Valve sparing aortic root reconstruction versus composite replacement -- perioperative course and early complications

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.

Early and Midterm Outcomes of Valve-Sparing Aortic Root Replacement-Reimplantation Technique

Background  Valve-sparing aortic root replacement (VSARR) is an increasingly popular alternative to traditional aortic root replacement for aortic root aneurysm disease with a normal aortic valve. We evaluated the early and midterm outcomes of VSARR—reimplantation technique (VSARR-RT) done at a single institution over a decade.

Materials and Methods  We performed a retrospective study of all patients who underwent VSARR-RT between January 2004 and July 2014.

Results A total of 85 patients underwent VSARR-RT. Median time to latest echocardiographic follow-up was 4 years (range: 15–72 months). Total observation time was 491 patient years. Mean age was 44.6 ± 14.3 years, and 13 (15%) were women. Thirty-nine (46%) patients had a connective tissue disorder and 6 (7%) had a bicuspid aortic valve. Thirty-three (39%) patients underwent concomitant procedures, including coronary artery bypass grafting ( n  = 9, 11%), mitral valve repair ( n  = 8, 9%), and aortic hemi-arch replacement ( n  = 7, 8%). There were no operative deaths or in-house mortality and no postoperative strokes. Kaplan-Meier analysis demonstrated survival of 99% (95% confidence interval [CI]: 97–100%) at 2 years and 98% (95% CI: 97–100%) at 8 years. Freedom from reoperation was 95.8% (95% CI: 91.2–100%) at 8 years. Freedom from endocarditis was 100% at 8 years. At the last echocardiographic follow-up, 95% of patients were free of severe aortic regurgitation (AR) and 82% free of moderate AR. Of the four patients who had severe AR, three underwent reoperations and received prosthetic valves and one is being clinically monitored.

Conclusion  This study reports early and midterm outcomes after VSARR-RT at our institution, including those patients who underwent a VSARR-RT procedure combined with other procedures. Further follow-up remains necessary to determine long-term outcomes.

Eighteen years of clinical experience with a modification of the Bentall button technique for total root replacement

Background

We retrospectively reviewed our experience with the modified Bentall procedure and evaluated the short- and long-term results over a period of 18 years.

Methods

Between 1999 and 2017, 89 patients with a mean age of 57.3±13.9 years underwent the modified Bentall operation with a slight modification for the correction of aortic root disease.

Results

The operative mortality was 1.1% while the overall early mortality rate, defined as death within 30 days of initial hospitalization, was 2.2% (2/89). Logistic regression analysis revealed that increased Euroscore and aortic cross-clamp times were associated with greater likelihood for complications. The overall survival rates for the 89 patients (including deaths occurred at the initial hospitalization) were 93.0% (SE =3.0%) at 6 months, 93.0% (SE =3.0%) at 1 year, 89% (SE =5.0%) at 5 years and 73.0% (SE =5.0%) at 10, 15 and 18 years. Multiple Cox regression analysis for survival identified that increased aortic cross-clamp time, increased age, having a concomitant cardiac procedure and increased NYHA Class were associated with greater hazard. Left ventricular remodeling was assessed by means of echocardiography preoperatively and 1, 3, 6 and 12 months postoperatively.

Conclusions

According to our experience, the Bentall procedure is a safe procedure, provides optimal long-term survival and can still be regarded as the gold standard procedure for aortic root replacement.

Comparison of David V valve-sparing root replacement and bioprosthetic valve conduit for aortic root aneurysm

OBJECTIVE

Valve sparing root replacement (VSRR) is an attractive option for the management of aortic root aneurysms with a normal native aortic valve. Therefore, we reviewed our experience with a modification of the David V VSRR and compared it with stented pericardial bioprosthetic valve conduit (BVC) root replacement in an age-matched cohort of older patients.

METHODS

A total of 48 VSRRs were performed at our institution, excluding those on bicuspid aortic valves. We compared these cases with 15 aortic root replacements performed using a BVC during the same period. Subgroup analysis was performed comparing 16 VSRR cases and 15 age-matched BVC cases.

RESULTS

The greatest disparity between the VSRR and BVC groups was age (53 vs 69 years, respectively; P < .0005). The matched patients were similar in terms of baseline demographics and differed only in concomitant coronary artery bypass grafting (2 VSRR vs 7 BVC patients; P = .036). None of the VSRR and 3 of the BVC procedures were performed for associated dissection (P = .101). Postoperative aortic insufficiency grade was significantly different between the 2 groups (P = .004). The cardiopulmonary bypass, crossclamp, and circulatory arrest times were not different between the VSRR and BVC groups (174 vs 187 minutes, P = .205; 128 vs 133 minutes, P = .376; and 10 vs 13 minutes, respectively; P = .175). No differences were found between the 2 groups with respect to postoperative complications. One postoperative death occurred in the BVC group and none in the VSRR group. The postoperative length of stay and aortic valve gradients were less in the VSRR group (6 vs 8 days, P = .038; 6 vs 11.4 mm Hg, P = .001). The intensive care unit length of stay was significantly less in the VSRR group (54 vs 110 hours, P = .001).

CONCLUSIONS

VSRR is an effective alternative to the BVC for aortic root aneurysm.

Long-term survival after composite mechanical aortic root replacement: a consecutive series of 448 cases

OBJECTIVE

To determine the effect of different etiologies on the outcome and mortality after mechanical composite aortic root/ascending replacement.

METHODS

From February 1998 to June 2011, 448 consecutive patients (358 men, age, 52.8 ± 12.3 years) underwent composite mechanical aortic root replacement. Of these 448 patients, 362 (80.8%) were treated for degenerative/atherosclerotic root/ascending aortic aneurysm (287 men, age, 53.0 ± 12.1 years), 65 (14.5%) for emergent acute type A aortic dissection (49 men, age, 51.0 ± 13.1 years), and 21 (4.7%) for active infective endocarditis (20 men, age, 46.5 ± 13.6 years); 15% (n = 68) were reoperative or redo procedures.

RESULTS

The overall hospital mortality after composite root/ascending replacement was 6.7% (n = 30). It was 3.9% (n = 14) after elective/urgent aneurysm replacement, 20.0% (n = 13) after emergency repair for acute type A aortic dissection, and 14.3% for active infective endocarditis (n = 3). The overall 1-year mortality--as a measure of operative success--was 5.2% (n = 19) after elective/urgent degenerative/atherosclerotic root/ascending aortic aneurysm repair, 21.5% (n = 14) after emergency repair for acute type A aortic dissection, and 14.3% (n = 3) after active infective endocarditis (degenerative/atherosclerotic root/ascending aortic aneurysm vs acute type A aortic dissection, P = .03; degenerative/atherosclerotic root/ascending aortic aneurysm vs active infective endocarditis, P = .08; acute type A aortic dissection vs active infective endocarditis, P = .8). Long-term survival was 88.3% at 5 years and 72.2% at 10 years, with a linearized mortality rate after 30 days of 2.5%/patient-year. Long-term survival after surgery for acute type A aortic dissection and active infective endocarditis was 72% and 72.3% at 5 years and 64.9% and 62% at 10 years, respectively, with a linearized mortality rate of 2.6%/patient-year for acute type A aortic dissection and 3.7% for active infective endocarditis. Survival after composite root replacement after the first year paralleled that of an age- and gender-matched population, regardless of the etiology. Women appeared to have less favorable longevity.

CONCLUSIONS

Composite root replacement remains a versatile choice for various pathologic features with excellent longevity and freedom from reoperation and should be strongly considered if conditions for valve-sparing repair are less than perfect.

Quality of life after aortic root surgery: reimplantation technique versus composite replacement

BACKGROUND

Recent studies indicate the safety of the aortic valve reimplantation technique (David operation) in the long-term follow-up. The aim of this study was to compare the results of the David operation with those of the aortic composite replacement procedure, with the focus on quality of life (QoL).

METHODS

Within a 6-year period, 143 patients received either an aortic composite replacement (composite group, n = 67) or the David-I operation (David group, n = 76). The QoL of 108 patients (87% of the living patients) was evaluated postoperatively by the 36-Item Short Form Health Survey. A subgroup analysis of QoL excluded patients with aortic stenosis and type A acute aortic dissection.

RESULTS

Hospital survival rates (89.6% versus 97.4%, p = 0.102), as well as actuarial 1-year survival rate (86.6% versus 91.9%) and 3-year survival rate (81.1% versus 91.9%) proved more successful among the David group. Incidences of serious adverse events during the follow-up period (10.8% versus 28.3%, p = 0.008) were higher for patients of the composite group. The QoL was found to be compromised for patients of the composite group, in relation to all criteria outlined in the 36-Item Short Form Health Survey. Subgroup analysis without patients with dissection and aortic stenosis demonstrated a significantly better postoperative QoL for patients of the David group. Patients belonging to the composite group were more frequently compromised by prosthetic valve noise (p < 0.001).

CONCLUSIONS

This study demonstrates the superiority of the aortic valve reimplantation compared with the aortic composite replacement, regarding both clinical outcome and postoperative QoL.

Aortic valve re-implantation technique with Gelweave Valsalva prosthesis: safety, reproducibility and pitfalls of a geometric reconstruction

BACKGROUND

To evaluate the safety, reproducibility and pitfalls of an aortic valve re-implantation (AVRei) technique.

METHODS

From June 2005 to December 2008, 30 patients underwent aortic valve-sparing re-implantation with Gelweave Valsalva prosthesis. Mean age was 66 +/- 7 years (range 47-81). Mean aortic root diameter was 49 +/- 6 mm (range 37-70) and 12 patients had an aortic insufficiency more than 2+. All the patients were elective, except three who underwent surgery for type A aortic dissection. Two patients had Marfan syndrome and one had a bicuspid aortic valve. Isolated aortic root replacement was performed in 26 patients, whereas hemiarch extension was required in four. All the survivors underwent serial echocardiographic assessment for functional results and multi-detector computed tomography (MDCT) for aortic root morphology evaluation.

RESULTS

There was one early death and one re-exploration for bleeding. Two patients suffered from a perioperative stroke and four required a pacemaker implantation because of a complete atrio-ventricular block. Mean follow-up was 12 +/- 10 months (range 1-42) with no late deaths, whereas freedom from reoperation was 100% and freedom from aortic insufficiency 2+ or more was 96.5%. MDCT aortic root reconstruction showed a pseudo-normalization of the neo-sinuses of Valsalva mimicking the human normal aortic root morphology.

CONCLUSION

AVRei with Valsalva conduit is a well-tolerated procedure both in elective and emergency situations. In well-selected patients, good functional and clinical results can be achieved, regardless of the cause of the aortic root disease. Application of simple surgical manoeuvres allows durable clinical efficacy to be obtained without the risk of major complications.

Embolic and bleeding events after modified Bentall procedure in selected patients

AIM

As valve-sparing procedures gain increasing popularity, the long-term results of the total aortic root replacement (TARR) were evaluated using mechanical valve grafts in selected patients.

METHODS AND RESULTS

From January 1993 to December 2003, 100 patients (87 men), aged >65 years (mean 51 (SD 10.4 years), presenting with isolated aortic root dilatation with or without aortic valve insufficiency, undergoing elective root replacement using a mechanical valve graft were reviewed. The aetiology of aortic root disease was degenerative in 69 patients and related to the bicuspid aortic valve in 31 patients. In 11 patients, concomitant coronary artery bypass graft was performed. Hospital mortality was 4%. Overall survival was 93.9% (2.4%), 89.1% (3.5%) and 83.2% (5.2%) at 1, 5 and 7 years, respectively. 14 patients experienced 45 embolic events (3.21 (2.64) events/patient; range: 1-10 events). Thus, the linearised rate of embolic events was 10.3 per 100 patient-years (95% confidence interval (CI) 7.29 to 13.31). The actuarial embolism-free survival was 96.6% (1.9%), 77.1% (6%) and 74.3% (6.4%) at 1, 5 and 7 years, respectively. The linearised rate of bleeding events was 2.2 per 100 patient-years (95% CI 0.87 to 3.71). Actuarial bleeding free survival was 95.6% (2.1%), 93.2% (2.6%) and 87.7% (5.8%) at 1, 5 and 7 years. respectively. None of the patients required reoperation and no cases of structural or non-structural valve dysfunction were observed.

CONCLUSIONS

TARR using mechanical valve grafts yields excellent survival results in selected patients. However, a high rate of minor thromboembolic events was recorded. Aspirin in combination with oral anticoagulants might be of potential interest in these patients.

Aortic root surgery in Marfan syndrome: comparison of aortic valve-sparing reimplantation versus composite grafting

OBJECTIVE

The objective of this study was to compare the results of aortic valve-sparing reimplantation and aortic root replacement with mechanical valve conduits in patients with Marfan syndrome undergoing operation for aortic root aneurysms. Patients and methods Between March 1979 and April 2002, 119 patients with clinical evidence of Marfan syndrome underwent composite graft replacement with mechanical valve conduits (n = 74) or aortic valve-sparing reimplantation according to David (n = 45). The underlying causes were aortic dissection type A (43 patients) and aneurysms (76 patients).

RESULTS

Patients undergoing aortic valve reimplantation were younger compared with patients undergoing composite grafting (28 vs 35 years, P =.002) and had longer intraoperative aortic crossclamp times (125 vs 78 minutes, P <.0001) and extracorporeal circulation times (162 vs 124 minutes, P <.0001). Early postoperative mortality was 6.8% (n = 5) in patients undergoing composite grafting and 0% in patients undergoing aortic valve reimplantation (P =.15). Mean follow-up was 30 months for patients undergoing aortic valve reimplantation and 114 months for patients undergoing composite grafting. Freedom from reoperation and death after 5 years postoperatively was 92% and 89% in patients undergoing composite grafting and 84% and 96% in patients undergoing aortic valve reimplantation (P =.31; P =.54), respectively. Thromboembolic complications or late postoperative bleeding occurred in 17 patients undergoing composite grafting, and an early postoperative event occurred in 1 patient undergoing aortic valve reimplantation.

CONCLUSIONS

The results of aortic valve reimplantation and composite grafting of the aortic valve and ascending aorta with mechanical valve conduits are similar with regard to early and mid-term postoperative mortality and to the incidence of late reoperations in patients with Marfan syndrome. The low risk of thromboembolic or bleeding complications favors aortic valve reimplantation in these patients.

Recurrent aortic dissection in Marfan's syndrome: possible effects of anticoagulation

Recent reports support the role of a valve-sparing procedure in ascending aortic dissection in patients with Marfans syndrome. A 49-year-old woman with Marfans syndrome and prior aortic aneurysm repaired with a composite graft presented with sudden-onset chest pain. Following an initial negative computed tomographic (CT) scan, a long dissection involving the descending thoracic and abdominal aorta was discovered on a repeat CT scan a few hours later. Symptoms improved gradually with optimal medical management and the patient was discharged home on anticoagulant therapy. Although no direct cause-and-effect relationship can be established, chronic anticoagulant therapy may accelerate the progression of recurrent dissection in these patients. A valve-sparing procedure should be considered in eligible patients with Marfans syndrome who need operative correction to avoid possible future untoward effects of long-term anticoagulant therapy.

Results of valve-sparing aortic root reconstruction in 158 consecutive patients

BACKGROUND

This study assesses the durability and clinical outcome of valve-sparing aortic root reconstruction using the reimplantation technique in a single center cohort.

METHODS

From July 1993 to July 2001, 158 patients underwent replacement of the ascending aorta with native valve reimplantation. Mean age of patients was 52 +/- 17 years (9 to 84 years), 103 were men (65%). Thirty-four patients (22%) suffered from Marfan's syndrome. Aortic dissection Stanford type A was present in 29 patients (19%) (22 acute, 7 chronic), and concomitant partial or total arch replacement was necessary in 57 patients (36%). One or more additional procedures were performed in 28 patients (18%). Mean follow-up was 36 +/- 25 months (0.4 to 96 months).

RESULTS

Thirty-day mortality was 3.8% (6 patients), but only 2.2% in elective patients. Mean bypass time was 169 +/- 50 minutes (99 to 440 minutes), aortic cross-clamp time was 129 +/- 31 minutes (79 to 205 minutes). In patients undergoing arch replacement, circulatory arrest was 26 +/- 18 minutes (7 to 99 minutes). During follow-up, there were 5 (3.3%) cardiac-related late deaths. Grade of aortic insufficiency (AI) decreased from 2.3 +/- 1.1 (0 to 4) preoperatively to 0.23 +/- 0.44 (0 to 2) postoperatively (p < 0.0001). Six patients required aortic valve replacement, 4 of those due to progressive AI. Average grade of AI increased significantly to 0.42 +/- 0.61 (0 to 3) at latest evaluation (p = 0.002). Two patients experienced a transient ischemic attack within the first postoperative week. No further thromboembolic complications were noticed. All patients presented with a favorable exercise tolerance.

CONCLUSIONS

The aortic valve reimplantation technique achieves excellent clinical outcome with few complications even in complex pathologies. Lack of anticoagulation and favorable durability encourage wider and earlier use of this technique.

Valve-sparing aortic root reconstruction in patients with significant aortic insufficiency

BACKGROUND

To assess the feasibility and outcome of the valve-sparing aortic root reimplantation technique in patients with severe preoperative aortic insufficiency (AI).

METHODS

Within 8 years we have operated on 158 patients with aneurysms of the ascending aorta using the reimplantation technique. We identified 83 patients with AI grade 3 or 4 (mean 3.1 +/- 0.4) preoperatively (study group). This cohort was compared with 71 patients with AI grade 2 or less (mean 1.3 +/- 0.9; control group) with regard to mortality, operative variables, complications, need for reoperation, postoperative AI, and clinical presentation during follow-up.

RESULTS

Patient demographics were comparable in both groups. However, Marfan's syndrome (32% versus 13%, p = 0.006) and acute type A aortic dissection (20% versus 8.4%, p = 0.059) were more frequent in the control group. In addition, bypass (177 +/- 60 minutes versus 160 +/- 36 minutes, p = 0.022) and cross clamp times (133 +/- 34 minutes versus 124 +/- 27 minutes, p = 0.049) were significantly longer in controls. Mortality was low in the study group and comparable with controls (30-day, 3.6% versus 4.2%; during follow-up, 3.8% versus 5.9%; p = not significant [NS]). Reoperation rate was almost identical in both groups (3.8% versus 4.4%, p = NS). Mean grade of AI was significantly higher in the study group early postoperatively (0.31 +/- 0.46 versus 0.18 +/- 0.42, p = 0.049) but comparable at the last visit (0.43 +/- 0.58 versus 0.42 +/- 0.62, p = NS). During follow-up neither thromboembolic complications nor bleeding events were noted in either group. Clinical performance at the last visit revealed no significant difference between the groups.

CONCLUSIONS

Preoperative severe aortic insufficiency does not impair the excellent outcome seen after a mean of 3 years of follow-up in patients undergoing the reimplantation technique for valve-sparing aortic root reconstruction.

Acute dissection of the ascending aorta: first results of emergency valve sparing aortic root reconstruction

OBJECTIVE

Acute dissection of the ascending aorta requires immediate surgical intervention. In this study, we report our first results with valve sparing aortic root reconstruction removing all the diseased tissues.

METHODS

From August 1995 to December 2000, 22 patients with acute aortic dissection of the ascending aorta (Stanford type A) underwent valve sparing aortic root reconstruction. Their ages ranged from 20 to 76 years (52+/-15, 68% males). Dissection was found in the ascending aorta (3 patients) or both in the ascending aorta and aortic arch (19 patients; 86%). Course and length of hospitalization, echocardiographic and clinical follow-up, complications and mortality were analysed.

RESULTS

Mean cardiopulmonary bypass time was 212+/-56 min (134-352 min), mean aortic cross clamp time was 157+/-24 min (114-205 min). In patients undergoing additional arch replacement (n=19), circulatory arrest was 35+/-18 min (11-75 min). After reconstruction, intraoperative echocardiography showed aortic insufficiency (AI) grade 0 in 16 patients (84%) and grade 1 in three patients (16%). Stay in intensive care unit was 2.1+/-0.7 days, and postoperative hospitalization was 21+/-14.4 days. There were three perioperative deaths (14%). Mean post-operative follow-up was 18.4+/-18 months (0.4-65.4 month). One patient died 10 months postoperatively. At follow-up, no patient suffered AI grade 2 or higher, and no reoperation for aortic valve failure was necessary. All patients presented with a favorable exercise tolerance being in New York Heart Association functional class I or II.

CONCLUSION

Valve sparing aortic root reconstruction in patients with type A dissection can be performed with acceptable intraoperative mortality and morbidity and excellent results during follow-up. The complete resection of the diseased aorta is particularly appealing.

[Replacement of the ascending aorta with aortic valve reimplantation - indication, technique, and results]

The main cause of aortic valve insufficiency is a dilatation of the sinotubular junction in patients with an ascending aortic aneurysm. Morphologically preserved aortic valve cusps represent an ideal condition for preservation and reconstruction of the aortic valve with an simultaneous replacement of the ascending aorta with a Dacron graft. This report presents the results of 140 patients, who underwent such surgery since 1993 in our institution. Indications for surgery, operative technique and different outcome parameters are discussed. Intra- and perioperative morbidity and mortality are low and quality of life excellent. Reoperation due to progressive aortic valve insufficiency was necessary in 2.1% of patients during follow-up. When compared with the standard operation (composite replacement utilizing a mechanical valve), patients with aortic valve reconstruction demonstrate similar results with regard to hospital stay and functional improvement. However, bleeding complications and thromboembolic events are significantly reduced in patients undergoing valve reconstruction. Due to these long-term results combined with excellent stress hemodynamics and improvement in LV function, aortic valve reconstruction currently represents our standard operative strategy in this patient group.