Functional classification of aortic root/valve abnormalities and their correlation with etiologies and surgical procedures

Aortic Regurgitation: From Valvular to Myocardial Dysfunction

Chronic aortic regurgitation (AR) leads to volume overload in the left ventricle (LV), which is well tolerated for years. In this condition, the LV usually dilates with minimal reduction in the ejection fraction (EF), even in the absence of symptoms. Echocardiography is the primary imaging test used to quantify AR. However, no single assessment of Doppler measures is accurate and precise in individual patients; therefore, the integration of multiple parameters is necessary. Recent guidelines recommend surgical treatment for severe AR in patients who are symptomatic or have an LVEF < 55% and an end-systolic diameter > 50 mm. Nevertheless, advances in imaging technology have improved the quantification of AR and the assessment of LV subclinical dysfunction. It is widely recognized that patients who undergo aortic valve replacement/repair (AVR) due to symptoms or a low LVEF experience worse outcomes than those undergoing AVR for non-Class I indications. In fact, subclinical irreversible myocardial damage may occur in clinically well-compensated and closely monitored patients while awaiting formal surgical indications. This condition could be prevented by the use of multimodal imaging parameters, in particular longitudinal LV strain and magnetic resonance imaging. In addition, better cut-off values for mortality predictors should be established. This review aims to identify simple models that integrate several echocardiographic and cardiac magnetic resonance-derived parameters to predict the optimal timing of surgical treatment in asymptomatic patients with chronic severe AR.

Association Between Aortic Valve Calcification and Severity of Concomitant Aortic Regurgitation in Patients With Severe Aortic Stenosis

BACKGROUND

Patients with severe aortic stenosis (AS) frequently have concomitant aortic regurgitation (AR), but the association between aortic valvular calcification (AVC) and the severity of AR remains unclear.Methods and Results: We retrospectively reviewed patients with severe AS who underwent transthoracic echocardiography and multidetector computed tomography (MDCT) within 1 month. The patients were divided into 3 groups according to the degree of concomitant AR. The association between AVC and the severity of concomitant AR was assessed in patients with severe AS. The study population consisted of 95 patients: 43 men and 52 women with a mean age of 82±7 years. Of the 95 patients with severe AS, 27 had no or trivial AR, 53 had mild AR, and 15 had moderate AR. The AVC score (AVCS) and AVC volume (AVCV) significantly increased as the severity of concomitant AR increased (P=0.014 for both), and similar findings were obtained for the AVCS and AVCV indexes (P=0.004 for both).

CONCLUSIONS

The severity of AR correlated with AVCS and AVCV measured by MDCT in patients with severe AS. AVC may cause concomitant AR, leading to worsening of disease condition.

Valve-Sparing Aortic Root Replacement State-of-the-Art Review, Part I: Anatomy and Physiology

Aortic valve disease is common, and valve-preserving operations are preferred whenever possible. Valve-sparing aortic root replacement has become an important tool for managing aortic root pathology in children and adults. The learning curve for this operation is challenging, but with increasing experience and technical modifications, early and late outcomes continue to improve. Durable long-term results vary based on the underlying anatomy, pathology, and patient selection, as well as surgeon expertise. The first installment of this Valve-Sparing Aortic Root Replacement State-of-the-Art Review article addresses patient anatomy and physiology as it relates to candidacy for VSRR.

Systematic adjustment of root dimensions to cusp size in aortic valve repair: a computer simulation

OBJECTIVES

Aortic valve repair requires the creation of a normal geometry of cusps and aortic root. Of the different dimensions, geometric cusp height is the most difficult to change while annular and sinotubular dimensions can be easily modified. The objective of this study was to investigate, by computer simulation, ideal combinations of annular and sinotubular junction size for a given geometric height.

METHODS

Based on a literature review of anatomical data, a computational biomechanics model was generated for a tricuspid aortic valve. We aimed to determine the ideal relationships for the root dimensions, keeping geometric height constant and creating different combinations of the annular and sinotubular junction dimensions. Using this model, 125 virtual anatomies were created, with 25 different combinations of annulus and sinotubular junction. Effective height, coaptation height and mechanical cusp stress were calculated with the valves in closed configuration.

RESULTS

Generally, within the analysed range of geometric heights, changes to the annular diameter yielded a stronger impact than sinotubular junction diameter changes for optimal valve configuration. The best results were obtained with the sinotubular junction being 2-4 mm larger than the annulus, leading to higher effective height, normal coaptation height and lower stress. Within the range tested, stenosis did not occur due to annular reduction.

CONCLUSIONS

In tricuspid aortic valves, the geometric height can be used to predict ideal post-repair annular and sinotubular junction dimensions for optimal valve configuration. Such an ideal configuration is associated with reduced cusp stress.

Predictors of long-term stenosis in bicuspid aortic valve repair

OBJECTIVES

The use of modern techniques for bicuspid aortic valve repair has been shown to provide safe and durable results against recurrent regurgitation. However, an emerging body of evidence is indicating that aortic stenosis might be an additional late complication of these procedures. To date, the pathogenesis and clinical impact of aortic stenosis after bicuspid aortic valve repair are poorly understood.

METHODS

A retrospective analysis of 367 patients with bicuspid aortic valve repair was performed to identify predictors of reoperation for stenosis. Bicuspid aortic valve repair was performed using a combination of procedures on the leaflet, annulus, and aortic root.

RESULTS

During a median follow-up of 8 years, reoperation for stenosis was required in 33 patients (9.0%). Freedom from reoperation for stenosis was 100%, 99.6%, 91.7%, and 74.9% at 1, 5, 10, and 15 years, respectively. The following factors were independently associated with reoperation for aortic stenosis: Leaflet or raphe resection with shaving was a protective factor (hazard ratio, 0.34; 95% confidence interval, 0.16-0.71; P = .004), whereas the use of expanded polytetrafluoroethylene for free-edge running suture (hazard ratio, 2.55; 95% confidence interval, 1.16-5.57; P = .019), supracoronary replacement of the ascending aorta in combination with valve repair (hazard ratio, 5.41; 95% confidence interval, 2.11-13.85; P = .001), and the need for a second aortic crossclamp (hazard ratio, 10.95; 95% confidence interval, 2.80-42.80; P = .001) were associated with increased risk of reoperation for aortic stenosis.

CONCLUSIONS

While confirming previous findings, our analysis suggests that the inability to restore leaflet mobility and polytetrafluoroethylene for free-edge running suture are risk factors for stenosis. The so-called ascending phenotypes are probably more prone to stenosis. If the first attempt to repair is unsuccessful, the risk of late reoperation for aortic stenosis is high.

The mid-term outcomes of aortic-root repair is not inferior to Bentall procedure in acute type-A aortic dissection

OBJECTIVE

Bentall procedure used to be standard operation for involved aortic root in acute type A aortic dissection (ATAAD). But aortic root repair for preserving valve is still controversial in ATAAD. This study aimed to evaluate the midterm outcomes of aortic root repair by comparing with Bentall approach.

METHODS

A retrospective analysis of 1075 ATAAD patients with aortic root involvement was conducted. The patients were divided into aortic root repair group (n = 447) and Bentall group (n = 628). The propensity score matching analysis (PSMA) was used to adjust the baseline.

RESULTS

The median follow-up was 44 months (interquartile range, 17-65 months; range, 1-130 months). The 30-day mortality in the repair and replacement groups was 15.0 % and 12.9 % (P = 0.327) respectively; the late overall mortality was 15.9 % and 14.0 % (P = 0.394) respectively. The Kaplan-Meier 10-year survival and free-from-reoperation was 86.0 % and 92.5 % respectively in the repair group. After PSMA, the cumulative survival rate [Hazard Ratio (HR) 0.685; 95 % Confidence Interval (CI) 0.457-1.027; P = 0.747]) and reoperation rate (HR 0.308; 95 % CI 0.070-1.355; P = 0.157) was not significantly higher in the repair group than in the Bentall group.

CONCLUSION

The mid-term outcome of aortic root repair is probably not inferior to Bentall procedure. Therefore, root repair is an alternative approach in ATAAD with the advantage of preserving native valve.

Echocardiographic assessment of aortic regurgitation: a narrative review

Aortic regurgitation (AR) is the third most frequently encountered valve lesion and may be caused by abnormalities of the valve cusps or the aorta. Echocardiography is instrumental in the assessment of AR as it enables the delineation of valvular morphology, the mechanism of the lesion and the grading of severity. Severe AR has a major impact on the myocardium and carries a significant risk of morbidity and mortality if left untreated. Established and novel echocardiographic methods, such as global longitudinal strain and three-dimensional echocardiography, allow an estimation of this risk and provide invaluable information for patient management and prognosis. This narrative review summarises the epidemiology of AR, reviews current practices and recommendations with regards to the echocardiographic assessment of AR and outlines novel echocardiographic tools that may prove beneficial in patient assessment and management.

Intraoperative Transesophageal Echocardiographic Assessment of Aortic Valve Repair in a Child - What to Look for?

ABSTRACT

Aortic valve (AV) repair is the desired surgical treatment option for young patients with aortic regurgitation (AR). It is considered as a class I indication for the surgical treatment of severeAR. The success of an AV repair depends on the detailed intraoperative transesophageal echocardiographic (TEE) examination which should fulfil the information required by the surgeon. The objective of this echo round is to describe the role of intraoperative TEE in systematic evaluation of the AV, before and after repair.

Multicentre experience with valve-sparing aortic root replacement by means of combined remodelling and external aortic ring annuloplasty in patients with Marfan syndrome

OBJECTIVES

The most recent valve-sparing root replacement technique combines the advantages of the reimplantation (David) and remodelling (Yacoub) techniques. The aortic root is reconstructed according to the remodelling technique, the aortic valve is repaired according to the principle of effective height, and an external ring provides annular support. The purpose of this study was to evaluate operative and mid-term outcomes using this technique in patients with Marfan syndrome.

METHODS

Adult patients with Marfan syndrome who had an indication for aortic root surgery according to European Society of Cardiology guidelines and were operated on using this new root replacement technique were retrospectively evaluated. Follow-up was obtained from standard outpatient visits and included echocardiography.

RESULTS

The study group comprised 22 patients (mean age 36 years, 68% males). Mean follow-up was 7.5 years. There were no mortalities. Two patients required aortic valve replacement because of aortic regurgitation. In both patients, the aortic root was severely dilated (≥65 mm) preoperatively, with grade III aortic valve regurgitation and aortic valve cusps that were very fragile. Aortic regurgitation was grade ≤I on follow-up in 18 of the remaining 20 patients.

CONCLUSIONS

Valve-sparing root replacement using remodelling combined with aortic-ring annuloplasty is safe in patients with Marfan syndrome. The mid-term outcome is promising in patients undergoing elective valve-sparing root replacement at recommended root diameters. However, in patients with extremely dilated aortic roots and already severe aortic regurgitation, the technique should be used cautiously as aortic cusps are fragile and might not be suitable for durable repair.

CLINICAL REGISTRATION NUMBER

UMCG Research registry #11208.

Surgical outcomes of aortic valve repair for specific aortic valve cusp characteristics; retraction, calcification, and fenestration

OBJECTIVES

We investigated the predictive value of aortic valve cusp retraction, calcification, and fenestration for aortic valvuloplasty feasibility.

METHODS

Multicenter data were collected for 2082 patients who underwent surgical aortic valvuloplasty or aortic valve replacement. The study population had retraction, calcification, or fenestration in at least one aortic valve cusp. Controls had normal or prolapsed cusps.

RESULTS

All cusp characteristics demonstrated significantly increased odds ratios [ORs] for switch to valve replacement. This effect was strongest for cusp retraction, followed by calcification and fenestration (OR, 25.14; P ≤ .001; OR, 13.50, P ≤ .001; OR, 12.32, P ≤ .001). Calcification and retraction displayed increased odds for developing grade 4 aortic regurgitation compared with grade 0 or 1 combined on average over time (OR, 6.67; P ≤ .001; OR, 4.13; P = .038). Patients with cusp retraction showed increased risk for reintervention at 1- and 2-year follow-up after aortic valvuloplasty (hazard ratio, 5.66; P ≤ .001; hazard ratio, 3.22, P = .007). Cusp fenestration was the only group showing neither an increased risk of postoperative severe aortic regurgitation (P = .57) or early reintervention (P = .88) compared with the control group.

CONCLUSIONS

Aortic valve cusp retraction, calcification, and fenestration were all related to increased rates of switch to valve replacement. Calcification and retraction were associated with recurrence of severe aortic regurgitation. Retraction was related to early reintervention. Fenestration was neither associated with recurrence of severe aortic regurgitation or reintervention. This indicates that surgeons are well able to distinguish aortic valve repair candidates in patients with cusp fenestration.

Contemporary Evaluation and Clinical Treatment Options for Aortic Regurgitation

Aortic regurgitation (AR) is the third most frequent form of valvular disease and has increasing prevalence with age. This will be of increasing clinical importance with the advancing age of populations around the globe. An understanding of the various etiologies and mechanisms leading to AR requires a detailed understanding of the structure of the aortic valve and aortic root. While acute and chronic AR may share a similar etiology, their hemodynamic impact on the left ventricle (LV) and management are very different. Recent studies suggest current guideline recommendations for chronic disease may result in late intervention and suboptimal outcomes. Accurate quantitation of ventricular size and function, as well as grading of the severity of regurgitation, requires a multiparametric and multimodality imaging approach with an understanding of the strengths and weaknesses of each metric. Echocardiography remains the primary imaging modality for diagnosis with supplemental information provided by computed tomography (CT) and cardiac magnetic resonance imaging (CMR). Emerging transcatheter therapies may allow the treatment of patients at high risk for surgery, although novel methods to assess AR severity and its impact on LV size and function may improve the timing and outcomes of surgical intervention.

Aortic root anatomy after aortic valve reimplantation

OBJECTIVE

During the last decade, special concerns have been raised about the anatomic relationships among the sinotubular junction, ventricular-aortic junction, and virtual basal ring to improve the results of root reconstruction. The aim of this study is to evaluate the in vivo anatomy of the aortic root after reimplantation with the Valsalva graft and the anatomic relationship between its components.

METHODS

We analyzed 10 consecutive patients with tricuspid aortic valves who underwent reimplantation with the Valsalva graft between September and December 2019. Surgical clips were applied as markers at the level of proximal annular knots and at the distal reimplanted commissures on the neo-sinotubular junction. Electrocardiogram-gated computed tomography scan of the aortic root was performed. Coordinates of the markers were exported on a 3-dimensional modeling software, and the distances between the virtual basal ring and the Dacron graft basal landmarks were measured.

RESULTS

The mean heights of Dacron graft basal landmarks from virtual basal ring were right-left commissure 7.1 ± 5.1 mm; right sinus 4.7 ± 4.1 mm; right-noncoronary commissure 2.8 ± 2.2 mm; noncoronary sinus 1.4 ± 1.6 mm; left-noncoronary commissure 2.2 ± 2.3 mm; and left sinus 2.0 ± 0.9 mm. The mean planar distances of basal Dacron graft landmarks from virtual basal ring (thickness) were right-left commissure 5.3 ± 3.1 mm; right sinus 2.8 ± 1.4 mm; right-noncoronary commissure 2.2 ± 1.5 mm; noncoronary sinus 1.5 ± 1.5 mm; left-noncoronary commissure 1.3 ± 1.0 mm; and left sinus 3.4 ± 2.5 mm.

CONCLUSIONS

After reimplantation, despite a complete dissection of the root, slight asymmetry of graft proximal seating exists. The inner annuloplasty is on the virtual basal ring, and the proximal edge of the Dacron graft is on the ventricular-aortic junction at a slightly different thickness and height along the annular circumference. At the level of the right sinus and left/right commissure, the Dacron graft is higher than the virtual basal ring and the relative wall thickness is increased. The annular stabilization is unaffected.

Valve Repair in Aortic Insufficiency: A State-of-the-art Review

Aortic valve insufficiency (AI) describes the pathology of blood leaking through the aortic valve to the left ventricle during diastole and is classified as mild, moderate or severe according to the volume of regurgitating blood. Intervention is required in severe AI when the patient is symptomatic or when the left ventricular function is impaired. Aortic valve replacement has been considered the gold standard for decades for these patients, but several repair techniques have recently emerged that offer exceptional stability and long-term outcomes. The appropriate method of repair is selected based on the mechanism of AI and each patient's anatomic variations. This review aims to describe different pathologies of AI based on its anatomy, along with the different surgical techniques of aortic repair and their reported results.

Conventional aortic root vs valve-sparing root replacement surgery in aortic dilatation syndromes: a comparison of mortality and postoperative complications

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.

Aortic cusp abnormalities in patients with trileaflet aortic valve and root aneurysm

BACKGROUND

The frequency of concomitant cusp pathology in aortic root aneurysm with or without aortic regurgitation is not well known, and the sensitivity and specificity of two-dimensional trans-oesophageal echocardiography (2D TEE) in its detection has not yet been specified.

OBJECTIVES

We analysed the type and frequency of concomitant cusp alterations in root aneurysm referred for surgery. Sensitivity and specificity of 2D TEE in detecting these alterations were determined.

METHODS

In 582 patients (age 56.8±15.4 years, 453 male) with trileaflet aortic valves undergoing root replacement for regurgitation (n=347) or aneurysm (n=235), details of valve morphology were analysed. In a subcohort (n=281), intraoperative TEEs were analysed retrospectively and correlated with the intraoperative findings.

RESULTS

Any cusp pathology was present in 90.9% (prolapse: n=473; retraction: n=30; calcification: n=14; fenestration: n=12), morphologically normal cusps were seen in only 52 patients (8.93%). Valve-sparing surgery was performed in 525 (90.2%) instances, composite replacement in 57 (9.8%). Preoperative TEE correctly identified any postroot repair prolapse in 70.6% and any retraction in 85%. The sensitivity of TEE in detecting any prolapse was 68.6% (specificity of 79.5%). The sensitivity was highest for the right cusp and intermediate for the non-coronary.

CONCLUSIONS

Cusp prolapse is frequent in root aneurysm and trileaflet aortic valves. Prolapse is underdiagnosed by 2D TEE in many cases because pre-existent stretching of cusp tissue is masked by the geometric effects of root dilatation.

Aortic Valve Repair Using HAART 300 Geometric Annuloplasty Ring: A Review and Echocardiographic Case Series

Aortic valve repair (AVr) aims to preserve the native aortic leaflets and restore normal valve function. In doing so, AVr is a more technically challenging approach than traditional aortic valve replacement. Some of the complexity of repair techniques can be attributed to the unique structure of the functional aortic annulus (FAA), which, unlike the well-defined mitral annulus, is comprised of virtual and functional components. Though stabilizing the ventriculo-aortic junction (VAJ), a component of the FAA, is considered beneficial for patients with chronic aortic insufficiency (AI), the ideal AVr technique remains a subject of much debate. The existing AVr techniques do not completely stabilize the VAJ which may increase susceptibility to recurrent AI due to VAJ dilation. An emerging new technique showing promise for the treatment of both isolated and complex AI is AVr using HAART 300^TM geometric annuloplasty ring (GAR). The GAR is implanted below the valve leaflets in the left ventricular outflow tract (LVOT), providing stability and creating a neo-annulus. As with other AVr subtypes, this procedure has a learning curve. There are unique surgical and echocardiographic aspects of AVr with GAR, including the appearance of the LVOT, the aortic valve leaflets, and their motion which cardiac anesthesiologists and echocardiographers must be familiar with. In this work, using an eight-patient echocardiographic case series, we provide an overview of this novel AVr technique, including some unique aspects of device sizing, patient selection, expected post-repair echocardiographic features, and a review of outcomes data.

Aortic regurgitation: A multimodality approach

Aortic regurgitation (AR) is a common valvular pathology. Multimodality noninvasive cardiovascular imaging is routinely used to assess the mechanism of AR, degree, and its hemodynamic impact on the cardiovascular system. Collecting this information is crucial in establishing the prognosis and in guiding patient management and follow-up. While echocardiography remains the primary test to assess AR, a comprehensive assessment of this valvulopathy can be obtained by combining the information from different techniques. This state-of-the-art review is intended to provide an update ed overview of the applications, strengths, and limits of transthoracic echocardiography, cardiac magnetic resonance, and cardiac computed tomography in patients with AR.

Aortic regurgitation management: a systematic review of clinical practice guidelines and recommendations

Guidelines for the diagnosis and management of aortic regurgitation (AR) contain recommendations that do not always match. We systematically reviewed clinical practice guidelines and summarized similarities and differences in the recommendations as well as gaps in evidence on the management of AR. We searched MEDLINE and Embase (1 January 2011 to 1 September 2021), Google Scholar, and websites of relevant organizations for contemporary guidelines that were rigorously developed as assessed by the Appraisal of Guidelines for Research and Evaluation II tool. Three guidelines met our inclusion criteria. There was consensus on the definition of severe AR and use of echocardiography and of multimodality imaging for diagnosis, with emphasis on comprehensive assessment by the heart valve team to assess suitability and choice of intervention. Surgery is indicated in all symptomatic patients and aortic valve replacement is the cornerstone of treatment. There is consistency in the frequency of follow-up of patients, and safety of non-cardiac surgery in patients without indications for surgery. Discrepancies exist in recommendations for 3D imaging and the use of global longitudinal strain and biomarkers. Cut-offs for left ventricular ejection fraction and size for recommending surgery in severe asymptomatic AR also vary. There are no specific AR cut-offs for high-risk surgery and the role of percutaneous intervention is yet undefined. Recommendations on the treatment of mixed valvular disease are sparse and lack robust prospective data.

Age-related etiologies of aortic regurgitation with moderate or greater severity and coronary cusp bending: evaluation using transesophageal echocardiography

PURPOSE

The prevalence of valvular heart disease has been rising, especially among those ≥ 65 years of age, because of age-related valvular degeneration resulting in an increase in the number of patients diagnosed with aortic regurgitation (AR). We analyzed transesophageal echocardiography (TEE) images in AR patients to identify the etiologies and investigate any differences in them according to age.

METHODS

We studied 146 consecutive patients with chronic moderate or severe AR who underwent TEE. AR etiology was evaluated based on the TEE images in all the patients, as well as in each group separated by age.

RESULTS

The total number of patients eligible was 126 (mean age 67 ± 12 years), consisting of an older group (n = 85, mean age 74 ± 5 years) and younger group (n = 41, mean age 52 ± 11 years). In total, the most common etiology of AR was cusp bending (33.0%). In the older group, it was the most frequent as well (48.2%), with the right coronary cusp being the most commonly affected site (90.2%). In the younger group, bicuspid aortic valve was the most common (36.5%). Subsequently, all the study subjects were re-classified into two groups according to the presence/absence of cusp bending. Multivariate analysis revealed that age was the only factor associated with cusp bending.

CONCLUSION

Cusp bending was the most frequent etiology of AR in the elderly. Preoperative detection of cusp bending by TEE would expand the therapeutic strategy for AR, including aortic valvuloplasty.

Relationship Between Leaflets and Root in Normal Aortic Valve Based on Computed Tomography Imaging: Implication for Aortic Valve Repair

Objective: By assessing the normal dimensions and the relationship between the aortic root and leaflets in Chinese population, the objective of this three-dimensional computed tomography (3DCT)-based study was to establish a matching reference for leaflets and aortic root for aortic valve (AV) repair.

Method: Electrocardiogram-gated multi-detector CT was performed on 168 Chinese participants with a normal aortic valve. Measurements of the aortic annuli and leaflets were obtained. The correlations between and the ratios of the specific root and leaflet measurements were analyzed. The references for the leaflet and root dimensions were suggested based on geometric height (gH) using a linear regression equation. The utility of the ratios was tested with CT images of 15 patients who underwent aortic valve repair.

Result: The mean annulus diameter (AD), sino-tubular junction (STJ) diameter, geometric height (gH), effective height (eH), free margin length (FML), commissural height (ComH), inter-commissural distance (ICD), and coaptation height (CH) were 22.4 ± 1.7 mm, 27.3 ± 2, 0.4 mm, 15.5 ± 1.7 mm, 8.9 ± 1.2 mm, 32.0 ± 3.4 mm, 17.9 ± 1.9 mm, 23.1 ± 2.3 mm, and 3.1 ± 0.6 mm, respectively. The gH/AD, FML/ICD, and eH/ComH ratios were 0.69 ± 0.07, 1.38 ± 0.08, and 0.50 ± 0.07, respectively. The gH correlated with all other leaflet and root measurements (P < 0.01), whereas the FML demonstrated a better correlation with ICD compared with gH (R² = 0.75, and R² = 0.37, respectively). The FML/ICD and eH/ComH ratios might be used to assess leaflet-root mismatch and post-repair leaflet billowing.

Conclusion: The normal aortic valve measurements based on 3DCT revealed a specific relationship between the root and leaflets; and this will guide the development of an objective method of aortic valve repair.

Characteristics of the aortic root morphology in conotruncal anomaly of the congenital heart disease

BACKGROUND

Aortopathy is a well-known feature of conotruncal anomalies, but it remains unknown whether valve-sparing aortic root replacement, such as the David procedure, is feasible in young patients with severe aortic regurgitation. We assessed the aortic valve complex and aortic root morphology in patients with conotruncal anomalies using echocardiography. Furthermore, we evaluated the relevant factors associated with aortopathy in this population.

METHODS

A total of 172 adult patients with conotruncal anomalies were enrolled in this study. Dimensions of the aortic valve complex were measured at the level of the sinus of Valsalva (SV) and sinotubular junction (STJ). The geometric height (GH), effective height (EH), and coaptation length (CL) were also assessed to analyze the aortic valve complex in detail.

RESULTS

Sixteen of 172 patients were excluded due to poor imaging; 105 patients with tetralogy of Fallot, 24 with double outlet right ventricle, and 27 with transposition of the great arteries totaling 156 patients (32+/-11 years old) were included in the analysis. The patients were divided into four groups: Group 1 (98 patients) had no dilatation of SV or STJ; Group 2 (32 patients) had dilated SV and STJ; Group 3 (14 patients) had dilated SV; and Group 4 (12 patients) had dilated STJ. GH and EH in Group 2 were also highest among the four, whereas CL was not significantly shortened. Multivariate analysis revealed that male sex, age, and conduit repair were risk factors for aortopathy in this population.

CONCLUSIONS

Patients with dilated SV and STJ (Group 2) were the most common among the patients with aortopathy (Groups 2, 3, and 4). The aortic valve leaflets themselves were enlarged, and the poor coaptation of the valve tips was compensated in spite of aortic root dilatation, which plays an important role in preventing severe aortic regurgitation in this population. Overall, valve-sparing aortic valve replacement is more feasible in the young populations than we expected.

International Consensus Statement on Nomenclature and Classification of the Congenital Bicuspid Aortic Valve and Its Aortopathy, for Clinical, Surgical, Interventional and Research Purposes

This International Consensus Classification and Nomenclature for the congenital bicuspid aortic valve condition recognizes 3 types of bicuspid valves: 1. The fused type (right-left cusp fusion, right-non-coronary cusp fusion and left-non-coronary cusp fusion phenotypes); 2. The 2-sinus type (latero-lateral and antero-posterior phenotypes); and 3. The partial-fusion (forme fruste) type. The presence of raphe and the symmetry of the fused type phenotypes are critical aspects to describe. The International Consensus also recognizes 3 types of bicuspid valve-associated aortopathy: 1. The ascending phenotype; 2. The root phenotype; and 3. Extended phenotypes. ©  2021 Jointly between the RSNA, the European Association for Cardio-Thoracic Surgery, The Society of Thoracic Surgeons, and the American Association for Thoracic Surgery. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. All rights reserved. Keywords: Bicuspid Aortic Valve, Aortopathy, Nomenclature, Classification.

Optimal Management of Chronic Severe Aortic Regurgitation - How to Determine Cutoff Values for Surgical Intervention?

Aortic regurgitation (AR) is a common valvular heart disease, but the optimal timing of surgical intervention remains controversial. In the natural history of chronic severe AR, sudden death is rare, and the annual mortality rate is comparatively low. Considering the hemodynamic features of combined volume and pressure overload and long-term compensation in patients with chronic AR, symptoms related to AR do not frequently occur. Therefore, the progression of left ventricular (LV) dysfunction is a key factor in determining the timing of surgical intervention in patients with severe chronic AR. In addition to symptoms, an ejection fraction <50% and an LV endsystolic diameter (LVESD) >45 mm are appropriate cutoff values for surgical intervention in Japanese patients, whereas LV end-diastolic diameter is not a good indicator. An LVESD index of 25 mm/m²is controversial, because adjusting for body size may cause overcorrection in Japanese patients who have a small body size compared with Westerners. Accumulation of data from the Japanese population is indispensable for establishing guidelines on optimal management of patients with chronic AR.

Neo-aortic posterior sinus of Valsalva reduction and closed coronary artery transfer as a method to approach aortopulmonary mismatch in transposition of great arteries

OBJECTIVE

In transposition of great arteries (TGA), aortopulmonary mismatch (APM) can determine postoperative neo-aortic insufficiency after arterial switch operation (ASO). The distortion of sinu-tubular junction may be the geometric mechanism responsible. We developed a strategy able to reduce the mismatch at the timing of ASO, and in this study, we aimed to describe our indications and results.

METHODS

Preoperative root circumferences at the level of the mid-portion of sinus of Valsalva and ascending aorta circumference were used to define APM. Indication to surgery was a neo-aortic root (NAR) to ascending aorta ratio ≥ 1.4. Along with standard ASO, posterior neo-aortic sinus inverted conal resection and punch technique for coronary reimplantation was used in all patients to re-establish the more geometric ratio possible between the two components. Hypoplastic aortic arch (HAA) and aortic coarctation (CA) were managed by aortic arch enlargement with an autologous pericardial patch.

RESULTS

Twenty patients (20 male), 19 with diagnoses TGA (17 with ventricular septal defect, 85%) and 1 with Taussig-Bing anomaly underwent ASO. HAA was present in three (15%) and CA in two (10%). The mean preoperative neo-aortic to ascending aorta ratio was 1.8 versus 1.1 postoperatively (p < .01). No moderate or severe neo-aortic insufficiency was observed before discharge and at a mean follow-up of 4.3 years (interquartile range = 0.5-12 years).

CONCLUSION

Neo-aortic reduction plasty with coronary reimplantation by punch technique is an effective strategy to approach preoperative APM in TGA. This technique confers a more harmonious geometry to NAR that can improve neo-aortic valve function.

Summary: international consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes

This International evidence-based nomenclature and classification consensus on the congenital bicuspid aortic valve and its aortopathy recognizes 3 types of bicuspid aortic valve: 1. Fused type, with 3 phenotypes: right-left cusp fusion, right-non cusp fusion and left-non cusp fusion; 2. 2-sinus type with 2 phenotypes: Latero-lateral and antero-posterior; and 3. Partial-fusion or forme fruste. This consensus recognizes 3 bicuspid-aortopathy types: 1. Ascending phenotype; root phenotype; and 3. extended phenotypes.

International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes

This International Consensus Classification and Nomenclature for the congenital bicuspid aortic valve condition recognizes 3 types of bicuspid valves: 1. The fused type (right-left cusp fusion, right-non-coronary cusp fusion and left-non-coronary cusp fusion phenotypes); 2. The 2-sinus type (latero-lateral and antero-posterior phenotypes); and 3. The partial-fusion (forme fruste) type. The presence of raphe and the symmetry of the fused type phenotypes are critical aspects to describe. The International Consensus also recognizes 3 types of bicuspid valve-associated aortopathy: 1. The ascending phenotype; 2. The root phenotype; and 3. Extended phenotypes.

Summary: International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional, and research purposes

This International evidence-based nomenclature and classification consensus on the congenital bicuspid aortic valve and its aortopathy recognizes 3 types of bicuspid aortic valve: 1. Fused type, with 3 phenotypes: right-left cusp fusion, right-non cusp fusion and left-non cusp fusion; 2. 2-sinus type with 2 phenotypes: Latero-lateral and antero-posterior; and 3. Partial-fusion or forme fruste. This consensus recognizes 3 bicuspid-aortopathy types: 1. Ascending phenotype; root phenotype; and 3. extended phenotypes.

International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes

This International Consensus Classification and Nomenclature for the congenital bicuspid aortic valve condition recognizes 3 types of bicuspid valves: 1. The fused type (right-left cusp fusion, right-non-coronary cusp fusion and left-non-coronary cusp fusion phenotypes); 2. The 2-sinus type (latero-lateral and antero-posterior phenotypes); and 3. The partial-fusion (forme fruste) type. The presence of raphe and the symmetry of the fused type phenotypes are critical aspects to describe. The International Consensus also recognizes 3 types of bicuspid valve-associated aortopathy: 1. The ascending phenotype; 2. The root phenotype; and 3. Extended phenotypes.

Summary: International Consensus Statement on Nomenclature and Classification of the Congenital Bicuspid Aortic Valve and Its Aortopathy, for Clinical, Surgical, Interventional and Research Purposes

This International evidence-based nomenclature and classification consensus on the congenital bicuspid aortic valve and its aortopathy recognizes 3 types of bicuspid aortic valve: 1. Fused type, with 3 phenotypes: right-left cusp fusion, right-non cusp fusion and left-non cusp fusion; 2. 2-sinus type with 2 phenotypes: Latero-lateral and antero-posterior; and 3. Partial-fusion or forme fruste. This consensus recognizes 3 bicuspid-aortopathy types: 1. Ascending phenotype; root phenotype; and 3. extended phenotypes.

International Consensus Statement on Nomenclature and Classification of the Congenital Bicuspid Aortic Valve and Its Aortopathy, for Clinical, Surgical, Interventional and Research Purposes

This International Consensus Classification and Nomenclature for the congenital bicuspid aortic valve condition recognizes 3 types of bicuspid valves: 1. The fused type (right-left cusp fusion, right-non-coronary cusp fusion and left-non-coronary cusp fusion phenotypes); 2. The 2-sinus type (latero-lateral and antero-posterior phenotypes); and 3. The partial-fusion (forme fruste) type. The presence of raphe and the symmetry of the fused type phenotypes are critical aspects to describe. The International Consensus also recognizes 3 types of bicuspid valve-associated aortopathy: 1. The ascending phenotype; 2. The root phenotype; and 3. Extended phenotypes.

Aortic valve neocuspidalization in paediatric patients with isolated aortic valve disease: early experience

OBJECTIVES

There is growing interest in the aortic valve (AV) neocuspidalization technique for the treatment of aortic valve disease (AVD). We report our medium-term results with this procedure performed in a paediatric patient population.

METHODS

Between July 2016 and May 2020, 22 patients with both congenital and acquired isolated AVD were treated with neocuspidalization. The primary outcome was progression of the preoperatively assessed AVD in the immediate postoperative course and at follow-up. Secondary outcome was freedom from reintervention by material used. Potential predictors of failure were analysed in relation to the primary outcome.

RESULTS

The median age at operation was 13.9 (interquartile range, 9.8-16.2) years, and the prevailing AV defect was stenosis in 10 cases (45%) and incompetence in 12 (55%). Pre-treated autologous pericardium was used in 13 patients whereas bovine pericardium in 9. Effective treatment of AV stenosis or regurgitation was achieved and remained stable over a median follow-up of 11.3 (4.7-21) months. Three patients required AV replacement at 4.9, 3.5 and 33 months. At follow-up, an upward trend of both median indexed vena contracta jet widths and aortic peak and mean gradients were recorded, the latter associated with a failure to grow the aortic annulus. Predictor of such outcome turned out to be the use of bovine pericardium. A significant inverse linear correlation between AV peak gradient at follow-up and preoperative aortic annular size (P = 0.008) was also demonstrated.

CONCLUSIONS

The Ozaki procedure is safe and effective in paediatric patients with AV disease. The use of heterologous pericardium should probably be minimized. Moreover, preoperative small aortic annuli should probably be promptly treated by means of an associated ring enlargement procedure.

Free margin length and geometric height in aortic root dilatation and leaflet prolapse: implications for aortic valve repair surgery

OBJECTIVES

Our goal was to assess the aortic leaflet free margin length (FML) and geometric height (gH) in a normal aortic valve (AV), aorta dilatation and aortic leaflet prolapse.

METHODS

We measured the FML and gH intraoperatively in 132 patients operated on for aortic insufficiency, aortic dilatation, endocarditis or fibroelastoma. Patients were divided into 3 groups: normal tricuspid AV (group 1, n = 12), aortic dilatation (group 2, tricuspid = 43, bicuspid = 18) and leaflet prolapse (group 3, tricuspid = 32, bicuspid = 27). The FML and gH were compared between the groups and between the leaflets within each group.

RESULTS

In a normal tricuspid AV, the mean FML and gH were 34.7 ± 3.1 mm and 18.8 ± 1.7 mm, respectively. In group 2 tricuspid, the FML and gH were greater than those in group 1 (FML 43.7 ± 4.4, P < 0.001; gH 21.2 ± 1.8, P = 0.003). In group 3, tricuspid, the FML of the prolapsing leaflet was greater than the FML of the non-prolapsing leaflet (48.3 ± 5.4 vs 42.2 ± 3.6; P < 0.001). In group 2, bicuspid, FML of both leaflets were similar in group 2, but augmented on the fused leaflet compared to the non-fused leaflet in group 3 (fused 55.4 ± 6.3; non-fused 46.2 ± 6.2; P < 0.001). In groups 2 and 3 bicuspid, the gH of the non-fused leaflet was systematically greater than the fused leaflet (group 2 non-fused 24.6 ± 2.5 vs fused 20.4 ± 2.1; P < 0.001).

CONCLUSIONS

In aortic dilatation and leaflet prolapse, FML and, to a lesser extent, gH increased significantly compared to those of normal AV function. FML and gH dimensions also depended on the valve configuration (tricuspid/bicuspid). These data provide new insight into the pathomorphology of AV disease and will serve to further develop new methods of AV repair based on intraoperative measurements of the FML.

Early safety performance of a modified technique of aorta replacement with sinotubular stabilization

BACKGROUND

We sought to determine if a modified technique for ascending aorta replacement with sinotubular junction reduction and stabilization was safe.

METHODS

This technique was performed by suspension of the three commissures, invagination of the aortic Dacron graft and advancing the graft into the ventricles. We included patients with dilatation of the ascending aorta, normal sinuses of Valsalva dimension (<45 mm), with or without aortic annulus enlargement (>25 mm) and with various degree of aortic insufficiency (from grade 1 to 3).

RESULTS

From April to October 2019, 20 patients were recruited from two centers; mean age was 66.9 ± 12.8 years, 13 were male; grade 1, 2 and 3 was present in 12, 2 and 6 patients, respectively. All patients underwent ascending aorta replacement with modified technique; an additional open subvalvular ring was used in 8 patients with aortic insufficiency ≥ 2; cusps repair was performed in 6 patients (5 plicating central stitches/1 shaving); concomitant coronary artery bypass grafting was performed in 10 patients. There was no 30-day mortality. One patient was re-explored for bleeding. All patients completed six-month follow-up; at the transthoracic echocardiography, there was no aortic insufficiency ≥ 1 except one patient with aortic insufficiency grade 1 who underwent ascending aorta replacement and subvalvular ring; no patients underwent reintervention.

CONCLUSIONS

This modified technique for ascending aorta replacement and sinotubular junction stabilization was safe. It could be associated with other aortic valve sparing techniques. However, such remodeling approach has to be validated in a larger cohort of patients with longer follow-up.

Trileaflet Aortic Valve Reconstruction Using Bovine Pericardium

AIM

For several years now, trileaflet aortic valve reconstruction has been performed in patients with various aortic valve diseases. This study aimed to explore the feasibility and durability of trileaflet aortic valve reconstruction with bovine pericardium.

METHOD

Trileaflet aortic valve reconstruction with bovine pericardium was performed in 519 patients with various aortic valve diseases from April 2008 to December 2019. The results for all 519 patients were reviewed retrospectively. Mean age was 48.04±19.08 years (range, 13-80 years), and 40 patients were younger than 18 years of age. Thirty-four (34) patients had aortic stenosis, 344 patients had aortic regurgitation, and 141 patients had both aortic stenosis and regurgitation. One hundred and fifty-four (154) patients had bicuspid aortic valves, and three patients had quadricuspid aortic valves. The size of the pericardial leaflets was designed to be individually proportional to the size of the aortic root.

RESULTS

Mean length of follow-up was 41.97±22.68 years (range, 1-127 months). In total, 448 patients were reviewed, and the follow-up rate was 86.4%. All procedures were successful without conversion to prosthetic valve replacement during the procedure. Six (6) patients died after the procedure (in-hospital mortality, 1.2%). All-cause mortality occurred in 11 patients during the follow-up period. The 10-year cumulative survival rate was 94.7%±2.9%. Redo aortic valve surgery was performed in 11 patients after the procedure. The actuarial freedom from redo aortic valve surgery after the procedure was 88.2%±5.2%. At the end of the follow-up, the mean peak was 29.1±9.6 mmHg and mean gradient was 15.6±6.2 mmHg.

CONCLUSIONS

The mid- and long-term outcomes in patients with various aortic valve diseases undergoing trileaflet aortic valve reconstruction with bovine pericardium are encouraging. The engineered pericardial leaflets should be individually proportional to the size of the aortic root.

Fate of mild-to-moderate bicuspid aortic valve disease untreated during ascending aorta replacement

BACKGROUND

Bicuspid aortic valve (BAV) is the most common congenital heart defect and it is responsible for an increased risk of developing aortic valve and ascending aorta complications. In case of mild to moderate BAV disease in patients undergoing supracoronary ascending aorta replacement, it is unclear whether a concomitant aortic valve replacement should be performed.

METHODS

From June 2002 to January 2020, 75 patients with mild-to-moderate BAV regurgitation (±mild-to-moderate stenosis) who underwent isolated supracoronary ascending aorta replacement were retrospectively analyzed. Clinical and echocardiographic follow-up was 100% complete (mean: 7.4 ± 3.9 years, max: 16.4). Kaplan-Meier estimates were employed to analyze long-term survival. Cumulative incidence function (CIF) for time to reoperation, recurrence of aortic regurgitation (AR) ≥3+ and aortic stenosis (AS) greater than moderate, with death as competing risk, were computed.

RESULTS

There was no hospital mortality and no cardiac death occurred. Overall survival at 12 years was 97.4 ± 2.5%, 95% confidence interval (CI: 83.16-99.63). At follow-up there were no cases of aortic root surgery whereas three patients underwent AV replacement. At 12 years the CIF of reoperation was 2.6 ± 2.5%, 95% CI [0.20-11.53]. At follow-up, AR 3+/4+ was present in 1 pt and AS greater than moderate in 3. At 12 years the CIF of AR more than 2+/4+ was 5.1 ± 4.98% and of AS more than moderate 6.9 ± 3.8%.

CONCLUSIONS

In our study mild to moderate regurgitation of a BAV did not do significantly worse at least up to 10 years after isolated supracoronary ascending aorta replacement.

Aortic Valve Neocuspidalization May Be a Viable Alternative to Ross Operation in Pediatric Patients

The aim of the study was to evaluate the medium-term results of aortic valve neocuspidalization according to Ozaki compared to Ross procedure for treatment of isolated aortic valve disease in pediatric age. Thirty-eight consecutive patients with congenital or acquired aortic valve disease underwent either Ozaki (n = 22) or Ross (n = 16) operation between 01/2015 and 05/2020. The primary outcome was progression of aortic valve disease and aortic ring and root dimension, whereas secondary outcome was freedom from reintervention or death by type of operation. Median age was 12.4 (8.8-15.8) years and the prevailing lesion was stenosis in 20 cases (52%) and incompetence in 18 (48%). One death occurred in the Ross group in the early postoperative period, while there were no deaths in the Ozaki group. Effective treatment of aortic valve stenosis or regurgitation occurred in both groups and remained stable over a median follow-up of 18.2 (5-32) months. In Ozaki group, 3 patients required aortic valve replacement at 4.9, 3.5, and 33 months, respectively. In Ross group, 1 patient required Melody pulmonary valve replacement, whereas none required aortic valve surgery. Finally, significantly higher aortic transvalvular gradient at follow-up was recorded in Ozaki group compared to Ross group. Overall, there was no significant difference in freedom from reoperation or death between the two groups. The medium-term outcome of Ozaki and Ross in pediatric patients is similar, despite an increased tendency of the former to develop aortic transvalvular gradient in the follow-up. Future larger multicenter studies with longer follow-up are warranted to confirm these results.

Mini or full sternotomy for aortic valve repair? A systematic review of the literature

INTRODUCTION

Minimally invasive aortic valve replacement is becoming a standard treatment. The possibility of extending this approach to more demanding aortic root pathologies is being debated with limited evidence. Attaining comfort in a complex aortic repair is a "dogma" that should always be achieved. Perhaps, the patient's condition, the aortic anatomy and the expertise creates the fundamental principles that achieve stable results over time.

EVIDENCE ACQUISITION

Selection of literature articles was performed using PubMed databases from inception to July 2020. We excluded editorials and expert opinions, review articles, congenital heart disease, and other types of valve repair. According to the limited studies available, case reports were included.

EVIDENCE SYNTHESIS

We identified 7 studies from 2015 to 2020 with the number of patients spanning 1 to 117 from single centers' experiences. Three were case reports with aortic repair of a bicuspid aortic valve. A total of 259 mini-AVr patients were analyzed.

CONCLUSIONS

In this review article, we sought to analyze and report the experience and results of a currently available series on aortic valve repair (with or without associated aortic root procedures) using mini sternotomy. Early- and long-term data will be reported and discussed in terms of survival and aortic valve function.

Mid-term outcomes of valve-sparing root reimplantation with leaflet repair

OBJECTIVES

Valve repair for aortic insufficiency (AI) requires a tailored surgical approach determined by the leaflet and aortic disease. In this study, we used a repair-oriented system for the classification of AI, and we elucidated long-term outcomes of aortic root reimplantation with this classification system.

METHODS

From 1999 to 2018, a total of 197 patients underwent elective reimplantation (mean age: 52.7 ± 17.7 years; 80% male). The aortic valve was tricuspid in 143 patients, bicuspid in 51 patients and quadricuspid in 3 patients. A total of 93 patients had type I AI (aortic dilatation), 57 patients had type II AI (cusp prolapse) and 47 patients had type III AI (restrictive). In total, 104 of the 264 patients (39%) had more than 1 identified mechanism.

RESULTS

In-hospital mortality was 0.5% (1/197). Mid-term follow-up (mean follow-up duration: 5.5 years) revealed a late mortality rate of 4.2% (9/197). Aortic valve reoperation was performed on 16 patients (8.0%). Rates of freedom from aortic valve replacement and freedom from aortic valve-related events at 10 years of follow-up were 87.0 ± 4.0% and 60.6 ± 6.0%, respectively; patients with type Ib AI (98.3 ± 1.7%; 80.7 ± 7.5%) had better outcomes than patients with type III AI (59.6 ± 15.6%; 42.2 ± 13.1%, P = 0.01). In patients with types II and III AI who had bicuspid aortic valves, rates of freedom from aortic valve-related events at 5 years of follow-up were 95.2 ± 4.7% and 71.7 ± 9.1%, respectively (P = 0.03).

CONCLUSIONS

This repair-oriented system for classifying AI could help to predict the durable aortic valve repair techniques. Patient selection according to the classification is particularly important for long-term durability.

CLINICAL TRIAL REGISTRATION NUMBER

B190050.

Guidelines for the Use of Transesophageal Echocardiography to Assist with Surgical Decision-Making in the Operating Room: A Surgery-Based Approach: From the American Society of Echocardiography in Collaboration with the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons

Intraoperative transesophageal echocardiography is a standard diagnostic and monitoring tool employed in the management of patients undergoing an entire spectrum of cardiac surgical procedures, ranging from "routine" surgical coronary revascularization to complex valve repair, combined procedures, and organ transplantation. Utilizing a protocol as a starting point for imaging in all procedures and all patients enables standardization of image acquisition, reduction in variability in quality of imaging and reporting, and ultimately better patient care. Clear communication of the echocardiographic findings to the surgical team, as well as understanding the impact of new findings on the surgical plan, are paramount. Equally important is the need for complete understanding of the technical steps of the surgical procedures being performed and the complications that may occur, in order to direct the postprocedure evaluation toward aspects directly related to the surgical procedure and to provide pertinent echocardiographic information. The rationale for this document is to outline a systematic approach describing how to apply the existing guidelines to questions on cardiac structure and function specific to the intraoperative environment in open, minimally invasive, or hybrid cardiac surgery procedures.

State of the Art Management of Aortic Valve Disease in Ankylosing Spondylitis

PURPOSE OF REVIEW

Cardiac involvement in patients with ankylosing spondylitis (AS) generally manifests itself as aortic insufficiency, aortitis, disturbance in cardiac conduction, and myocardial dysfunction. We have used a case-based approach to review the current state of the art knowledge regarding the diagnosis and management of aortic valve disease and aortitis in patients with AS.

RECENT FINDINGS

The risk for aortic valve disease and aortic valve replacement or repair is significantly higher than in people without AS, and this risk increases with age. Echocardiography, cardiac MRI, and CT can serve as effective tools for screening and follow-up. Surgical repair/replacement remains the mainstay of therapy for aortic insufficiency and aortic dilation, whereas transcatheter-based techniques may be favorable in the setting of aortic stenosis. Aortic valve and atrioventricular conduction abnormalities contribute to overall cardiovascular burden in AS. Optimal timing and therapeutic technique are dependent on assessment of overall risk and serial follow-up.

Prognostic factors associated with postoperative adverse outcomes in patients with aortic valve prolapse

BACKGROUND AND AIM

Aortic valve (AV) cusp prolapse and subsequent aortic insufficiency (AI) are 2 of factors leading to left ventricular (LV) enlargement and decreased LV function. Aortic valve replacement (AVR) has been the standard surgical procedure for AI. However, few data is available on the prognosis of these patients undergoing AVR procedure, especially in Chinese population. The study aims to evaluate the potential risk factors affecting the mid-term adverse outcomes after AVR.

METHODS

One hundred thirty-four patients (mean age: 46.7 years old) with AV cusp prolapse and severe AI who all received surgical aortic valve replacement were recruited in our hospital between January 1, 2009 and December 30, 2017. The clinical characteristics, echocardiography parameters, as well as operative parameters were obtained. The primary endpoint included death, heart failure development, and reoperation.

RESULTS

There were 14 adverse events altogether with the primary endpoint during a median follow-up of 8.6 (6-10) months. The multivariable Cox regression analysis revealed that baseline LVEDD (hazard rate, HR = 1.08, 95% CI: 1.01-1.15, P = .021), moderate pulmonary hypertension (HR = 9.36, 95% CI: 1.81-48.28, P = .008), and the time of assisted mechanical ventilation (HR = 1.01, 95% CI: 1.00-1.01, P = .022) were independently associated with the primary endpoint. Kaplan-Meier survival curve showed a significant worse survival free of the endpoint for patients with LVEDD≥70 mm, indexed LVEDD≥37.3 mm/m (the mean in this study), indexed LVESD≥25 mm/m or baseline LVEF <50% (all P<.05).

CONCLUSION

Baseline enlarged LV dimensions, low LV function, moderate pulmonary hypertension, and prolonged assisted mechanical ventilation may predict the poor mid-term postoperative outcomes for AV cusp prolapse patients undergoing AVR procedure.

Aortic valve repair techniques: an early UK experience

Objectives

Retrospective review of early results with aortic valve repair (AVr) techniques.

Methods

61 consecutive patients underwent AVr surgery at our institutions between 2008 and 2018. 14 patients had a bicuspid aortic valve and 16 had a connective tissue disorder. In 48 patients, aortic regurgitation (AR) was secondary to an aortic root and/or ascending aneurysms, while in 13 it was due to primary cusp pathologies. 13 patients underwent isolated cusp repair, 19 sinotubular junction remodelling, 25 valve-sparing root replacement (VSRR) and 4 hemiroot replacement. Cusp repair techniques included: 18 free margin plication, 18 commissural re-suspensions, 3 raphe resections and 1 free-edge reinforcement. Subcommissural annuloplasty was performed in 25 patients (42%) with a dilated annulus (>28 mm).

Results

50 patients (82%) left the operating theatre with no AR, 8 with mild central and 3 with mild eccentric AR. In-hospital survival was 100%. Clinical follow-up was complete at 5.08±2.29 years and all patients were alive. Transthoracic echocardiographic follow-up was complete at 2.35±1.92 years and showed the presence of a moderate AR in 10 patients (18%) and severe AR in 2 patients (4%). One of these required re-do aortic valve replacement 6 years after VSRR. Freedom from re-operation at 8 years was 88.15%±1.51%.

Conclusion

Good early results are achievable following AVr with acceptable medium-term outcomes. AVr surgery continues to evolve, and concentrating the experience in specialist centres in the UK is recommended.

Quantitative three-dimensional echocardiographic analysis of the bicuspid aortic valve and aortic root: A single modality approach

BACKGROUND

Patients with bicuspid aortic valves (BAV) are heterogeneous with regard to patterns of root remodeling and valvular dysfunction. Two-dimensional echocardiography is the standard surveillance modality for patients with aortic valve dysfunction. However, ancillary computed tomography or magnetic resonance imaging is often necessary to characterize associated patterns of aortic root pathology. Conversely, the pairing of three-dimensional (3D) echocardiography with novel quantitative modeling techniques allows for a single modality description of the entire root complex. We sought to determine 3D aortic valve and root geometry with this quantitative approach.

METHODS

Transesophageal real-time 3D echocardiography was performed in five patients with tricuspid aortic valves (TAV) and in five patients with BAV. No patient had evidence of valvular dysfunction or aortic root pathology. A customized image analysis protocol was used to assess 3D aortic annular, valvular, and root geometry.

RESULTS

Annular, sinus and sinotubular junction diameters and areas were similar in both groups. Coaptation length and area were higher in the TAV group (7.25 ±  0.98 mm and 298 ± 118 mm² , respectively) compared to the BAV group (5.67 ± 1.33 mm and 177 ± 43 mm² ; P = .07 and P = .01). Cusp surface area to annular area, coaptation height, and the sub- and supravalvular tenting indices did not differ significantly between groups.

CONCLUSIONS

Single modality 3D echocardiography-based modeling allows for a quantitative description of the aortic valve and root geometry. This technique together with novel indices will improve our understanding of normal and pathologic geometry in the BAV population and may help to identify geometric predictors of adverse remodeling and guide tailored surgical therapy.