. This study investigated outcomes of these two procedures in patients with nonstenotic valves.

METHODS

Between January 7, 2007 and June 30, 2019, 475 patients with aortic root aneurysm without aortic stenosis underwent VSARR (151) or VRARR (324) techniques. Propensity score-matching (PSM) was used to alleviate confounding. Endpoints were 30-day mortality, 8-year survival and reoperation, aortic regurgitation, and valve gradients.

RESULTS

PSM created 69 pairs of patients with a mean age 52 ± 13 years (10.1% Marfan syndrome, 34.8% bicuspid aortic valve). There was no statistically significant difference in major perioperative morbidity or 30-day mortality (0% VSARR vs. 1.4% VRARR; p = 0.316). Overall survival was significantly higher (p = 0.025) in the VSARR group versus the VRARR group (8-year estimates 100% vs. 88.9%, respectively), while freedom from valve reoperation was similar (p = 0.97, 8-year estimates 90.9% vs. 96.7%, respectively). Freedom from > moderate-severe AR was not significantly different (p = 0.08, 8-year estimates 90.0% VSARR group vs. 100% VRARR), but mean valve gradients at last follow-up were better in the VSARR group (5.9 vs. 13.2 mmHg, p < 0.001).

CONCLUSIONS

VSARR is a safe operation in patients with aortic root aneurysm and nonstenotic aortic valves in the hands of experienced surgeons. Freedom from reoperation is similar and the mode of aortic valve failure differs between the two groups.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Fifteen-Year Outcomes Following Valve-Sparing Aortic Root Replacement in Elderly Patients

BACKGROUND

Valve-sparing aortic root replacement (VSRR) techniques have several advantages such as preservation of physiological haemodynamics of the native aortic valve and avoidance of prosthetic valve-related complications. However, VSRR procedures are generally performed in young patients and the long-term results in elderly patients (≥65 years) are scarce.

METHODS

Fifty-six (56) consecutive patients underwent VSRR surgery by a single surgeon at the current centre between January 2006 and December 2013; a modified "remodelling technique" was typically performed. The mean age was 58.86±12.5 years; Marfan syndrome and bicuspid aortic valve were both present in six patients (10.7%); 38 patients (67.8%) presented with greater than moderate aortic regurgitation; and 17 patients (30.4%) were in New York Heart Association (NYHA) class III before surgery. They were divided into two groups according to their ages receiving VSRR surgery: Group E (elderly patients aged ≥65 years, n=24) and Group Y (young patients aged <65 years, n=32). The primary outcomes were aortic valve-related reoperation, cardiovascular reoperation, all-cause mortality, and functional status.

RESULTS

One (1) patient in Group E was converted to aortic valve replacement as a result of a failed aortic valve repair. No perioperative mortality was observed. The mean follow-up was 11.5±2.9 years. Aortic valve-related reoperation was noted in two patients of each group (one with endocarditis, one with severe aortic regurgitation). Cardiovascular reoperations were observed in three and six patients, and all-cause deaths in seven and two patients in Group E and Group Y, respectively. The 10-year freedom from aortic valve-related reoperation was estimated to be 91.7±5.6% and 92.7±5.0% (p=0.594), the 10-year freedom from cardiovascular reoperation was 86.4±7.3% and 81.1±7.7% (p=0.781), and the cumulative 10-year survival rates were 74.0±9.2% and 93.8±4.3% (p=0.018) in Group E and Group Y, respectively. During follow-up, 6.7% of patients were in NYHA class III and 6.4% of patients developed moderate-to-severe aortic regurgitation. Cox regression analysis failed to identify predictors for primary outcomes.

CONCLUSION

Valve-sparing aortic root replacement can safely be performed in elderly patients with low early mortality and satisfactory long-term freedom from aortic valve-related and cardiovascular re-intervention.

Valve Sparing Root Replacement versus Bio-Bentall: Inverse Propensity Weighting of 796 Patients

BACKGROUND

This large cohort, single center study aims to compare the 10-year survival and freedom from aortic valve reintervention between valve sparing root replacement (VSRR) and bioprosthetic Bentall (bio-Bentall).

METHODS

All patients undergoing elective VSRR or bio-Bentall for aortic root aneurysm between March 2005 through October 2019 were retrospectively reviewed (n=796 [VSRR = 360]). Inverse probability of treatment weighting (IPTW) balanced clinical variables between groups. Mean follow-up was 58.0 +/- 45.4 (range 0-167) months.

RESULTS

After IPTW adjustment, 10-year survival did not differ between groups (VSRR: 87.0% vs bio-Bentall: 92.7%, p=0.780). Cumulative incidence of aortic valve reintervention was 5.9% for VSRR (95% CI, 2.9%-10.4%) and 10.6% for bio-Bentall (95% CI, 6.2%-16.4%, p=0.798). Fine and Gray computing risk regression model identified age at surgery (sHR 0.97, 95% CI, 0.95-0.99, p=0.015), body surface area (sHR 6.21, 95% CI, 1.97-19.59, p=0.002) and bicuspid aortic valve (sHR 2.15, 95% CI, 1.04-4.44, p =0.038) as independently associated with aortic valve reintervention. For patients ≤50-year-old, cumulative incidence of aortic valve reintervention was 16.2% for VSRR (95% CI, 7.0%-28.8%) and 17.8% for bio-Bentall (95% CI, 6.9%-32.8%)(p=0.363).

CONCLUSIONS

VSRR and bio-Bentall show similar excellent survival and freedom from aortic reintervention rates up to 10 years; however, a durable valve solution for young patients with bicuspid aortic valve remains a challenge.

Assessment of long-term outcomes: aortic valve reimplantation versus aortic valve and root replacement with biological valved conduit in aortic root aneurysm with tricuspid valve

OBJECTIVES

We compared the long-term outcomes between aortic valve reimplantation [David V (DV)] and aortic valve and root replacement with biological valved conduit [Bentall-De Bono (BD)] for the patients with aortic root aneurysm with tricuspid valve.

METHODS

Among 876 patients who underwent aortic root replacement in our institution between 2005 and 2018, 371 patients who underwent DV (n = 199) or BD (n = 172) for aortic root aneurysm with tricuspid valve were retrospectively reviewed. Exclusion criteria included aortic stenosis, infective endocarditis, previous prosthetic aortic valve, bicuspid aortic valve, aortic dissection and mechanical Bentall procedure. Propensity score matching was performed based on the patient characteristics, matching 90 patients in each group. The primary end point was all-cause mortality. Secondary end points were reoperation for any cause and specifically for aortic valve-related cause.

RESULTS

After propensity score matching, DV and BD groups each had 1 in-hospital mortality (1.1%). Survival at 10 years was 95.3% [95% confidence interval (CI) 85.8-98.5] in DV and 98.6% (95% CI 90.8-99.8) in BD (P = 0.345). The cumulative incidences of reoperation at 10 years in DV versus BD were 3.9% (95% CI 0.7-11.8) vs 18.1% (95% CI 6.9-33.4) for any cause (P = 0.046) and 1.9% (95% CI 0.1-8.8) vs 15.9% (95% CI 5.5-31.4) for aortic valve-related causes (P = 0.032). The reasons for valve-related reoperation were aortic insufficiency (3/5 in DV vs 5/10 in BD), aortic stenosis (0/5 vs 2/10) and infective endocarditis (2/5 vs 3/10).

CONCLUSIONS

Both DV and BD procedures for patients with aortic root aneurysm with tricuspid valve resulted in excellent 10-year survival. All-cause and aortic valve-related reoperations were significantly less frequent with valve-sparing root replacement, suggesting an advantage of DV over biological BD.

Incidence, Cause, and Outcome of Reinterventions after Aortic Root Replacement

BACKGROUND

This study aims to comprehensively characterize the details of the aortic and aortic valve reinterventions after aortic root replacement (ARR).

METHODS

Between 2005 and 2019, 882 patients underwent ARR. The indication was for aneurysm in 666, aortic valve-related in 116, aortic dissection in 64, and infective endocarditis (IE) in 36. Valve-sparing root replacement was performed in 290 while Bio-Bentall was done in 528. Among them, 52 (5.9%) patients required reintervention. The incidence, cause, and time to reintervention, as well as outcomes after reintervention were investigated. Cause-Specific Cox hazard model was performed to identify predictors for reintervention after ARR.

RESULTS

The 10-year cumulative incidence of aortic and aortic valve reintervention after ARR was 10.3% [95%CI, 7.3%-14.0%]. Age per year decrease was the only independent predictor for reintervention [sHR, 0.97; 95%CI, 0.95-0.99]. The causes for 52 reinterventions were: 29 (55.8%) for aortic valve causes including aortic stenosis/insufficiency, and prosthetic valve dysfunction; 15 (28.9%) for IE; 7 (13.5%) for aortic-related causes including pseudoaneurysm, development of aneurysm, and residual dissection; and 1 (1.9%) for coronary button pseudoaneurysm. Median times to reintervention were 11.0 [IQR, 2.0-20.5] months for IE, 24.0 [IQR, 3.7-46.1] months for aortic-related causes, 77.0 [IQR, 28.4-97.6] months for aortic valve-related causes (p=.005). Overall in-hospital mortality after the reinterventions was 7.7% (4/52) with 20.0% with IE (3/15) .

CONCLUSIONS

Reintervention for IE occurs relatively early after ARR while aortic valve- and aortic-related reinterventions gradually increase over time. In-hospital mortality after the reintervention is low, unless it is for IE.

Preoperative Eccentric Aortic Regurgitation and Outcomes Following Valve-Sparing Root Replacement

The David V valve-sparing root replacement (VSRR) is well-established for the treatment of aortic insufficiency (AI) and advanced root aortopathy. The impact of cusp repair in trileaflet aortic valve (TAV) patients, however, with preoperative moderate-severe AI and an eccentric jet is unclear. This study compares outcomes in TAV patients with pre-operative AI >2+ based on jet centricity and cusp repair status. Review of a single institutional database identified 309 consecutive patients undergoing VSRR from 2005 to 2018. Of these, 51 patients had TAV with AI >2+: 25 concentric and 26 eccentric jets. Mean follow-up was 58 (SD = 44) months. Echocardiographic parameters were compared pre- and post-operatively. Kaplan-Meier analysis, longitudinal mixed modeling, and cumulative incidence were used to compare long-term survival, recurrence of AI >1+, and valve specific re-intervention, respectively. The mean age was 48 (SD = 12) years and 84% were male. Differences in preoperative comorbidities and echocardiographic parameters between groups were not statistically significant. Postoperative outcomes were similar in concentric vs. eccentric and cusp vs. no cusp repair. Recurrence of AI>1+ was minimal and unrelated to jet centricity (concentric = 1, eccentric = 3) and cusp repair (no cusp repair = 1, cusp repair = 3) long-term. Aortic valve replacement cumulative incidence was 0% for central and 5% for eccentric at 3-, 5-, and 10-years, respectively. Long-term mortality was similar regardless of jet centricity and cusp repair. In appropriately selected TAV patients with preoperative AI >2+, current results suggest VSRR provides a durable repair regardless of jet centricity or the need for cusp repair based on low rates of reintervention reported.

Fifteen Years of Aortic Valve-sparing Root Replacement and Impact of Eccentric Jets on Late Outcomes

BACKGROUND

Valve-sparing root replacement is more challenging with eccentric aortic insufficiency due to cusp and root asymmetry, which may impact valve durability and survival. This study analyzed the effect of jet eccentricity on long-term outcomes in tricuspid aortic valves (TAVs) and bicuspid aortic valves (BAVs).

METHODS

From 2005 to 2019, 111 patients (65 TAVs, 46 BAVs) with >2+ aortic insufficiency underwent valve-sparing root replacement at an academic center. Pre- and postoperative echocardiograms were analyzed. Of these, 32 patients presented with concentric jets (29 TAVs, 3 BAVs) and 71 with eccentric jets (28 TAVs, 43 BAVs). Median follow-up was 49 months (interquartile range, 12-93). Kaplan-Meier analysis and cumulative risk were used to compare long-term survival and valve-related reintervention.

RESULTS

Mean patient age was 44 ± 12 years. Compared with TAV, more BAV patients presented with eccentric jets (93.5% vs 43.1%, P < .001). All BAV patients received cusp repair compared with 52.3% of TAV patients (P < .001). At 3, 5, and 10 years the cumulative risk of aortic valve replacement for TAV (4.7%, 6.4%, and 6.4%) versus BAV (5.8%, 7.8%, and 7.8%) patients (P = .87) and concentric (0%, 0%, and 0%) versus eccentric (6.4%, 9.4%, and 9.4%) jets (P = .98) was similar. Overall survival at 10 years was 71% for TAV and 97% for BAV (P = .19) and 86% for concentric and 79% for eccentric jets (P = .17).

CONCLUSIONS

In patients presenting for valve-sparing root replacement with >2+ aortic insufficiency the risk of valve-related reintervention long term was low after cusp repair in TAVs and BAVs. Current results suggest preoperative jet eccentricity does not impact long-term survival and valve durability.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Bicuspid Aortic Valve: An Update in Morphology, Genetics, Biomarker, Complications, Imaging Diagnosis and Treatment

The bicuspid aortic valve, a kind of heart disease that comes from parents, has been paid attention around the world. Although most bicuspid aortic valve (BAV) patients will suffer from some complications including aortic stenosis, aortic regurgitation, endocarditis, and heart dysfunction in the late stage of the disease, there is none symptom in the childhood, which restrains us to diagnose and treatment in the onset phase of BAV. Hemodynamic abnormalities induced by the malformations of the valves in BAV patients for a long time will cause BAV-associated aortopathy: including progress aortic dilation, aneurysm, dissection and rupture, cardiac cyst and even sudden death. At present, preventive surgical intervention is the only effective method used in this situation and the diameter of the aorta is the primary reference criterion for surgery. And the treatment effects are always not satisfactory for patients and clinicians. Therefore, we need more methods to evaluate the progression of BAV and the surgery value and the appropriate intervention time by combining basic research with clinical treatment. In this review, advances in morphology, genetic, biomarkers, diagnosis and treatments are summarized, which expects to provide an update about BAV. It is our supreme expectations to provide some evidences for BAV early screening and diagnosis, and in our opinion, personalized surgical strategy is the trend of future BAV treatment.

Valve-Sparing Root Replacement in Elderly Patients With Annuloaortic Ectasia

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.