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Desai ND, Kelly JJ, Iyengar A, Zhao Y, Cannon BJ, Grimm JC, Patrick WL, Ibrahim M, Freas M, Siki M, Szeto WY, Bavaria JE. Midterm Results of an Algorithmic 3-Pronged Approach to Bicuspid Aortic Valve Repair. Ann Thorac Surg 2024; 117:950-957. [PMID: 37517532 DOI: 10.1016/j.athoracsur.2023.07.014] [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: 05/13/2021] [Revised: 06/27/2023] [Accepted: 07/08/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND This study evaluated midterm outcomes of a 3-pronged algorithm for bicuspid aortic valve (BAV) repair. Valve-sparing root reimplantation (VSRR) was performed for patients with aortic root dilatation. In those without a root aneurysm, external subannular ring (ESAR) was performed for annuli ≥28 mm and subcommissural annuloplasty (SCA) for annuli <28 mm. METHODS This was a retrospective review of prospectively collected data of 242 patients undergoing primary BAV repair from April 29, 2004, to March 1, 2023, at a single institution. Primary end points were mortality, structural valve degeneration (SVD), which was defined as a composite of more than moderate aortic insufficiency or severe aortic stenosis, and reintervention. RESULTS The algorithm was used to treat 201 patients; of these, 130 underwent VSRR, 35 had ESAR, and 36 underwent SCA. Most were men with mean age of 43.8 years (SD, 12.0 years), which was similar between groups. Preoperative aortic insufficiency more than moderate was more common for ESAR compared with VSRR and SCA (74.3% vs 37.7% vs 44.4%, P < .001). At 30 days, mortality was 0.8% (n = 1) for VSRR and 0% for ESAR and SCA. At 6 years, overall Kaplan-Meier survival was 98.9% (95% CI, 97.3%-100%), with no differences between groups (P = .5). The cumulative incidence of SVD was 4.7% (95% CI, 0.1%-9.2%) for VSRR, 6.4% (95% CI, 0%-14.6%) for ESAR, and 0% for SCA (P = .4). Similarly, the cumulative incidence of reintervention with all-cause mortality as a competing risk was 2.2% (95% CI, 0.4%-6.9%), 6.1% (95% CI, 1%-17.9%), and 0% for VSRR, ESAR, and SCA, respectively (P = .506). CONCLUSIONS A 3-pronged algorithmic approach to BAV repair results in excellent survival and freedom from reoperation at 6 years.
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Affiliation(s)
- Nimesh D Desai
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania.
| | - John J Kelly
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yu Zhao
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brittany J Cannon
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua C Grimm
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - William L Patrick
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Michael Ibrahim
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melanie Freas
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary Siki
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
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Devine K, Augoustides JG. Aortic Valve Repair: The Evolving Frontiers of Aortic Annuloplasty. J Cardiothorac Vasc Anesth 2022; 36:3999-4000. [PMID: 35989242 DOI: 10.1053/j.jvca.2022.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Katelyn Devine
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Acharya M, Sherzad H, Tan SZCP, Bashir M, Mariscalco G. External or subcomissural annuloplasty in bicuspid aortic valve repair: Which is better? J Card Surg 2021; 37:532-534. [PMID: 34820900 DOI: 10.1111/jocs.16152] [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: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 11/27/2022]
Abstract
Patients with a bicuspid aortic valve (BAV) are at increased risk of valvular regurgitation compared to their counterparts with a tri-leaflet aortic valve. There is now increasing emphasis to offer BAV repair to mitigate the risks of prosthesis-related complications, including thromboembolism, hemorrhage and endocarditis, as well as structural valve deterioration and future reoperation with conventional valve replacement, particularly in younger populations. Furthermore, over the preceding two decades, our greater understanding of the functional anatomy of the BAV, pathophysiological mechanisms of BAV insufficiency, and the development of a functional classification of aortic regurgitation have significantly contributed to the evolution of aortic valve reconstructive surgery. In this commentary, we discuss a recent article from the Journal of Cardiac Surgery comparing external annuloplasty and subcommissural annuloplasty as techniques for BAV repair.
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Affiliation(s)
- Metesh Acharya
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, UK
| | - Hiwa Sherzad
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, UK
| | | | - Mohamad Bashir
- Division of Vascular and Endovascular Surgery, Health Education and Improvement Wales, Nantgarw, UK
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Prinzing A, Boehm J, Erlebach M, Sideris K, Lange R, Krane M. Comparison of outcomes following isolated repair of tricuspid versus bicuspid aortic valves. J Thorac Dis 2020; 12:3514-3523. [PMID: 32802430 PMCID: PMC7399387 DOI: 10.21037/jtd-19-4193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Aortic valve repair (AV-repair) is an alternative treatment option for patients with aortic regurgitation (AR), but durability is still reason for concern, especially for bicuspid aortic valves (BAV). We retrospectively evaluated mid-term results after AV-repair in patients with BAV or tricuspid aortic valves (TAV), including reoperation rates, recurrence of regurgitation, and survival. Methods Patients undergoing AV-repair between November 2004 and March 2016 without procedures involving the aortic root were included. Echocardiographic examinations were performed before and after the operation and at follow-up. Repair techniques were recorded and evaluated. Results Of 150 patients, 89 (59.3%) had TAV and 61 (40.7%) BAV. AR ≥ moderate was found in 66 patients with TAV (74.2%) and 49 with BAV (80.3%). At discharge, 74 TAV-patients had ≤ mild AR (84.4%), 11 (12.4%) moderate. 57 patients (93.4%) with BAV had ≤ mild AR, 1 (1.6%) moderate and 2 (3.3%) severe. Mean follow-up was 4.4±2.7 years with ≤ mild AR in 56 TAV patients (73.7%) and moderate in 18 (20.2%). In patients with BAV, 43 (76.8%) had ≤ mild AR and 4 (6.6%) moderate. Survival in patients with TAV was significantly decreased compared to BAV (P=0.033), but reoperation-rates did not differ significantly (P=0.651). Conclusions AV-repair is a safe and feasible option in patients with AR and can achieve similar results in patients with TAV and BAV. The complexity of the repair technique predicts repair failure.
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Affiliation(s)
- Anatol Prinzing
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Insure (Institute for Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Johannes Boehm
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Insure (Institute for Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Magdalena Erlebach
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Insure (Institute for Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Konstantinos Sideris
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Insure (Institute for Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Ruediger Lange
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Insure (Institute for Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Markus Krane
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Insure (Institute for Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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Patlolla SH, Schaff HV, Stulak JM, Michelena HI, Saran N, King KS, Dearani JA. Bicuspid Aortic Valve Repair: Causes of Valve Failure and Long-Term Outcomes. Ann Thorac Surg 2020; 111:1225-1232. [PMID: 32599047 DOI: 10.1016/j.athoracsur.2020.04.146] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 03/30/2020] [Accepted: 04/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Repair of bicuspid aortic valves (BAVs) for aortic regurgitation (AR) has favorable outcomes, but the impact of natural disease progression on durability of repair is uncertain. We evaluated causes of reoperation and compared outcomes of BAV repair to those of patients undergoing aortic valve replacement (AVR). METHODS Between January 1993 and December 2016, 113 patients had BAV repair at our institution for significant AR. Operative notes and pathology reports were studied to identify late causes of repair failure. For comparison with AVR, we utilized propensity score weighting with the score derived from preoperative and operative characteristics using gradient boosting machine model. RESULTS A total of 26 patients had late AVR after initial repair. Causes of late valve dysfunction included calcification or fibrosis of the cusps (68%), concomitant replacement addressing moderate degree of aortic valve disease to avoid future operation (20%), and cusp prolapse (12%). Pathological evaluation of these excised valves reported calcification and fibrosis in 88% of the valves. Ten-year survival of patients undergoing BAV repair was 91% compared with 90% for patients undergoing AVR with a mechanical valve and 79% for AVR with a bioprosthesis (P = .6). Incidence of reoperation after AVR with a bioprosthesis was similar to risk after repair whereas AVR with mechanical valve showed significant advantage. CONCLUSIONS Disease progression with calcification or fibrosis is the most common cause of valve failure after initial repair of BAV. Clinical outcomes of BAV repair for severe AR appear superior to AVR with bioprosthesis.
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Affiliation(s)
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Katherine S King
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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Lenihan M, Vegas A, Buys M, Mashari A, Feindel C, Djaiani G. Re: "Bicuspid Aortic Valve Associated Aortopathy: A Primer for Cardiac Anaesthesiologists". J Cardiothorac Vasc Anesth 2019; 34:325-334. [PMID: 31451372 DOI: 10.1053/j.jvca.2019.07.151] [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: 07/21/2019] [Accepted: 07/27/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Martin Lenihan
- Department of Anesthesia & Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Annette Vegas
- Department of Anesthesia & Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Mathilde Buys
- Department of Anesthesia & Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Azad Mashari
- Department of Anesthesia & Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Christopher Feindel
- Department of Anesthesia & Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - George Djaiani
- Department of Anesthesia & Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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Orlov OI, Shah VN, Orlov CP, Kaleda VI, Plestis KA. Minimally invasive bicuspid aortic valve repair with external ring annuloplasty. Ann Cardiothorac Surg 2019; 8:441-443. [PMID: 31240197 DOI: 10.21037/acs.2019.05.06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Oleg I Orlov
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Wynnewood, PA, USA
| | - Vishal N Shah
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Wynnewood, PA, USA
| | - Cinthia P Orlov
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Wynnewood, PA, USA
| | - Vasily I Kaleda
- Department of Cardiac Surgery, Central Clinical Hospital, Moscow, Russian Federation
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