Selective Sinus Replacement for Aortic Root Aneurysm: Durable Approach in Selected Patients

Thoracic aortic aneurysm

Aortic medicine has undergone remarkable progress in recent decades with regard to our understanding and treatment of aortic disease. In the past decade, the scientific community has called for the aorta to be viewed as an independent organ, advocating for a holistic approach to understanding thoracic aortic disease, integrating its embryological development, wall composition, pathophysiological mechanisms, surveillance and treatment. Thoracic aortic aneurysm (TAA) is a potentially fatal disease characterized by abnormal dilation of the thoracic aorta, whereby the structural integrity of the vessel wall is compromised. Although epidemiological studies of TAA are confounded by its asymptomatic nature and diagnostic challenges, available evidence suggests that TAA prevalence and treatment outcomes vary according to race, sex and socioeconomic factors. Pathophysiological mechanisms involve interactions between vascular smooth muscle cells and the extracellular matrix, influenced by genetic predisposition and embryological factors as well as arterial hypertension. Diagnosis relies on advanced imaging techniques, with CT angiography considered to be the gold standard diagnostic tool and with genetic screening recommended for heritable conditions. Preventive measures focus on managing cardiovascular risk factors, whereas treatment includes medical management, as well as endovascular and open surgical repair. TAA has a major effect on quality of life, particularly in younger, female and genetically predisposed patients, necessitating further research and tailored interventions.

Mid-term outcomes of aortic valve repair using an anatomically shaped internal annuloplasty ring

OBJECTIVES

The Hemispherical Aortic Annuloplasty Reconstructive Technology (HAART) ring is a rigid, internal and geometric device. The objective of this article is to assess the mid-term outcomes of aortic valve repair (AVr) using this prosthesis.

METHODS

A prospectively maintained database was used to obtain outcomes for adult patients undergoing AVr using the HAART ring between September 2017 and June 2023. All aortic patients at our institution undergo life-long surveillance with regular assessment and valve imaging.

RESULTS

Seventy-one patients underwent AVr using the HAART device: 53 had a trileaflet valve and 18 a bicuspid valve. The median age was 54 years, and most were male (79%). Many required concomitant intervention: 46% had a root procedure and 77% an arch repair. There were no in-hospital deaths, and the median postoperative stay was 5 days. At a mean follow-up of 3.9 (±1.1) years, freedom from reoperation was 94%. Late imaging demonstrated: zero trace (25%), 1+ (54%), 2+ (15%) and 4+ (6%) aortic insufficiency (AI). Eleven patients have ≥moderate AI under surveillance, all of whom have a trileaflet valve (21% of trileaflet patients). Four patients required reoperation: 3 for ring dehiscence and 1 for endocarditis.

CONCLUSIONS

Although early results using the HAART device are encouraging, mid-term results raise concern as 21% of trileaflet patients developed recurrent ≥moderate AI by 4 years post-repair. We experienced 3 incidences of ring dehiscence requiring reoperation. Based on this, we recommend caution using the sub-annular approach for stabilization in patients with trileaflet aortic valves. Long-term results are needed to assess outcomes against established techniques.