Acute aortic dissection versus aortic root aneurysm: comparison of indications for valve sparing aortic root reconstruction☆

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.

Early results of valve-sparing aortic root replacement in high-risk clinical scenarios

BACKGROUND

The feasibility of valve-sparing aortic root procedures (David) in certain high-risk situations has been questioned. We sought to determine the safety of the David procedure in the following high-risk subgroups: acute type A dissection, severe aortic insufficiency (AI), and reoperations.

METHODS

From 2005 through 2007, 110 root replacements were performed for the above criteria: 73 root replacements with a composite valve-conduit (Bentall) and 37 David procedures. The reimplantation technique was used in all 37 David patients, with 7 requiring aortic cusp repair.

RESULTS

There were no significant differences in preoperative or intraoperative variables between the groups, with the exception of cross-clamp time, which was longer for David patients. There was a slight, but nonsignificant increase in mortality among Bentall patients (8.2% [6 of 73]) compared with David patients (5.4% [2 of 37], p = 0.59]. There were no differences with respect to postoperative stroke, renal failure, or respiratory failure. Predischarge echocardiogram in the surviving 35 David patients demonstrated no AI in 25 patients and trace/mild AI in 10. Freedom from AVR at a mean follow-up of 8.8 months (range, 1 to 40) was 94.3% (33 of 35). One patient required AVR because of endocarditis at 9 months, and 1 had severe AI 13 months postoperatively.

CONCLUSIONS

Valve-sparing aortic root replacement can be performed safely in the setting of acute dissection, severe AI, and reoperations with acceptable early results. Long-term follow-up is needed to determine the durability of repair in these high-risk groups.

Aortic Root Remodeling With Aortic Annuloplasty Mid-Term Results

BACKGROUND

A retrospective study was performed to determine the appropriateness of aortic root remodeling with aortic annuloplasty (m-Yacoub operation).

METHODS AND RESULTS

A group of 60 patients with aortic valve disease with concomitant dilated or dissected ascending aorta, who underwent surgery between 1997 and 2003, were evaluated. Nineteen patients whose aortic valves were well preserved (mean age: 57.8+/-13.2 years) underwent the m-Yacoub operation with or without aortic valve leaflet suspension. The average follow-up period was 34.5+/-19.0 months. There were no operative or hospital deaths. Preoperatively, 16 patients had grade 4 aortic regurgitation (AR), 2 had grade 3 AR, and 1 had grade 1 AR. At the latest follow-up, 1 patient had grade 2 AR, 11 had grade 1, and 7 had grade 0. At 5-year follow-up the survival rate was 100+/-0.0%, and the reoperation-free rate was 82.5+/-11.3%.

CONCLUSION

Where it is possible to preserve the aortic valve, the m-Yacoub operation is an attractive option.

Should a reimplantation valve sparing procedure be done systematically in type A aortic dissection?

OBJECTIVE

To evaluate the risks and benefits of a systematic reimplantation valve sparing procedure in the surgical treatment of type A aortic dissection (TAAD).

PATIENTS AND METHODS

From February December 2005, 15 consecutive patients (mean age 61+/-12 years) who underwent surgery for TAAD were analyzed prospectively. Eleven had a preoperative CT-scan and all had an echography. Eight patients presented with a preoperative aortic insufficiency>2/4 and seven had an ascending aortic aneurysm over 50mm. In 11 cases, arterial cannulation was performed directly into the ascending aorta. Surgical technique included complete resection and replacement of the ascending aorta using a reimplantation valve sparing technique (David), associated in 12 patients with an arch replacement, under mild (29.7+/-3.0 degrees C) hypothermia and cerebral selective antegrade perfusion.

RESULTS

Aortic clamping, cerebral perfusion and cardiopulmonary bypass (CPB) times were respectively 93+/-29, 18+/-9, and 131+/-38min. Mean bleeding at 24h was 1165+/-846ml. Troponin I level at 24h was 21+/-30 microg/l. One patient had a right coronary artery bypass for a chronically occluded coronary. Another had a triple arterial revascularisation for pre-existing coronary dissection. One patient presented with a postoperative regressive right hemiparesia (normal CT-scan). Two patients underwent revision for bleeding (one was undergoing treatment by clopidogrel). One patient had at day 7 an implantation of a covered stentgraft on the descending aorta for a concomitant penetrating aortic ulcer. One patient died suddenly on POD 7 during a tracheal aspiration. Intubation and ICU times were respectively 9.5+/-16.3 and 16.2+/-20.9 days. Four patients with severe preoperative co morbidities had long intubations. Echographic and CT-scan control, done in postoperative and after a mean follow up of 11.0+/-4.8 months, did not show any residual aortic insufficiency (actuarial survival rate at 2 years of 93.3%).

CONCLUSION

A reimplantation valve sparing procedure in the TAAD seems to be reliable and should be proposed systematically without emphasizing perioperative morbidity.

Current Perspective on Aortic Valve Repair and Valve-Sparing Aortic Root Replacement

Aortic valve repair and valve-sparing aortic root replacement are attractive concepts because they offer the possibility of valve competence without structural deterioration due to nonviability and they preclude the need for anticoagulation. Enthusiasm for aortic valve repair has waxed and waned over the past 45 years due in part to the inherent technical difficulties and poor mid-term results. Renewed interest in the concept of aortic valve repair has paralleled the development of valve-sparing aortic root replacement over the last 20 years. A current perspective on aortic valve repair and valve-sparing aortic root replacement is presented in the following review. Historical background, indications for repair, technical considerations, and outcomes data are discussed.

Restitution of the Aortic Valve: What is New, What is Proven, and What is Obsolete?

Restitution strategies of the insufficient aortic valve belong to the clinical armamentarium. To date, the accumulated body of evidence comprises 126 articles dealing with restitution strategies on the insufficient aortic valve with concomitant aortic surgery. In a cumulative analysis an almost identical number of reimplantation (506) and remodeling (489) procedures were found in the literature, whereas 357 patients underwent aortic valve resuspension. The cumulative results tend to favor the reimplantation technique in terms of longevity of the reconstruction, particularly in congenital degenerative disorders of the aortic wall, whereas remodeling appears to exhibit a more physiologic behavior of the reconstructed valve and re-suspension serves as a simplified approach particularly in acute type A dissection. Although restitution of the native aortic valve has its place in current treatment options, the accumulated worldwide numbers indicate that it is not yet routinely implemented in the vast majority of cardiac institutions.