Surgery of the aortic valve

Aortic Valve Intervention During Aortic Root Surgery in Children: A Systematic Review

BACKGROUND

Pediatric aortic root dilatation is a life-threatening condition that lacks guidelines for surgical management. We aimed to analyze the data on aortic valve interventions during root surgery to guide decision-making.

METHODS

A search was performed of MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, and WHO ICTRP. Citations were screened in duplicate and independently to identify randomized controlled trials, cohorts, and case series involving populations aged 0 to 18 years, who received valve-sparing and valve-replacing aortic root surgeries between 1999 and 2019. Outcomes considered included mortality (perioperative, one year, five year), reintervention rates.

RESULTS

After duplicate removal, 689 citations were screened through abstract and full text review, identifying five eligible studies. All five were observational studies evaluating valve-sparing procedures. There were 81 patients with a mean study age range of 9.9 to 13.9 years. Both reimplantation (74%) and remodeling (26%) subtypes were done. Range of mean duration of follow-up was 1.2 to 4.4 years. There was no mortality reported until the one-year follow-up period. The long-term mortality rate was calculated as 0.02 per patient-year (95% CI: 0.01-0.05). The long-term reintervention rate was 0.08 per patient-year (95% CI: 0.05-0.13).

CONCLUSIONS

There is limited experience on aortic valve intervention during aortic root surgery in children. Single-arm studies on valve-sparing surgeries show excellent survival up to one year. Mortality and reintervention rates increase in the longer term. The small sample size and lack of controlled studies do not allow for direct comparisons between procedure types.

Bicuspid aortic valve disease: recent insights in pathophysiology and treatment

Bicuspid aortic valve is a common congenital cardiac malformation with a broad spectrum of clinical outcomes. Bicuspid aortic valve may go undetected throughout an individual's lifetime or, alternatively, they may have devastating clinical consequences, resulting in death. Both clinicians and medical scientists have taken a renewed interest in the development, pathophysiology and treatment options for this subtle but often substantial clinical entity. Evidence is mounting to suggest that an underlying disease of the aorta is inherited with bicuspid aortic valve, although considerable controversy surrounds this theory. Novel molecular mechanisms underlying the valve and vascular pathologies, as well as new surgical therapies for these patients have been proposed in the past 10 years.

Two-patch repair of a bicuspid aortic valve with vegetation on its raphe

We report the successful repair of a bicuspid aortic valve with vegetation on its thickened raphe by using two pericardial patches. After excising the vegetation and thickened raphe, the first patch was sewn between the remaining leaflets. Another patch was then sewn at the base of the cusp to create sufficient geometrical height for good coaptation. Our two-patch technique may facilitate intraoperative accommodation of the 3-D shape of the new cusp.

Modified patch repair for bicuspid aortic valve with thickened raphe

We report a successful repair of bicuspid aortic valve having thickened raphe using pericardial patch. After excising the thickened portion, the patch was sewn to the remaining leaflet and root. To note, the height the patch was sewn to the root was lowered to the equivalent level of the corresponding portion of the other cusp, to create symmetrical bicuspid configuration. Postoperative echocardiography revealed trivial aortic regurgitation with improved leaflet motion and transvalvular flow.

Aortic valve-sparing operations: state of the art

PURPOSE OF REVIEW

Aortic valve-sparing (AVS) operations include an armamentarium of procedures, which preserve the aortic cusps in aortic root dilation with aortic insufficiency. The purpose of this review article is to specifically outline the surgical indications, to describe the various techniques, and to present results from the most current series in AVS operations.

RECENT FINDINGS

In the worldwide literature, there is promising data on AVS operations. Patients undergoing AVS operations not only have better long-term survival but also appear to have a reduced risk of aortic insufficiency and thromboembolic complications.

SUMMARY

AVS operations are an excellent option for patients with an aortic root aneurysm and normal/minimally diseased aortic cusps.

The influence of operative techniques on the outcomes of bicuspid aortic valve disease and aortic dilatation

BACKGROUND

Bicuspid aortic valve is associated with aortic aneurysm formation that may extend beyond the ascending aorta.

METHODS

Between 1979 and 1997, 143 bicuspid aortic valve patients had aortic valve operations with replacement of an aneurysmal ascending aorta: 93 (65%) underwent full root replacement and 50 (35%) underwent separate valve and graft replacement. Distal aortic anastomosis was open in 42 patients (29%) and closed in 101 (71%). Late survival and complications were compared by surgical technique.

RESULTS

Patients undergoing full root replacement tended to be younger (mean age 46 +/- 16 vs 59 +/- 13, p < 0.001) and presented with more aortic insufficiency (80% vs 35%, p < 0.001). Three (2.1%) hospital deaths occurred. Event-free survival was 82% (95% confidence interval, 75% to 88%) at 10 years and 41% (95% confidence interval, 11% to 71%) at 20 years. At a median follow-up of 11.5 years, the incidence of new aneurysms and late aortic complications were not significantly different among the procedure groups. Age at the time of operation was the only predictor of late survival (hazard ratio, 1.07; p = 0.007).

CONCLUSIONS

Aortic root replacement with distal aortic reconstruction can be achieved with very low operative mortality and excellent long-term outcomes in patients with bicuspid aortic valve and dilated ascending aorta. The type of surgical procedure done in the aortic root and in the distal ascending aorta does not influence late survival, subsequent operation, or aortic complications. This is likely influenced by our patient-specific strategy when replacing the aortic root and distal ascending aorta.

Postimplantation morphologic changes of glutaraldehyde-fixed porcine aortic roots and risk of aneurysm and rupture

OBJECTIVE

Rupture of glutaraldehyde-fixed porcine aortic roots has been reported, but the mechanism and incidence of this complication is unknown. This study evaluates the clinical outcomes and the risk of dilation and rupture of porcine aortic roots after implantation.

METHODS

Commercially available porcine aortic roots were used for aortic root replacement in 308 patients (Freestyle bioprosthesis [Medtronic, Minneapolis, Minn] in 251 patients and Toronto Root [St Jude Medical, St Paul, Minn] in 57 patients) whose mean age was 62 +/- 13 years. The main indication for aortic root replacement was dilation of the native aortic root. Clinical follow-up was complete at a mean of 5.3 +/- 2.5 years. Valve function and aortic root diameter were assessed by means of echocardiography.

RESULTS

There were 10 (3.2%) operative and 39 (12.6%) late deaths. At 8 years, patients' survival was 79.0% +/- 3.1%, freedom from reoperation was 95.3% +/- 1.7%, and freedom from severe aortic insufficiency was 93.8% +/- 2.7%. The diameter of the aortic sinuses increased from 31.9 +/- 4.3 to 34.1 +/- 4.8 mm (P < .0001), and it exceeded 40 mm in 10% of the patients. Linear regression analysis revealed that the duration of follow-up (P < .0001) and the size of the valve implanted (P < .0001) were associated with risk of sinus dilation. There was only 1 early rupture of the noncoronary aortic sinus and 2 late aneurysms that required repeat operations. Histologic examination of explanted aneurysmal porcine roots revealed marked changes in the xenograft arterial wall, with abundant mononuclear cells suggestive of immunologic reaction.

CONCLUSIONS

Mild dilation of porcine aortic roots after aortic root replacement is common, but aneurysm formation and rupture are rare during the first decade of follow-up. Annual surveillance with echocardiography is recommended.

Aortic root remodeling: Ten-year experience with 274 patients

OBJECTIVES

Dilatation of the aortic root with concomitant aortic regurgitation can be treated by valve-preserving surgery. We have consistently chosen root remodeling rather than reimplantation whenever the aortoventricular junction was not dilated. We have analyzed our 11-year experience with root remodeling.

METHODS

Between October 1995 and October 2006, 274 patients (201 male; 73 female, aged 59 +/- 15 years) were treated by root remodeling in the presence of a preserved aortoventricular diameter (<30 mm). Acute aortic dissection was present in 46 patients. The valve anatomy was tricuspid in 193 and bicuspid in 81 patients. Cusp disease was additionally corrected in 173 (63%) patients. Follow-up was complete in 99%. Cumulative follow-up was 1045 patient-years (mean of 4.0 +/- 2.7 years).

RESULTS

Hospital mortality was 3.6% (elective 3.1%; emergency 6.5%). One patient had endocarditis 2 months postoperatively and subsequently underwent valve replacement. Freedom from aortic regurgitation of grade II or more was 91% and 87% at 10 years for bicuspid and tricuspid aortic valves. Nine patients required reoperation: in 6 patients the valve was replaced and in 3 patients rerepaired. Freedom from reoperation was 96% at 5 and 10 years, and freedom from valve replacement was 98% at 5 and 10 years. A comparison of 3 operative periods (1995-1998, 1999-2002, and 2003-2006) showed that with increasing experience cusp prolapse was diagnosed and corrected more frequently (8/49 = 17%; 62/105 = 59%; 103/108 = 82%; P < .0001), and repair stability significantly improved over time (P = .007).

CONCLUSIONS

Root remodeling leads to durable restoration of aortic valve function in both tricuspid and bicuspid valve anatomy. Aggressive correction of cusp prolapse seems to have a beneficial effect on aortic valve competence.

Aortic valve replacement in elderly patients: what are the limits?

PURPOSE OF REVIEW

Increased life expectancy has led to a growing elderly population frequently presenting with aortic stenosis. This review focuses on modalities of aortic valve replacement designed to cope with the risks from multiple co-morbidities prevalent in the elderly.

RECENT FINDINGS

Cardiac surgery is safe in octogenarians; very low risks are associated with aortic valve replacement. Good short-term and medium-term results are seen with early surgical intervention for aortic stenosis in the relatively asymptomatic patient. The benefits seen with minimally invasive surgery make it more acceptable. A hybrid approach that deploys a drug-eluting stent for concomitant moderate coronary artery disease has shown promising results. An extension of this concept is the percutaneous aortic valve implantation that offers hope to the nonsurgical candidate. A systematic approach of minimally invasive surgery in patients with prior coronary artery bypass grafting minimizes injury to grafts. Bioprosthetic tissue valves are the valves of choice in all the above interventions.

SUMMARY

Cardiac surgery is used increasingly for aortic stenosis in elderly patients. Current experiences in minimally invasive and percutaneous approaches have opened the doors to hybrid strategies, which may be the mainstay of treatment for older patients needing aortic valve replacements in the future.

Carpentier-Edwards Perimount Magna Valve Versus Medtronic Hancock II: A Matched Hemodynamic Comparison

BACKGROUND

The Perimount Magna valve (Edwards Lifesciences, Irvine, CA) was designed to minimize the amount of obstruction to blood flow across the valve. We compared hemodynamic performance of the Perimount Magna valve with the Hancock II valve (Medtronic, Minneapolis, MN), a second-generation porcine bioprosthesis with proven long-term results.

METHODS

The 57 patients who received a Magna valve at our institution from 2003 to 2005 were matched 1:1 with 57 patients who received a Hancock II valve on variables known to affect hemodynamic measurements: size of implanted valve, age, sex, and body surface area. Early postoperative transthoracic echocardiography was performed in 100% of patients.

RESULTS

In addition to the matched variables, patients in both groups were similar for all measured preoperative characteristics and perioperative clinical outcomes. One week postoperatively, Magna patients had significantly lower peak (22.1 +/- 7.4 mm Hg versus 32.3 +/- 15.1 mm Hg) and mean transvalvular gradients (10.4 +/- 4.0 mm Hg versus 18.5 +/- 15.5 mm Hg, both p < 0.001). The Magna group also had a trend towards a larger effective orifice area (1.40 +/- 0.24 cm2 versus 1.29 +/- 0.34 cm2, p = 0.07), despite a similar left ventricular outflow tract diameter (2.0 +/- 0.2 cm versus 2.0 +/- 0.1 cm, p = 0.7). Patient-prosthesis mismatch, as defined by measured effective orifice area of less than 0.65 cm2/m2, was significantly less common in the Magna group (30% versus 52%, p = 0.02).

CONCLUSIONS

The Magna valve has more favorable early postoperative hemodynamics than the Hancock II valve. Further studies should be performed comparing the Magna valve to newer-generation, low-profile porcine valves.

Aortic valve repair after blunt chest trauma: repair of traumatic aortic valve rupture

A frequent reason of admission to the emergency room is blunt chest trauma following car accidents. Chest injuries may cause a wide range of cardiac lesions, extending from myocardial contusion, to heart or great vessels rupture, to valvular lesions. We present a case of aortic valve rupture after blunt chest trauma.

Replacement of the ascending aorta with reduction of the diameter of the sinotubular junction to treat aortic insufficiency in patients with ascending aortic aneurysm

OBJECTIVE

Ascending aortic aneurysm often causes dilation of the sinotubular junction with consequent aortic insufficiency despite normal aortic cusps.

METHODS

Replacement of the ascending aorta with reduction of the diameter of the sinotubular junction to correct aortic insufficiency was performed in 103 consecutive patients. Twenty-nine also needed repair of cusp prolapse. The patients' mean age was 65 +/- 12 years and all had ascending aortic aneurysm; 63 also had arch aneurysm and 21 had aneurysm of the entire aorta. The aortic insufficiency was graded as moderate in 54 patients and severe in 49. Patients were followed up prospectively and had echocardiographic studies annually. The mean follow-up was 5.7 +/- 3.4 years.

RESULTS

There were 2 operative and 30 late deaths. Cardiovascular events were the cause of death in 19 patients. Arch aneurysm and age were the only predictors of late death. Overall survival at 10 years was 54% +/- 7%. Seven patients had moderate and 1 had severe aortic insufficiency. The freedom from moderate or severe aortic insufficiency at 10 years was 80% +/- 7% and from severe aortic insufficiency, 98% +/- 1%. Two patients required aortic valve replacement, 1 because of severe aortic insufficiency and 1 for endocarditis. The freedom from aortic valve replacement at 10 years was 97% +/- 1%. At the latest follow-up, 98% of the patients were in functional class I or II.

CONCLUSIONS

Reduction in the diameter of the sinotubular junction restores aortic valve competence in patients with ascending aortic aneurysm and aortic insufficiency with normal aortic cusps. Late survival of these patients is suboptimal because they often have extensive aneurysmal disease.

Aortic Valve Preservation in Patients With Aortic Root Aneurysm: Results of the Reimplantation Technique

BACKGROUND

A study was conducted to determine the long-term results of aortic valve reimplantation to treat aortic root aneurysm.

METHODS

Prospective follow-up with clinical assessments and echocardiography was done of 167 consecutive patients who had reimplantation of the aortic valve as treatment of aortic root aneurysm. Their mean age was 45 +/- 15 years, 78% were men, 38% had Marfan syndrome, 14% had aortic dissection, and 7% had bicuspid aortic valve. The aortic valve was reimplanted into a straight Dacron (Dupont, Wilmington, DE) tube in 89 patients and in a Dacron tube with creation of neoaortic sinuses in 78. Aortic cusp repair was performed in 66 patients, and the free margin was reinforced with a fine Gore-Tex suture (W.L. Gore & Assoc, Flagstaff, AZ) in 36. The mean follow-up was 5.1 +/- 3.8 years and was 100% complete.

RESULTS

There were two operative and six late deaths. Survival at 10 years was 92% +/- 3%. Moderate aortic insufficiency developed in 3 patients, and severe developed in 2. Freedom from moderate or severe aortic insufficiency was 94% +/- 4% at 10 years. Two patients required aortic valve replacement. Freedom from aortic valve replacement was 95% +/- 4% at 10 years. At the latest follow-up, 90% of the patients were in New York Heart Association functional class I and 10% were in class II.

CONCLUSIONS

Reimplantation of the aortic valve to treat patients with aortic root aneurysm is associated with excellent long-term survival and low rates of valve-related complications. Reimplantation of the aortic valve is a durable type of aortic valve repair.

Long-term results of aortic valve-sparing operations for aortic root aneurysm

OBJECTIVES

To examine the results of aortic valve sparing for aortic root aneurysm.

METHODS

Two hundred twenty consecutive patients who had aortic valve sparing for aortic root aneurysm were prospectively studied with annual clinical assessments and echocardiography. Their mean age was 46 +/- 15 years, 40% had Marfan syndrome, 17% had aortic dissection, and 7% had bicuspid aortic valve. Reimplantation of the aortic valve was performed in 167 patients and remodeling of the aortic root in 53. Aortic cusp repair was performed in 80 patients, and reinforcement of the free margin of one of the cusps with a fine polytetrafluoroethylene (Gore-Tex) suture in 48. The mean follow-up was 5.2 +/- 3.7 years and it was complete.

RESULTS

There were 3 operative and 13 late deaths. Patients' survival at 10 years was 88% +/- 3%. Age older than 65 years, advanced functional class, and ejection fraction less than 40% were independent predictors of death. Moderate aortic insufficiency developed in 7 patients and severe insufficiency in 6. Freedom from moderate or severe aortic insufficiency at 10 years was 85% +/- 5% for all patients, but it was 94% +/- 4% after reimplantation and 75% +/- 10% after remodeling (P = .04). Five patients required aortic valve replacement; the freedom from valve replacement at 10 years was 95% +/- 3%. One case of endocarditis developed 11 years postoperatively. At the latest follow-up, 88% of the patients were in functional class I, and 10% were in class II.

CONCLUSIONS

Aortic valve-sparing operation is associated with low rates of valve-related complications. The probability of late aortic insufficiency was lower after the reimplantation procedure than after remodeling in our experience.

Stentless Aortic Valves are Hemodynamically Superior to Stented Valves During Mid-Term Follow-Up: A Large Retrospective Study

BACKGROUND

Several studies have compared left venticular mass (LVM) regression and hemodynamic data for stentless versus stented aortic bioprostheses with conflicting results. The major limitations of these studies are their small sample size and short-term follow-up. We therefore compared midterm LVM regression, hemodynamic data, and survival in a large population of tissue aortic valve replacement (AVR) patients.

METHODS

All patients undergoing tissue AVR at our institution between 1998 and 2001 were included (n = 737). Patients were divided into two groups according to type of bioprosthetic implanted: stentless patients (total n = 310) (Toronto SPV [St Jude Medical, St Paul, MN], n = 146 and Freestyle [Medtronic, Minneapolis, MN], n = 164) and stented patients (total n = 427) (Perimount [Edwards Life Sciences Inc, Irvine, CA], n = 291 and Mosaic [Medtronic], n = 136).

RESULTS

The two groups of patients had similar preoperative transvalvular gradients and LVM index (130 +/- 47 vs 130 +/- 42 g/m2 for stentless versus stented valves, respectively). Predischarge echos revealed that stentless patients had significantly lower mean transvalvular gradients (11 +/- 5 vs 15 +/- 6 mm Hg, p < 0.001) and larger effective orifice areas (1.32 +/- 0.52 vs 1.22 +/- 0.48 cm2, p = 0.01). Follow-up echocardiograms were obtained in 99% of surviving patients 28 +/- 22 (range, 0-79) months postoperatively. Stentless patients had significantly lower LVM index during follow-up (100 +/- 32 vs 107 +/- 32 g/m2, p = 0.005) and stentless valves were an independent predictor of LVM regression. Furthermore, a higher proportion of stented patients had residual LV hypertrophy during follow-up (28% vs 18%, p = 0.001). Stentless valves were associated with improved midterm survival by univariate analysis, but not by multivariable analysis.

CONCLUSIONS

Midterm follow-up in a large number of patients reveals that stentless bioprostheses are hemodynamically superior to stented valves.

Aortic root replacement surgery: indications, techniques and outcomes

Aortic root pathology is a common cause of aortic insufficiency. Aortic root aneurysm and aortic dissection, if left untreated, carry significant risk of mortality and morbidity. Surgical treatment involves replacement of the aortic valve, sinuses and ascending aorta. A number of prosthetic options have been developed including composite valve-synthetic graft, xenograft, homograft and pulmonary autograft. The current review describes the two main indications for aortic root replacement surgery, aortic dissection and root aneurysm, and discusses the various operative strategies and outcomes.

Should the ascending aorta be replaced more frequently in patients with bicuspid aortic valve disease?

OBJECTIVE

The optimal diameter at which replacement of the ascending aorta should be performed in patients with bicuspid aortic valve disease is not known.

METHODS

We reviewed all patients with bicuspid aortic valves undergoing aortic valve replacement at our institution from 1979 through 1993 (n = 201). Patients undergoing concomitant replacement of the ascending aorta were excluded.

RESULTS

Follow-up was obtained on 98% of patients and was 10.3 +/- 3.8 (mean +/- SD) years. The average patient age was 56 +/- 15 years, and 76% were male. The ascending aorta was normal (<4.0 cm) in 115 (57%) patients, mildly dilated (4.0-4.4 cm) in 64 (32%) patients, and moderately dilated (4.5-4.9 cm) in 22 (11%) patients. All patients with bicuspid aortic valves with marked dilation (>5.0 cm) underwent replacement of the ascending aorta and were therefore excluded. Fifteen-year survival was 67%. During follow-up, 44 patients required reoperation, predominantly for aortic valve prosthesis failure. Twenty-two patients had long-term complications related to the ascending aorta: 18 required an operative procedure to replace the ascending aorta (for aortic aneurysm), 1 had aortic dissection, and 3 experienced sudden cardiac death. Fifteen-year freedom from ascending aorta-related complications was 86%, 81%, and 43% in patients with an aortic diameter of less than 4.0 cm, 4.0 to 4.4 cm, and 4.5 to 4.9 cm, respectively ( P < .001).

CONCLUSIONS

Patients undergoing operations for bicuspid aortic valve disease should be considered for concomitant replacement of the ascending aorta if the diameter is 4.5 cm or greater.

Snake venom thrombin-like enzymes: from reptilase to now

The snake venom thrombin-like enzymes (SVTLEs) comprise a number of serine proteases functionally and structurally related to thrombin. Until recently, only nine complete sequences of this subgroup of the serine protease family were known. Over the past 5 years, the primary structure of several SVTLEs has been characterized, and now this family includes several members. Of particular interest is their possible use in pathologies such as thrombosis. The aim of the present review is to summarize the state of the art concerning the evolutionary, structural and biological features of the SVTLEs.

Management of Chronic Aortic Regurgitation

Aortic regurgitation may be the most treacherous of the valvular lesions due to subtlety of symptoms and physical findings and due to difficulty in timing surgical intervention to prevent permanent cardiac dysfunction. Cardiac imaging (eg, echocardiography or magnetic resonance) is critical to quantify the degree of regurgitation and to detect significant left ventricular dysfunction or dilation. Stress testing can be useful in timing surgical intervention in borderline cases. Medical therapy consists of afterload reduction, diuresis, and inotrope administration. Surgical therapy today consists of aortic valve repair in a minority of cases or aortic valve replacement in the remainder. Percutaneous means to replace the aortic valve are in development. Cardiac decompensation may require cardiac transplantation.

Impact of valve prosthesis-patient mismatch on short-term mortality after aortic valve replacement

BACKGROUND

The prosthesis used for aortic valve replacement (AVR) can be too small in relation to body size, thus causing valve prosthesis-patient mismatch (PPM) and abnormally high transvalvular pressure gradients. This study examined if there is a relation between PPM and short-term mortality after operation.

METHODS AND RESULTS

The indexed valve effective orifice area (EOA) was estimated for each type and size of prosthesis being implanted in 1266 consecutive patients and used to define PPM as not clinically significant if >0.85 cm2/m2, as moderate if >0.65 cm2/m2 and <or=0.85 cm2/m2, and as severe if <or=0.65 cm2/m2; it was correlated with 30-day mortality and compared with other relevant variables. Moderate or severe PPM was present in 38% of patients. Thirty-day mortality was 4.6% (58/1266 patients) and the strongest independent predictors in multivariate analysis were left ventricular ejection fraction <40% (P=0.007), infectious endocarditis (P=0.002), emergent/salvage operation (P=0.002), cardiopulmonary bypass time >120 minutes (P=0.001), and PPM (P=0.003). Relative risk of mortality was increased 2.1-fold (95% confidence interval, 1.2 to 3.7) in patients with moderate PPM and 11.4-fold (4.4 to 29.5) in those with severe PPM. Moreover, risk of mortality for every category of PPM was higher in patients with a left ventricular ejection fraction <40% as compared with >or=40% (nonsignificant PPM, 2.7 versus 1.0; moderate PPM, 7.1 versus 1.8; severe PPM, 77.1 versus 11.3).

CONCLUSIONS

PPM is a strong and independent predictor of short-term mortality among patients undergoing AVR, and its impact is related both to its degree of severity and the status of left ventricular function. In contrast to other risk factors, moderate-severe PPM can be largely avoided with the use of a prospective strategy at the time of operation.

The Ross procedure in adults: intermediate-term results

BACKGROUND

The durability of the Ross procedure may be optimized by appropriate geometric matching of the aortic and pulmonary artery roots. We employed a surgical strategy to standardize the operation in order to avoid more readily a geometric mismatch.

METHODS

The Ross procedure was performed as a root replacement. Without regard for patient body surface area, the aortic annulus was plicated to 23 mm and externally buttressed with felt. Geometric mismatch of the distal autograft anastomosis was avoided by liberal use of a synthetic interposition graft, and the anastomosis was also externally buttressed with felt. An over-sized pulmonary homograft (27 to 28 mm) was routinely used to reconstruct the right ventricular outflow tract.

RESULTS

Forty-four consecutive patients (27 men and 17 women; mean age, 49 +/- 9 years) were operated on between January 1997 and March 2002. Mean follow-up was 38 +/- 5 months. Twenty-nine patients had aortic stenosis and 15 had aortic regurgitation. Aortic annular plication was done in 41 (93%) and an aortic interposition was used in 14 (32%). There were three hospital deaths, with no subsequent deaths. Only 1 patient required reoperation 2.5 years postoperatively from recurrent endocarditis. No patient has more that "trivial" autograft insufficiency, and the mean autograft gradient was 7 +/- 3 mm Hg. No patient has significant pulmonary homograft stenosis.

CONCLUSIONS

Geometric matching of the aortic and pulmonary roots may be readily accomplished using a standardized approach to the Ross procedure. In turn, this may optimize the durability of the operation.

A new equine pericardial stentless valve

OBJECTIVE

Small aortic valve replacement remains a challenging hemodynamic problem. A new bioprosthesis (3F Therapeutics, Lake Forest, Calif) was designed to further improve the hemodynamic performance currently achieved with stentless bioprostheses. This valve consists of a tubular structure assembled from 3 equal sections of equine pericardial material, with virtually no foreign material except for a thin polyester ring. Its hemodynamic performance was compared with that of a commercially available stentless prosthesis in a bovine model.

PATIENTS AND METHODS

Twelve calves (55 +/- 2.8 kg) received a 19-mm 3F valve (3F group, n = 6) or a 19-mm stentless control valve (control group, n = 6). The animals were fully equipped for hemodynamic monitoring and transvalvular gradient measurements. After implantation, dopamine was infused in increasing doses, and the hemodynamic values were recorded at each step of 100-microg/min increase. Linear regression analysis was applied for group comparison of each variable.

RESULTS

The mean transvalvular gradient at 4.5 L/min was 3.48 +/- 0.14 mm Hg (95% confidence interval) in the 3F group and 5.72 +/- 0.28 mm Hg in the control group (P <.0001) and at 6.5 L/min, 7.4 +/- 1.55 mm Hg, and 11.13 +/- 0.18 mm Hg, respectively (P <.0001). The effective orifice area at 4.5 L/min was 2.4 +/- 0.03 cm(2) in the 3F group and 1.86 +/- 0.02 cm(2) in the control group (P <.0001) and at 6.5 L/min, 2.41 +/- 0.04 cm(2), and 1.96 +/- 0.02 cm(2), respectively (P <.0001).

CONCLUSIONS

This new bioprosthesis without a stent and without a supporting wall that has its commissures fixed directly to the aorta outperforms in vivo standard stentless prostheses in the immediate postimplant period.

Results of surgery for aortic root aneurysm in patients with Marfan syndrome

OBJECTIVES

This study was undertaken to examine the long-term results of surgery for aortic root aneurysm in patients with Marfan syndrome.

METHODS

Forty-four patients underwent aortic root replacement and 61 underwent aortic valve-sparing operations for aortic root aneurysm. Patients who underwent aortic root replacement had more severe symptoms, worse left ventricular function, more severe aortic insufficiency, and larger aortic root aneurysms than did patients who had aortic valve-sparing operations. Two types of valve-sparing operations were performed: reimplantation of the aortic valve in 39 patients and remodeling of the aortic root in 22 patients. Echocardiography was performed annually during follow-up. The mean follow-ups were 75 +/- 54 months for the aortic root replacement group and 49 +/- 38 months for the aortic valve-sparing group.

RESULTS

There were 1 early death and 7 late deaths; 6 deaths were in the aortic root replacement group and 2 were in the aortic valve-sparing group. Survivals at 10 years were 87% in the aortic root replacement group and 96% in the aortic valve-sparing group (P =.3). Freedoms from reoperation at 10 years were 75% in the root replacement group and 100% in the valve-sparing group (P =.1). Freedoms from valve-related mortality and morbidity were 65% after root replacement and 100% after valve-sparing operation (P =.02). Freedom from aortic insufficiency greater than 2+ after aortic valve-sparing operations was 75% at 10 years and was similar for both types of valve-sparing operations; however, the diameters of the aortic annulus and neoaortic sinuses increased only after the remodeling procedure.

CONCLUSIONS

This study suggests that aortic valve-sparing operations provide similar survival but lower rates of valve-related complications than aortic root replacement for patients with Marfan syndrome. Reimplantation of the aortic valve may be more appropriate than remodeling of the aortic root to prevent dilation of the aortic annulus, and for this reason we now use only this technique to treat patients with Marfan syndrome.

Aortic valve-sparing operations in patients with aneurysms of the aortic root or ascending aorta

BACKGROUND

Aortic valve-sparing operations are an alternative to aortic root replacement in patients with aortic root aneurysms, or aortic valve replacement and supracoronary replacement of the ascending aorta in patients with ascending aorta aneurysms and dilated sinotubular junctions with consequent aortic insufficiency.

METHODS

From 1988 to 2001, 230 patients underwent aortic valve-sparing operations for aortic root aneurysms (151 patients) or ascending aortic aneurysms with aortic insufficiency (79 patients). Two types of aortic valve-sparing operations were performed in patients with aortic root aneurysms: reimplantation of the aortic valve and remodeling of the aortic root. Mean follow-up was 3.8 +/- 2.8 years.

RESULTS

Patients with aortic root aneurysms were younger, had less severe aortic insufficiency, less extensive vascular disease, and better left ventricular function than patients with ascending aorta aneurysms. The 8-year survival was 83% +/- 5% for the first group and 36% +/- 14% for the second. The freedom from aortic valve reoperation at 8 years was 99% +/- 1% for the first group and 97% +/- 2% for the second. In patients who had aortic root aneurysms, 3 developed severe aortic insufficiency (AI), and 15 developed moderate AI, for an 8-year freedom from significant AI of 67% +/- 7%. But freedom from AI was 90% +/- 3% after the technique of reimplantation, and 55% +/- 6% after the technique of remodeling (p = 0.02). In patients with ascending aortic aneurysms, the freedom from AI greater than 2+ at 8 years was 67% +/- 11%.

CONCLUSIONS

The long-term results of aortic valve sparing for aortic root aneurysms are excellent, and reimplantation of the aortic valve may provide a more stable repair of the aortic valve than remodeling of the aortic root.

Dilation of the sinotubular junction causes aortic insufficiency after aortic valve replacement with the Toronto SPV bioprosthesis

OBJECTIVE

This study was undertaken to examine the causes of late aortic insufficiency in patients who had aortic valve replacement with the Toronto SPV bioprosthesis (St Jude Medical, Inc, St Paul, Minn).

METHODS

From 1991 to 1996, 174 patients with a mean age of 63 +/- 11 years underwent aortic valve replacement with the Toronto SPV bioprosthesis and were evaluated annually by Doppler echocardiographic studies to assess valve function. The diameters of the aortic root were retrospectively measured in all patients who had aortic insufficiency and also in a random sample of 23 patients without aortic insufficiency. The mean follow-up was 5.8 years (range 4 to 9 years).

RESULTS

Aortic insufficiency greater than 1+ developed in 19 patients. The diameter of the sinotubular junction increased in these patients and did not change in those without aortic insufficiency. The ratio between the diameter of the sinotubular junction and the size of the Toronto SPV bioprosthesis increased in patients who had aortic insufficiency and did not change in those without aortic insufficiency. Both 2-way analysis of covariance and analysis by a mixed linear model demonstrated a significant difference in slopes between the patients with aortic insufficiency greater than 1+ and in those without insufficiency for the ratio of the diameter of the sinotubular junction/diameter of the Toronto SPV relationships over time (aortic insufficiency. Year; P <.001). Structural valve deterioration was observed in 5 valves, and in 4 of them the sinotubular junction of the aortic root had dilated. The freedom from structural valve deterioration was 99% +/- 1% for patients without aortic insufficiency and 82% +/- 12% for those with aortic insufficiency of more than 1+ at 8 years (P =.004). One patient had moderate aortic insufficiency without structural valve deterioration and dilation of the sinotubular junction.

CONCLUSIONS

Dilation of the sinotubular junction causes aortic insufficiency after aortic valve replacement with the Toronto SPV bioprosthesis and increases the risk of structural valve deterioration. Banding the sinotubular junction may prevent dilation and enhance the durability of this valve.

Aortic valve-sparing operations for aortic root aneurysm

The object of this report is to review the clinical outcomes of aortic valve-sparing operations in patients with aortic root aneurysm. From May 1988 to June 2000, 120 patients with aortic root aneurysm with or without aortic insufficiency underwent aortic valve-sparing operations. There were 83 men and 37 women whose mean age was 46 years (range 16 to 72 years). Forty-eight patients had the Marfan syndrome, and 22 had either acute or chronic type A aortic dissections. Reconstruction of the aortic root was performed using the technique of reimplanation of the aortic valve in 64 patients and the remodeling of the aortic root in 56. The mean follow-up was 35 months (range 2 to 145 months), and it was complete. Aortic valve function was assessed by echocardiography. There were 2 operative and 5 late deaths. The 10-year survival for patients with aortic root aneurysm was 88% +/- 4%. Two patients have required aortic root replacement: one on the first postoperative day because of severe aortic insufficiency and one paraplegic patient 12 years after surgery because of infective endocarditis with aortic root abscess. Both patients survived reoperation. The 10-year freedom from aortic root reoperation was 99% +/- 1%. Three patients suffered transient ischemic attacks. The 10-year freedom from thromboembolic events was 89% +/- 5%. Seven patients had moderate aortic insufficiency at the latest echocardiographic study. The 10-year freedom from severe or moderate aortic insufficiency was 83% +/- 8%. Aortic valve-sparing operations have provided excellent clinical outcomes and few valve-related complications. The function of the reconstructed aortic root remains unchanged in most patients during the first decade of follow-up.

Results of aortic valve-sparing operations

OBJECTIVE

To review the late results of valve-sparing operations in patients with aortic root aneurysm and in those with ascending aortic aneurysm and aortic insufficiency.

METHODS

From May 1988 to June 2000, 120 patients with aortic root aneurysm and 68 with ascending aortic aneurysm and aortic insufficiency underwent aortic valve-sparing operations. Patients with aortic root aneurysm were younger, were predominantly male, and had less severe aortic insufficiency than patients with ascending aortic aneurysm, who were older and often had aneurysm of the transverse arch. Forty-eight patients with aortic root aneurysm had the Marfan syndrome. The prevalence of aortic dissection was similar in both groups. Reconstruction of the aortic root was performed by reimplanation of the aortic valve in 64 patients and by remodeling of the aortic root in 56. Patients with ascending aortic aneurysm and aortic insufficiency were treated by replacement of the ascending aorta with reduction in the diameter of the sinotubular junction. Approximately two thirds of the latter patients also required replacement of the transverse aortic arch. The mean follow-up was 35 +/- 31 months for patients with aortic root aneurysm and 26 +/- 23 months for those with ascending aortic aneurysm.

RESULTS

There were 2 operative and 5 late deaths in patients with aortic root aneurysm and 1 operative and 9 late deaths in patients with ascending aortic aneurysm. The 5-year survival for patients with aortic root aneurysm was 88% +/- 4% and for patients with ascending aortic aneurysm, 68% +/- 12% (P =.01). Severe aortic insufficiency developed in 2 patients, and they required aortic valve reoperation. The 5-year freedom from aortic valve reoperation was 99% +/- 1% for patients with aortic root aneurysm and 97% +/- 4% for those with ascending aortic aneurysm. Seven patients had moderate aortic insufficiency at the latest echocardiographic study. The 5-year freedom from severe or moderate aortic insufficiency was 90% +/- 4% in patients who had aortic root aneurysm and 98% +/- 2% in those who had ascending aortic aneurysm.

CONCLUSIONS

Aortic valve-sparing operations have provided excellent clinical outcomes and few valve-related complications. The function of the reconstructed aortic root remains unchanged in most patients during the first 5 years of follow-up.

Patient-prosthesis mismatch can be predicted at the time of operation

BACKGROUND

Patient-prosthesis mismatch is a frequent cause of high postoperative gradients in normally functioning prostheses. The objective of this study was to determine whether mismatch can be predicted at the time of operation.

METHODS

Indices used to predict mismatch were valve size, indexed internal geometric area, and projected indexed effective orifice area (EOA) calculated at the time of operation, and results were compared with indexed EOA and mean gradients measured by Doppler echocardiography after operation in 396 patients.

RESULTS

The sensitivity and specificity of these indices to detect mismatch, defined as a postoperative indexed EOA of 0.85 cm2/m2 or less, were respectively: 35% and 84% for valve size, 46% and 85% for indexed internal geometric area, and 73% and 80% for projected indexed EOA. Projected indexed EOA also correlated best with resting (r = 0.67) and exercise (r = 0.77) postoperative gradients.

CONCLUSIONS

The projected indexed EOA calculated at the time of operation accurately predicts mismatch as well as resting and exercise postoperative gradients, whereas valve size and indexed internal geometric area cannot be used for this purpose.

Ruptured sinus of valsalva aneurysm: early recurrence and fate of the aortic valve

BACKGROUND

We reviewed our experience with congenital ruptured sinus of Valsalva aneurysms (RSVA) to determine patterns of early recurrence and the fate of the aortic valve (AV).

METHODS

Over a 28-year period, RSVA was identified in 34 patients, (mean age 31.6 years). Primary closure of the RSVA was performed in 10 patients, and a patch employed in 24. Aortic insufficiency was present in 24 patients. AV replacement (AVR) was performed in 5 patients; AV repair in 6.

RESULTS

Follow-up of 9.2 +/- 8.3 years (6 months to 24 years) was complete in all but 2 patients. Five early fistula recurrences (in 4 patients) correlated with primary rather than patch closure (p < 0.03). Kaplan-Meier survival at 10 years is 90 +/- 7%. Freedom from reoperative AVR at 10 years is 83 +/- 9%. Late AVR was performed in 6 patients for progressive aortic insufficiency due to bicuspid valve (n = 3), cusp disease of affected sinus (n = 2), or aortic root dilatation (n = 2).

CONCLUSIONS

Patch closure of the RSVA should be routinely employed. A bicuspid valve may be associated with the late need for AVR.

Dilation of the pulmonary autograft after the Ross procedure

OBJECTIVE

Dilation of pulmonary autograft after the Ross procedure is being recognized with increasing frequency. This study was undertaken to examine the extent of this problem and factors that may be associated with it.

METHODS

The clinical, operative, and echocardiographic data of 118 patients who underwent the Ross procedure were reviewed. The mean age of 79 men and 39 women was 34 +/- 9 years, range 17 to 57 years. Bicuspid or other congenital aortic valve disease was present in 81% of patients. The pulmonary autograft was sutured as a valve in the subcoronary position in 2 patients, as a root inside of the aortic root in 45, and was used for complete aortic root replacement in 71. Teflon felt was not used to buttress the proximal or the distal anastomosis of the pulmonary autograft. The diameters of the sinuses of Valsalva, aortic anulus, and sinotubular junction were measured early and late after the operation with echocardiography. The mean follow-up was 44 months.

RESULTS

The diameter of the sinuses of Valsalva increased from 31.4 +/- 0.4 mm to 33.7 +/- 0.5 mm (P =.01). Analysis of covariance revealed a significant change over time in this diameter, as well as a difference between operative techniques, with replacement of the aortic root being associated with a higher risk of dilation (P =. 0006). In 13 patients the diameter ranged from 40 to 51 mm. The diameter of the aortic anulus decreased in most patients and increased in 15, but there was no interaction between these changes and the operative technique. The diameter of the sinotubular junction increased in patients who had aortic root replacement and decreased in patients who had aortic root inclusion (P =.007). Moderate aortic insufficiency developed in 7 patients, and 3 required replacement of the pulmonary autograft. All patients with moderate aortic insufficiency had dilation of the aortic anulus and/or sinotubular junction.

CONCLUSIONS

Dilation of the pulmonary autograft after the Ross procedure may occur because of an intrinsic abnormality of the pulmonary root in patients with congenital aortic valve disease. The technique of aortic root replacement is associated with a higher risk of dilation of the sinuses of Valsalva and sinotubular junction than the technique of aortic root inclusion.