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Rosinski BF, Hodges K, Vargo PR, Roselli EE, Koprivanac M, Tong M, Rajeswaran J, Blackstone EH, Svensson LG. Outcomes of aortic root replacement with tricuspid aortic valve reimplantation in patients with residual aortic regurgitation. J Thorac Cardiovasc Surg 2024; 167:101-111.e4. [PMID: 37532029 DOI: 10.1016/j.jtcvs.2023.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/22/2023] [Accepted: 07/25/2023] [Indexed: 08/04/2023]
Abstract
OBJECTIVE To characterize residual aortic regurgitation (AR), identify its risk factors, and evaluate outcomes following aortic root replacement with aortic valve reimplantation. METHODS From 2002 to 2020, 756 patients with a tricuspid aortic valve underwent elective reimplantation for aortic root aneurysm. AR on transthoracic echocardiograms before hospital discharge was graded as mild or greater. Machine learning was used to identify risk factors for residual AR and subsequent aortic valve reoperation. RESULTS Sixty-five patients (8.6%) had mild (58 [7.7%]) or moderate (7 [0.93%]) residual postoperative AR. They had more severe preoperative AR (38% vs 12%; P < .0001), thickened cusps (7.7% vs 2.2%; P = .008), aortic valve repair (38% vs 23%; P = .004), and multiple returns to cardiopulmonary bypass for additional repair (11% vs 3.3%; P = .003) than those without AR. Predictors of residual AR were severe preoperative AR, smaller aortic root graft, and concomitant cusp repair. At 10 years, patients with versus without residual AR had more moderate or severe AR (48% vs 7.0%; P < .0001) and freedom from reoperation was worse (89% vs 98%; P < .0001). Residual AR was a risk factor for early reoperation. Concomitant coronary bypass, lower body mass index, and lower ejection fraction were risk factors for late reoperation. Ten-year survival was similar among patients with and without residual AR (97% vs 93%; P = .43). CONCLUSIONS Residual AR after elective reimplantation of a tricuspid aortic valve for aortic root aneurysm is uncommon. Patients with severe preoperative AR and those who undergo valve repair have higher risk for residual AR, which can progress and increase risk of aortic valve reoperation.
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Affiliation(s)
- Brad F Rosinski
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kevin Hodges
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Patrick R Vargo
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Michael Tong
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- The Aorta Center, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio.
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Abstract
The clinical outcome of severe aortic regurgitation (AR) remains suboptimal, but surgery has been shown to have survival benefit over medical therapy. Postoperative survival is inferior in patients with reduced left ventricular function, and therefore early surgical intervention is recommended. Aortic valvuloplasty (AVP) is an attractive option to avoid the major drawbacks of prosthetic valves but has not been widely adopted. The etiology of AR is classified functionally into three groups: normal leaflet motion (type I), cusp prolapse (type II), and restriction (type III). Type I with dilatation of the sinus of Valsalva (type Ib) can be repaired by aortic valve reimplantation or aortic root remodeling with similar valve stability. Type I with dilatation of the aortic annulus (type Ic) can be managed by annuloplasty. Type II can be corrected by plication or resuspension techniques. Pericardial patch is necessary in AVP for type Id (perforation/fenestration) and type III but is associated with risk of recurrence. Bicuspid aortic valve is classified according to commissure angle: symmetrical, asymmetrical, and very asymmetrical. Tricuspidization is recommended for repair of very asymmetrical valves to avoid postoperative stenosis. Recent progress has achieved similar reoperation rates between bicuspid and tricuspid aortic valve repair. For Marfan syndrome, valve-sparing root replacement is advantageous compared to Bentall operation regarding late survival, thromboembolic and hemorrhagic events, and endocarditis. Similar findings have been reported in acute aortic dissection. Both remodeling and reimplantation procedures provide similar favorable outcomes in these settings. Recent advances in AVP are summarized by quantitative assessment of cusp configuration (effective height and geometric height), graft size decision, use of template to cut the graft, and videoscopic assessment of post-repair cusp configuration. Due to these advances, AVP shows superior results to replacement surgery. Further concrete evidence with larger case volumes and longer observation periods are necessary to popularize AVP.
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Rashid HN, Chehab O, Hurrell H, Androshchuk V, Sularz A, Patterson T, Lucchese G, Redwood S. Conventional aortic root vs valve-sparing root replacement surgery in aortic dilatation syndromes: a comparison of mortality and postoperative complications. Expert Rev Cardiovasc Ther 2023; 21:57-65. [PMID: 36543329 DOI: 10.1080/14779072.2023.2162039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Conventional aortic root and valve-sparing root replacement surgery are two current surgical treatments for aortic dilatation syndromes. This review article aims to review the current literature surrounding these two established techniques. AREAS COVERED This review article will address the current indications for valve-sparing root replacement surgery, technical considerations in surgical planning and a comparison of clinical outcomes between these two surgical techniques. EXPERT OPINION Valve-sparing root replacement surgery is a safe and established treatment for aortic syndromes. Valve-sparing surgery procedure avoids the inherent risk of prosthetic valve dysfunction and prosthesis infection by preserving the native aortic valve compared to conventional aortic root surgery. This has been demonstrated in various observational studies and should be considered in clinically and anatomically appropriate patients. Other technical considerations, such as reimplantation versus remodeling technique and aortic cusp repair in select patients, may impact in short-term procedural and long-term clinical success with valve-sparing surgery.
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Affiliation(s)
- Hashrul N Rashid
- Department of Cardiology and Cardiac Surgery, Guy's & St. Thomas' Hospital, London, UK
- School of Cardiovascular Medicine & Sciences, King's College London, London, UK
| | - Omar Chehab
- Department of Cardiology and Cardiac Surgery, Guy's & St. Thomas' Hospital, London, UK
- School of Cardiovascular Medicine & Sciences, King's College London, London, UK
| | - Harriet Hurrell
- Department of Cardiology and Cardiac Surgery, Guy's & St. Thomas' Hospital, London, UK
- School of Cardiovascular Medicine & Sciences, King's College London, London, UK
| | - Vitaliy Androshchuk
- Department of Cardiology and Cardiac Surgery, Guy's & St. Thomas' Hospital, London, UK
- School of Cardiovascular Medicine & Sciences, King's College London, London, UK
| | - Agata Sularz
- Department of Cardiology and Cardiac Surgery, Guy's & St. Thomas' Hospital, London, UK
| | - Tiffany Patterson
- Department of Cardiology and Cardiac Surgery, Guy's & St. Thomas' Hospital, London, UK
- School of Cardiovascular Medicine & Sciences, King's College London, London, UK
| | - Gianluca Lucchese
- Department of Cardiology and Cardiac Surgery, Guy's & St. Thomas' Hospital, London, UK
| | - Simon Redwood
- Department of Cardiology and Cardiac Surgery, Guy's & St. Thomas' Hospital, London, UK
- School of Cardiovascular Medicine & Sciences, King's College London, London, UK
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Mazine A, Chu MWA, El-Hamamsy I, Peterson MD. Valve-sparing aortic root replacement: a primer for cardiologists. Curr Opin Cardiol 2022; 37:156-164. [PMID: 35058413 DOI: 10.1097/hco.0000000000000951] [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] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this article is to review the contemporary evidence supporting valve-sparing aortic root replacement as the best option for patients with aortic root aneurysms and preservable aortic valves as well as to review the technical variations and modern adjuncts of these operations that impact both short and long-term durability. RECENT FINDINGS In patients with an aortic root aneurysm, with or without aortic valve regurgitation, valve-sparing aortic root replacement provide excellent clinical outcomes and stable valve function over several decades. Successful execution of this operation depends on careful patient selection and a thorough understanding of the anatomical and physiological relationships between the various components of the aortic root. Echocardiography remains the mainstay of imaging to determine the feasibility of valve-sparing root replacement. SUMMARY Valve-sparing aortic root replacement is an excellent alternative to composite valve graft replacement in nonelderly patients with aortic root aneurysms. Dedicated aortic root surgeons perform several technical variations of valve-sparing procedures aimed at matching the specific aortic root disorder with the optimal operation.
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Affiliation(s)
- Amine Mazine
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto
| | - Michael W A Chu
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mark D Peterson
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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