Aortic Valve and Ascending Aorta Guidelines for Management and Quality Measures

Clinical medical decision-making of acute aortic intramural hematoma: A non-randomized retrospective case study

Objective

This study explored the timing of interventional treatment for acute intramural aortic hematoma (IMH) and the corresponding high-risk factors for its development into local aortic dissection (AD).

Method

This retrospective case study method examined clinical follow-up data of 42 patients with acute IMH between April 2013 and October 2016 from the First Affiliated Hospital of Xiʹan Jiaotong University. SPSS 17.0 and PPMS1.5 were used to analyze follow-up data spanning 3–12 months (mean, 7.5 ​± ​3.7 months).

Results

Patients were divided into the conversion group and the hematoma group according to whether they developed AD. Among them, 16 patients (38.1%) developed AD and were treated with thoracic endovascular aortic repair (TEVAR). The remaining patients (61.89%) were treated conservatively. After 1 week, the mean aortic diameter of the conversion versus hematoma group was significantly widened. Hemodynamically unstable patients and those with hematoma to the abdominal aorta extension were more likely to develop AD. Patient outcomes after TEVAR were similar between groups.

Conclusion

Our findings suggest that aortic isthmus diameter ≥3.0 ​cm, hematoma extending to the abdominal aorta, and hemodynamic instability are associated with AD development in acute IMH patents. TEVAR should be considered if hematoma thickening, calcification ingression, ulcer progression, or contrast enhancement within the intramural hematoma is noted beyond 2 weeks after IMH onset.

How to repair an acquired Gerbode defect using an aortic root xenograft

A 74-year old female patient presented with a 3-week history of fever, general weakness, and later developed complete heart block. On admission, the patient was febrile (temperature of 39°C) and tachypnoeic (respiratory rate of 29/min) with oxygen saturation of 95% on 2 L of oxygen. Her heart rate was 60 beats/min (VVI pacing), arterial blood pressure was 135/60 mm Hg and the Glasgow Coma Scale was 15. On chest auscultation, she had a harsh systolic murmur over her left precordium and bilateral rales. Blood tests demonstrated moderate anemia (hemoglobin of 95 g/L), leucocytosis (white blood cell count of 13.13 x 10^9/L), hypoalbuminemia (albumin concentration of 18 g/L), normal liver function tests and creatinine clearance of 45 ml/min. Computed tomography aortography demonstrated an irregular mass arising from the aortic root that extended into the right atrium (RA) and a fistulous tract (the Gerbode defect) between the left ventricular outflow tract (LVOT) and the right ventricle (RV). Transoesophageal echocardiography showed large vegetation in the RA and left to right cardiac shunt through the Gerbode defect from the LVOT to the RA and the RV. Using cardiopulmonary bypass, the patient underwent resection of the aortic cusps, debridement of the aortic root, septal and anterior leaflets of the tricuspid valve, and the membranous septum. The Gerbode defect was closed with an autologous pericardial patch, then a sliding annuloplasty of the septal leaflet of the tricuspid valve was performed. Finally, the aortic root was replaced with a 23 mm Freestyle xenograft.

In Situ Composition of Valved Conduit for Complex Reoperative Aortic Root Replacement

We describe a novel technique, in situ composition of a valved conduit, for complex reoperative aortic root replacement. The absence of a rigid stented aortic valve prosthesis facilitates left ventricular outflow tract (LVOT) reconstruction and coronary reimplantation. First, a Dacron graft, inverted and inserted into the LVOT, is sewn to the LVOT, followed by coronary button reimplantation and then prosthetic valve implantation. For cases that require LVOT reconstruction, the graft below the prosthetic valve serves as a circumferential patch. Our technique requires only surgical materials that are readily available without the need for a specialized skillset.

Sinus of Valsalva Aneurysms: A State-of-the-Art Imaging Review

Cardiovascular imaging has an important role in the assessment and management of aortic root and thoracic aorta ectasia and aneurysms. Sinus of Valsalva aneurysms are rare entities. Unique complications associated with sinus of Valsalva aneurysms make them different from traditional aortic root aneurysms. Established guidelines on the diagnosis and management of sinus of Valsalva aneurysms are lacking. This article reviews the applications of multimodality cardiovascular imaging (echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging) for the dedicated assessment and imaging-guided management of sinus of Valsalva aneurysms.

Outcomes and Quality of Life After Ross Reintervention: Would You Make the Same Choice Again?

BACKGROUND

The Ross procedure was introduced as a long-term if not definitive solution for aortic pathology. However, the rate of reoperation is not negligible.

METHODS

This single-center prospective study assessed the general outcome of Ross reoperation and patients' perceived quality of life compared with 2 control groups (Ross non-reoperation and mechanical aortic valve replacement). Patient's preference regarding the choice between mechanical aortic valve and Ross procedure was investigated in a subgroup that could theoretically have been directed to either of the 2 procedures.

RESULTS

Between 2005 and 2017, 64 consecutive patients underwent reoperation after Ross. Median age was 31 years. Median freedom from reoperation after the Ross procedure was 136 months. An autograft reoperation was required in 49, and 25 had homograft failure. No in-hospital death was recorded. Mean follow-up was 77 months (range, 6-164 months). Quality of life was assessed with the 36-Item Short Form Health Survey questionnaire. The Ross reoperation group showed a lower score involving psychological concerns compared with the other groups. In the reoperated-on patients group, 52 had adequate aortic annulus dimensions to receive a prosthetic valve instead of a Ross procedure. When asked whether they would make the same choice, only 31% confirmed the preference.

CONCLUSIONS

Reoperations after Ross procedure have low mortality and morbidity. Long-term follow-up showed a high quality of life, even after reoperations. However, owing to psychological concerns after the redo operation, when choosing a Ross procedure, it is our duty to thoroughly explain to patients that a high level of disillusion is predictable in case of reoperations.

The American Association for Thoracic Surgery consensus guidelines on bicuspid aortic valve-related aortopathy: Full online-only version

Bicuspid aortic valve disease is the most common congenital cardiac disorder, being present in 1% to 2% of the general population. Associated aortopathy is a common finding in patients with bicuspid aortic valve disease, with thoracic aortic dilation noted in approximately 40% of patients in referral centers. Several previous consensus statements and guidelines have addressed the management of bicuspid aortic valve-associated aortopathy, but none focused entirely on this disease process. The current guidelines cover all major aspects of bicuspid aortic valve aortopathy, including natural history, phenotypic expression, histology and molecular pathomechanisms, imaging, indications for surgery, surveillance, and follow-up, and recommendations for future research. It is intended to provide clinicians with a current and comprehensive review of bicuspid aortic valve aortopathy and to guide the daily management of these complex patients.

The American Association for Thoracic Surgery consensus guidelines on bicuspid aortic valve-related aortopathy: Executive summary

Bicuspid aortic valve disease is a common congenital cardiac disorder, being present in 1% to 2% of the general population. Associated aortopathy is a common finding in patients with bicuspid aortic valve disease, with thoracic aortic dilation noted in approximately 40% of patients in referral centers. Several previous consensus statements and guidelines have addressed the management of bicuspid aortic valve-associated aortopathy, but none focused entirely on this disease process. The current document is an executive summary of "The American Association for Thoracic Surgery Guidelines on Bicuspid Aortic Valve-Related Aortopathy." All major aspects of bicuspid aortic valve aortopathy, including natural history, phenotypic expression, histology and molecular pathomechanisms, imaging, indications for surgery, surveillance, and follow-up, and recommendations for future research are contained within these guidelines. The current executive summary serves as a condensed version of the guidelines to provide clinicians with a current and comprehensive review of bicuspid aortic valve aortopathy and to guide the daily management of these complex patients.

The fate of mild to moderate proximal aortic dilatation after isolated aortic valve replacement in tricuspid aortic valve patients

BACKGROUND

Proximal aortic dilatation is frequently associated with aortic valve pathology. The treatment of mild to moderate proximal aortic dilatation (maximal diameter: 40-50 mm) at the time of aortic valve replacement (AVR) is still controversial. We retrospectively analyzed the fate and progression of the proximal dilated aorta after isolated AVR in tricuspid aortic valve (TAV) patients, to determine if ascending aortic replacement (AAR) is recommended at the time of the initial AVR.

METHODS

The review of our hospital database revealed a subgroup of 127 TAV disease patients with mild to moderate ascending aortic dilatation, who underwent isolated AVR (group I, n = 68) or AVR combined AAR (group II, n = 59) from January 2000 to December 2013. Follow-up was obtained through a telephone interview/outpatient interview. Adverse aortic events were defined as aortic dissection/ rupture, or diameter of proximal aorta ≥55 mm, or re-do aortic surgery contributable to the dilated aorta during follow-up.

RESULTS

There were no differences in age, gender, heart function, hypertension, diabetes, smoking, chronic renal failure, and atrium fibrillation between two groups except for the maximum aortic diameter (group I 43.91 ± 2.0 vs group II 45.20 ± 2.63, P < .05). The cross-clamp time and cardiopulmonary bypass time was significantly less in group I than that in group II, owing to the replacement of the proximal aorta. A total of 126 patients were discharged home successfully, with 0.79% hospital mortality. There was no significant difference of hospital mortality and morbidity between the two groups. Follow-up was successfully obtained in 106 patients (84.13%). Mean follow-up time was (9.60 ± 3.47) years. The overall survival at 10-year follow-up was 72.46% ± 6.42% in group I versus 74.55% ± 6.87% in group II ( P = .73). The freedom from adverse aortic events at 10-year was 89.59% ± 4.02% in group I versus 96.88% ± 3.07% in group II ( P = .09). No significant difference in survival rate and freedom from adverse aortic events can be obtained between the two groups.

CONCLUSION

Progression of proximal aorta leading to adverse aortic events after isolated AVR in TAV patients is infrequent. AVR alone is acceptable and reasonable in patients with mild to moderate proximal aortic dilatation if connective tissue disorders are not present.

Does the Knowledge of the Local Thickness of Human Ascending Thoracic Aneurysm Walls Improve Their Mechanical Analysis?

Ascending thoracic aortic aneurysm (ATAA) ruptures are life threatening phenomena which occur in local weaker regions of the diseased aortic wall. As ATAAs are evolving pathologies, their growth represents a significant local remodeling and degradation of the microstructural architecture and thus their mechanical properties. To address the need for deeper study of ATAAs and their failure, it is required to analyze the mechanical behavior at the sub-millimeter scale by making use of accurate geometrical and kinematical measurements during their deformation. For this purpose, we propose a novel methodology that combined an accurate tool for thickness distribution measurement of the arterial wall, digital image correlation to assess local strain fields and bulge inflation to characterize the physiological and failure response of flat unruptured human ATAA specimens. The analysis of the heterogeneity of the local thickness and local physiological stress and strain was carried out for each investigated subject. At the subject level, our results state the presence of a non-consistent relationship between the local wall thickness and the local physiological strain field and high heterogeneity of the variables. At the inter-subject level, thicknesses were studied in relation to physiological strain and stress and load at rupture. The rupture pressure was correlated with neither the average thickness nor the lowest thickness of the specimens. Our results confirm that intrinsic material strength (hence structure) differs a lot from a subject to another and even within the same subject.

Repair of Aortic Valve Insufficiency and Ascending Aortic Aneurysm Using Geometric Ring Annuloplasty

This video demonstrates aortic valve repair during ascending aneurysm replacement for a 71-year-old man with congestive heart failure, grade 3 aortic insufficiency, and a 5.4-cm ascending aneurysm. On testing, the noncoronary leaflet is prolapsing, the annulus is 27 mm, and the leaflets size to a 21-mm ring. The ring is sutured beneath the aortic valve annulus with nine horizontal mattress sutures. The noncoronary leaflet is plicated, correcting the prolapse. A 28-mm Dacron tube graft (Maquet Hemashield, Baden-Württemberg, Germany) is sutured to the supracoronary and distal aorta. After repair, aortic insufficiency is trivial with a mean systolic gradient of 9 mm Hg. The patient recovered uneventfully.

The Ross procedure in adults presenting with bicuspid aortic valve and pure aortic regurgitation: 85% freedom from reoperation at 20 years

OBJECTIVES

The Ross procedure has demonstrated excellent results when performed in patients with aortic stenosis or mixed aortic valve disease [aortic stenosis and aortic regurgitation (AR)]. However, due to its reported risk of late reoperation, it is not recommended under current guidelines for patients presenting with bicuspid aortic valve and pure AR. We have analysed our own results in light of this recommendation.

METHODS

Between 1993 and 2016, 129 consecutive patients with a mean age of 34.7 ± 10.6 years (range 16-64 years) presented with bicuspid aortic valve and pure AR and underwent the Ross procedure. Patients were reviewed annually and had 2nd yearly transthoracic echocardiograms during follow-up. The unit had a liberal reoperation policy where reoperation was performed if patients developed recurrent moderate or greater AR during follow-up.

RESULTS

There was 1 inpatient death, and 3 late deaths over a mean follow-up duration of 9.6 ± 6.8 years. Late survival at 10 and 20 years post-surgery were 99% [95% confidence interval (CI) 94-100] and 95% (95% CI 85-99), respectively. Eleven patients underwent redo aortic valve replacement (AVR) and 4 patients had redo pulmonary valve replacement. Freedom from reoperation for AVR and more-than-mild AR at 10 and 20 years post-surgery were 89% (95% CI 81-94) and 85% (95% CI 74-92), respectively. Having longer aortic cross-clamp (hazard ratio 1.03, 95% CI 1.00-1.06; P = 0.05) and cardiopulmonary bypass times (hazard ratio 1.02, 95% CI 1.00-1.05; P = 0.05), and having a larger preoperative sinotubular junction diameter (hazard ratio 1.15, 95% CI 1.03-1.30; P = 0.02) were significant predictors of having redo AVR or significant AR at follow-up.

CONCLUSIONS

With a 20-year freedom from redo AVR and greater-than-mild residual AR of 85%, the utilization of the Ross procedure in bicuspid aortic valve patients with pure AR should be considered.

Histopathological evaluation of aortic dissection: a comparison of congenital versus acquired aortic wall weakness

OBJECTIVES

The aim of this study was to identify pathological changes of aortic dissection based on histopathological evaluation of aortic wall weakness by comparing patients with and without congenital abnormalities.

METHODS

We reviewed records of patients who underwent repair for dissection-related aortic disease between 2008 and 2015. Fifty patients (20 men and 30 women; mean age 66.9 ± 14.0 years) who underwent surgery with subsequent histopathological examination of the aortic wall were divided into 2 groups. Group 1 had congenital abnormalities, including Marfan syndrome and bicuspid aortic valve (n = 5), and Group 2 had no congenital abnormalities (n = 45). We compared the histopathological characteristics of the aortic wall in these patients.

RESULTS

There were significant differences in age and body surface area between the 2 groups. Although 80% of Group 1 patients developed dissection at the middle of the media, all Group 2 patients developed dissection at the outer one-third of the media, which is along the pathway of the vasa vasorum of the aortic wall. Both groups showed the same extent of degeneration of the vasa vasorum. Group 1 showed a severe score of mucoid extracellular matrix accumulation in the aortic media.

CONCLUSIONS

Although it may be multifactorial, congenital maldevelopment of the media tends to result in dissection of the centre of the media, and acquired aortic wall weakness is concentrated in the outer third of the media. Degeneration of the vasa vasorum may be an important emerging substrate for developing aortic dissection.

Geometric Ring Annuloplasty for Aortic Valve Repair During Aortic Aneurysm Surgery: Two-Year Clinical Trial Results

OBJECTIVE

An aortic annuloplasty ring could be useful for aortic valve repair. This trial evaluated intermediate-term outcomes of internal geometric ring annuloplasty for repair of trileaflet and bicuspid aortic insufficiency associated with ascending aortic and/or aortic root aneurysms.

METHODS

Under regulatory supervision, 47 patients with aortic insufficiency and ascending aortic (n = 22) and/or aortic root (n = 25) aneurysms were managed with aortic valve repair and aneurysm resection. Valve repair was performed using trileaflet (n = 40) or bicuspid (n = 7) internal geometric rings, together with leaflet reconstruction. Ascending aortic and/or remodeling root replacements were accomplished with Dacron grafts 5 to 7 mm larger than the rings. An Echo Core Lab provided independent echocardiographic assessments, and changes over time were evaluated by Friedman tests.

RESULTS

Mean ± SD age was 60 ± 14 years, 57% (27/47) were male, 15% (7/47) had bicuspid valves, 87% (41/47) had moderate-to-severe aortic insufficiency, and 13% (6/47) had mild aortic insufficiency. All patients had annular dilatation, with a mean ± SD of 26.5 ± 2.6 mm before repair, and mean ± SD ring sizes were 21.7 ± 1.7 mm. Follow-up was 42 months (mean = 27 months). No operative mortality or valve-related complications occurred. Two patients died beyond 1 year from nonvalve-related causes. One patient required valve replacement for repair failure. Survival free of complications or valve replacement was 94% at 2 years. Significant reduction in aortic insufficiency and New York Heart Association class were observed (P < 0.0001), and valve gradients remained low. No heart block or direct ring complications occurred.

CONCLUSIONS

In preliminary regulatory studies, aortic ring annuloplasty seemed safe and effective during aortic aneurysm surgery. This approach could help standardize aortic valve repair.

Predictors of Outcome for Aortic Valve Reimplantation Including the Surgeon-A Single-Center Experience

INTRODUCTION

Aortic valve reimplantation is considered technically demanding. We searched for predictors of long-term outcome including the surgeon as risk factor.

METHODS

We selected all aortic valve reimplantations performed in our department between December 1999 and January 2017 and obtained a complete follow-up. The main indications were combined aortic aneurysm plus aortic valve regurgitation (AR), 69% and aortic dissections (15%). In 14%, valves were bicuspid. Cusp repair was performed in 27% of patients. One-third received additional procedures (coronary artery bypass grafting, mitral, or arch surgery). We performed multivariable analyses for independent risk factors of short- and long-term outcomes, including "surgeon" as variable. Twelve different surgeons operated on 193 patients. We created three groups: surgeons A and B with 84 and 64 procedures, respectively, and surgeon C (10 surgeons for 45 patients).

RESULTS

Cardiopulmonary bypass and clamp times were 176 ± 45 and 130 ± 24 minutes, respectively. In-hospital mortality was 2%. Postoperatively, 5% had mild and 0.5% had moderate AR. Kaplan-Meier's survival estimates, freedom from reoperation, and freedom from severe AR at 12 years were 97 ± 1, 93 ± 2, and 91 ± 3%, respectively. Age and chronic obstructive pulmonary disease appeared as risk factors for perioperative complications by univariate analysis. Age, coronary artery disease, and duration of cardiopulmonary bypass, but not surgeon, presented as risk factors by multivariable analysis.

CONCLUSION

The results suggest that if a David procedure is performed successfully, long-term durability may be excellent. They also suggest that good and durable results are possible even with limited experience of the operating surgeon.

Structural valve deterioration of bioprosthetic aortic valves: An underestimated complication

OBJECTIVES

Structural valve deterioration (SVD) remains a major bioprosthesis-related complication, as recently described for the Mitroflow valve (models LX and 12A) (LivaNova, London, United Kingdom). The real incidence of the SVD risk remains unclear, often due to methodologic pitfalls by systematically using the Kaplan-Meier estimator and/or the Cox model. In this report, we propose for the first time a precise statistical modeling of this issue.

METHODS

Five hundred sixty-one patients who underwent aortic valve replacement with the aortic Mitroflow valve between 2002 and 2007 were included. We used an illness-death model for interval-censored data. Median follow-up was 6.6 years; 103 cases of SVD were diagnosed.

RESULTS

The 4-year and 7-year SVD cumulative incidences after the first anniversary of surgery were 15.2% (95% confidence interval, 11.9-19.1) and 31.0% (95% confidence interval, 25.8-37.2), respectively. Female gender, dyslipidemia, chronic obstructive pulmonary disease, and severe patient-prosthesis mismatch were significant risk factors of SVD. The occurrence of SVD was associated with a 2-fold increase in the risk of death.

CONCLUSIONS

Appropriate statistical models should be used to avoid underestimating the SVD complication associated with worse long-term survival.

CT angiography for depiction of complications after the Bentall procedure

Following a Bentall procedure, which comprises a composite replacement of both the aortic valve and the ascending aorta, the imaging modality of choice to depict known or suspected complications is CT angiography. An update and extension of the literature regarding complications after the Bentall procedure is provided. The wider availability of ECG-gating has allowed for a clearer depiction of the aortic valve and ascending aorta. This resulted not only in the identification of previously undetectable complications, but also in a more precise assessment of the pathophysiology and morphology of known ones, reducing the need for additional imaging modalities. Moreover, the possibility to combine positron emission tomography images with CT angiography offers new insights in case of suspected infection. Due to the complexity of the operation itself and concomitant or subsequent additional procedures, as well as the wide spectrum of underlying pathology, new scenarios with multiple complications can be expected.

Practice Pattern Variation in the Use of Transesophageal Echocardiography for Open Valve Cardiac Surgery

OBJECTIVE

The authors sought to assess for the presence of practice variation in the use of intraoperative transesophageal echocardiography (TEE) for open cardiac valve surgery.

DESIGN

This study was a retrospective cohort analysis.

SETTING

The administrative claims data used for this investigation were multi-institutional and a representative sample of commercially insured patients in the United States between 2010 and 2015.

PARTICIPANTS

The cohort consisted of adult patients, aged 18 years or older, undergoing open mitral valve (MV) or aortic valve (AV) surgery.

INTERVENTIONS

This was an observational analysis without interventions.

MEASUREMENTS AND MAIN RESULTS

Of 19,386 valve surgeries, 12,313 (64%) underwent AV replacement, 6,192 (32%) underwent MV repair or replacement, and 881 (<5%) underwent both MV and AV surgery. The overall rate of intraoperative TEE was 82% (95% confidence interval [CI]: 81%-82%), less frequently observed in AV procedures compared to MV or combined MV-AV procedures (80% v 85%, p < 0.001). Rates of intraoperative TEE claims varied markedly across U.S. states. After adjustment, the relative odds of an intraoperative TEE claim ranged across states from 0.26 (Louisiana, 95% CI: 0.18-0.36; p < 0.001) to 2.10 (North Carolina, 95% CI: 1.57-2.82; p < 0.001).

CONCLUSION

Among adult patients undergoing open AV or MV surgery in the United States, 82% had a claim for an intraoperative TEE with marked variability across U.S. states. Increasing adherence to intraoperative TEE guidelines for valve surgery may represent an unrecognized opportunity to improve the quality of cardiac surgical care.

Congenital aortic stenosis due to unicuspid unicommissural aortic valve: a case report

BACKGROUND

Unicuspid unicommissural aortic valve is an extremely rare congenital anomaly that usually presents in adulthood but can rarely present in infancy. We report a 17-year-old patient with congenital aortic stenosis secondary to unicuspid unicommissural aortic valve that was successfully treated with aortic valve replacement.

CASE PRESENTATION

The patient was diagnosed with aortic stenosis after a murmur was heard in the newborn nursery and subsequently underwent aortic balloon valvuloplasty 6 weeks after birth. He had been regularly followed up since and underwent numerous cardiac catheterizations, including another aortic balloon valvuloplasty at age 13. During follow-up at age 17, the patient presented with symptomatic severe aortic stenosis and mild left ventricular hypertrophy. Aortic valve replacement was planned since the patient was nearly adult-sized and to reduce the risk of cardiac decompensation. During the operation an unicuspid unicommissural aortic valve was revealed. The patient recovered well post-operatively. He was discharged 5 days after the surgery in good condition and was completely symptom-free at follow-up 6 weeks later.

CONCLUSIONS

Unicuspid aortic valve is a rare congenital anomaly that can cause congenital aortic stenosis. It is seldom diagnosed pre-operatively but should be suspected in infants presenting with aortic stenosis.

Aortic root replacement with cryopreserved homograft for infective endocarditis in the modern North American opioid epidemic

OBJECTIVE

To study mid-term survival in patients with infective endocarditis as a result of IV drug use undergoing aortic root replacement with cryopreserved aortic homograft.

METHODS

Patients undergoing aortic root homograft replacement from 2011-2017 were studied retrospectively. Aortic root replacement was performed using a modified Bentall technique. Primary outcomes included both short-term and mid-term survival. Secondary outcomes included immediate postoperative complications.

RESULTS

A total of 138 patients underwent cryopreserved homograft replacement of the aortic root for aortic root abscesses. Eighty-five patients (61.6%) underwent reoperative sternotomy, and 12 patients (8.7%) underwent second or third reoperative sternotomy. Sixty-seven (48.5%) patients had severe aortic insufficiency preoperatively. Operative mortality was 12.3% (17 patients). Five patients (3.6%) sustained a permanent stroke. Twenty-one patients (15.2%) required dialysis for renal failure, and 21 patients (15.2%) had complete heart block necessitating a permanent pacemaker. Estimated 5-year mortality for the cohort was 43%.

CONCLUSIONS

Cryopreserved homograft replacement is a safe and desirable option for high-risk patients with infective endocarditis and aortic root abscess. Homograft accommodation for a widely debrided aortic annular bed provides a reasonable surgical strategy for patients needing aortic root replacement with annular abscess.

Influence of Cryopreservation on Structural, Chemical, and Immunoenzymatic Properties of Aortic Valve Allografts

OBJECTIVES

The problems in preparing (including cryopreservation) and implanting aortic valve allografts (AVAs) is widely elaborated, but some issues need explanation.

MATERIAL AND METHODS

Twenty AVAs cryopreserved in dimethylsulphoxide/RPMI solution under -160°C for 1-15 years and 3 controls stored at +4°C up to 2 weeks, from 19 male and 4 female donors, aged 20-51, ±30.8 years, were examined using light (LM), digital (DM), and scanning electron microscopy (SEM), energy dispersion X-ray spectroscopy (EDS), and enzyme-linked immunosorbent assay immunoenzymatic tests (PECAM1, CD34).

RESULTS

All AVAs were macroscopically correct. LM revealed normal structure of leaflets but massive endothelial decellularization (±59 cells remained on the surface of 5 mm scraps). DM and SEM demonstrated generally normal collagen structures, but local alterations, probably influenced by freezing-thawing (gaps, separated plates) or being initial phase of native degeneration (grains). EDS detected a little elevated calcium amount in 1 specimen only. The mean PECAM1 and CD34 concentrations were at similar low level in all probes.

CONCLUSIONS

Fresh and cryopreservation technologies did not significantly influence the basic properties of AVA leaflets; however, massive endothelial decellularization was present in both groups. Therefore, no endocardial cell activity nor signs of inflammation were observed. These results were independent of donors' age and sex, processing technology, and time of storage of cryopreserved AVAs.

Mechanical versus Tissue Aortic Prosthesis in Sexagenarians: Comparison of Hemodynamic and Clinical Outcomes

Background

The question of which type of prosthetic aortic valve leads to the best outcomes in patients in their 60s remains controversial. We examined the hemodynamic and clinical outcomes of aortic valve replacement in sexagenarians according to the type of prosthesis.

Methods

We retrospectively reviewed 270 patients in their 60s who underwent first-time aortic valve replacement from 1995 to 2011. Early and late mortality, major adverse valve-related events, anticoagulation-related events, and hemodynamic outcomes were assessed. The mean follow-up duration was 58.7±44.0 months.

Results

Of the 270 patients, 93 had a mechanical prosthesis (mechanical group), and 177 had a bioprosthesis (tissue group). The tissue group had a higher mean age and prevalence of preoperative stroke than the mechanical group. The groups had no differences in the aortic valve mean pressure gradient (AVMPG) or the left ventricular mass index (LVMI) at 5 years after surgery. In a sub-analysis limited to prostheses in the supra-annular position, the AVMPG was higher in the tissue group, but the LVMI was still not significantly different. There was no early mortality. The 10-year survival rate was 83% in the mechanical group and 90% in the tissue group. The type of aortic prosthesis did not influence overall mortality, cardiac mortality, or major adverse valve-related events. Anticoagulation-related events were more common in the mechanical group than in the tissue group (p=0.034; hazard ratio, 4.100; 95% confidence interval, 1.111–15.132).

Conclusion

The type of aortic prosthesis was not associated with hemodynamic or clinical outcomes, except for anticoagulation-related events.

Impact of Bicuspid Aortic Valve Morphology on Aortic Valve Disease and Aortic Dilation in Pediatric Patients

Bicuspid aortic valve (BAV) is the most common congenital heart defect. BAV is associated with aortic stenosis and insufficiency, and aortic dilation in adult groups, but data in pediatric groups are limited. We sought to assess the impact of BAV morphology on aortic valve disease and aortic dilation in pediatric patients. We performed a retrospective review of all echocardiograms in patients with isolated BAV who were followed at our institution from July 2002 to July 2012. BAV morphology, aortic valve stenosis and/or insufficiency, and aortic dimensions were measured manually. Comparisons were made between right-left cusp fusion (RL) and right-noncoronary cusp fusion (RN) BAV morphologies. Generalized least square models were fit to analyze the impact of specific variables on aortic dilation. There were 1075 echocardiograms in 366 patients (72% male) with isolated BAV. Aortic valve insufficiency and stenosis were more common in RN (p < 0.001 for both). The median aortic sinus Z score was higher in the RL (0.47; IQR - 0.31 to 1.44) than in the RN group (0.02; - 0.83 to 0.82) (p < 0.001). There was no difference in median ascending aorta Z score between groups. Patients with the highest weights had larger aortas (p < 0.001), but the absolute difference between the highest and lowest weight groups was small (1.5 mm). The impact of BAV morphology on aortic valve disease and aortic dilation in pediatric patients presages that seen in adults. Patient body weight does not make significant clinical impacts on aortic diameters, suggesting that Z scores for aortic diameters should be based on ideal body weights.

Natural history of moderately dilated tubular ascending aorta: implications for determining the optimal imaging interval

OBJECTIVES

For a moderately dilated ascending aorta (diameter 35-54 mm), current guidelines recommend continuous annual or semi-annual examinations with computed tomography or magnetic resonance imaging. However, few data have shown the yield and benefit of such a protocol. This study aimed to investigate the fate of a moderately dilated ascending aorta and thereby determine the adequate imaging interval.

METHODS

In our institutional database, we identified adult patients having an ascending aortic diameter ≥40 mm in contrast-enhanced computed tomography and follow-up imaging(s) after ≥1 year. Of the 509 patients (mean age 67.2 ± 10.4 years) enrolled in the study, the maximal diameter of the ascending aorta was compared between the first and last images. Also, their medical records were reviewed to investigate the associated illness and clinical events.

RESULTS

The mean growth rate of the patients with a 40-44 mm ( n  = 321), 45-49 mm ( n  = 142) and ≥50 mm ( n  = 46) ascending aorta was 0.3 ± 0.5, 0.3 ± 0.5 and 0.7 ± 0.9 mm/year, respectively. During the mean interval of 4.3 ± 2.4 years, significant progression (diameter increase by ≥5 mm) occurred in 3.4, 5.6 and 21.7%, respectively. The 3- to 5-year rates of freedom from significant progression were 99.1%-96.5% (40-44 mm) and 97.8%-96.4% (45-49 mm). In multivariate analysis, initial ascending aortic diameter ≥45 mm and aortic valve regurgitation were significantly associated with significant progression. Acute type A aortic dissection occurred in 5 patients (1%), before the maximal diameter of the ascending aorta reached 55 mm or significant progression was observed.

CONCLUSIONS

For a moderately dilated ascending aorta not exceeding 45 mm in maximal diameter and stable in the first annual follow-up image, a 3- to 4-year interval would be reasonable before subsequent imaging. More frequent imaging may be warranted in patients with aortic valve insufficiency or with an aortic diameter ≥45 mm.

Expanding Eligibility for the Ross Procedure: A Reasonable Proposition?

BACKGROUND

Although the Ross procedure offers potential benefits in young adults, technical complexity represents a significant limitation. Therefore, the safety of expanding its use in more complex settings is uncertain. The aim of this study was to compare early outcomes of standard isolated Ross procedures vs expanding elgibility to higher-risk clinical settings.

METHODS

From 2011 to 2016, 261 patients (46 ± 12 years) underwent Ross procedures in 2 centres. Patients were divided into 2 groups: standard Ross (n = 166) and expanded eligibility Ross (n = 95). Inclusion criteria for the expanded eligibility group were previous cardiac surgery, acute aortic valve endocarditis, severely impaired left ventricular (LV) function and patients undergoing concomitant procedures. All data were prospectively collected and are 100% complete.

RESULTS

Hospital mortality was 0% in the standard group (0/166) vs 2% in the expanded eligibility group (2/95) (P = 0.13). Sixteen patients (10%) developed acute renal injury in the standard group vs 13 (14%) patients in the expanded eligibility group (P = 0.31). There were no postoperative myocardial infarctions, no neurological events, and no infectious complications. Median intensive care unit (ICU) stay in the standard group was 2 vs 3 days in the expanded eligibility group (P = 0.004), whereas median hospital stay was 6 vs 7 days, respectively (range: 3-19 days) (P < 0.001).

CONCLUSION

Aside from longer ICU and hospital lengths of stay after the Ross procedure in higher-risk clinical scenarios, perioperative mortality and morbidity is similar to standard Ross procedures. Expanding the use of the Ross operation in young adults is a safe alternative in centres of expertise.

Transesophageal echocardiography evaluation of the aortic arch branches

Visualization of aortic arch branches by transesophageal echocardiography has been technically challenging. Visualizing these vessels helps in identifying the extent of dissection of the aorta, assessing the severity of carotid artery stenosis, presence of atheromatous plaques, patency of the left internal mammary artery graft, confirmation of subclavian artery cannulation, confirming holodiastolic flow reversal in the left subclavian artery by spectral Doppler imaging in case of severe aortic regurgitation, and confirming the optimal position of the intraaortic balloon perioperatively. The information obtained is helpful for diagnosis, monitoring, and decision-making during aortic surgery.

The influence of Marfans and bicuspid valves on outcomes following aortic valve reimplantation

BACKGROUND

We analyzed our early and midterm results with aortic valve reimplantation surgery to determine the influence of Marfan syndrome and bicuspid valves on outcomes with this technique.

METHODS

Between March 2004 and December 2015, 267 patients underwent aortic valve reimplantation operations. The mean diameter of the sinuses of Valsalva was 50 ± 3 mm and moderate/severe aortic regurgitation was present in 34.4% of these patients. A bicuspid aortic valve was present in 21% and 40% had Marfan syndrome.

RESULTS

Overall 30-day mortality was 0.37% (1/267). Mean follow-up was 59.7 ± 38.7 months. Overall survival at 1, 3, and 5 years was 98 ± 8%, 98 ± 1%, and 94 ± 2%, respectively. Freedom from reoperation and aortic regurgitation >II was 99 ± 5%, 98 ± 8%, 96.7 ± 8%, and 99 ± 6%, 98 ± 1%, 98 ± 1%, respectively at 1, 3, and 5 years follow-up, with no differences between Marfan and bicuspid aortic valve groups. (p = 0.94 and p = 0.96, respectively). No endocarditis or thromboembolic complications were documented, and 93.6% of the patients did not receive any anticoagulation therapy.

CONCLUSIONS

The reimplantation technique for aortic root aneurysms is associated with excellent clinical and functional outcomes at short and mid-term follow-up.

A Protocol for Diagnosis and Management of Aortic Atherosclerosis in Cardiac Surgery Patients

In patients undergoing cardiac surgery, use of perioperative screening for aortic atherosclerosis with modified TEE (A-View method) was associated with lower postoperative mortality, but not stroke, as compared to patients operated on without such screening. At the time of clinical implementation and validation, we did not yet standardize the indications for modified TEE and the changes in patient management in the presence of aortic atherosclerosis. Therefore, we designed a protocol, which combined the diagnosis of atherosclerosis of thoracic aorta and the subsequent considerations with respect to the intraoperative management and provides a systematic approach to reduce the risk of cerebral complications.

Evolution of Precision Medicine and Surgical Strategies for Bicuspid Aortic Valve-Associated Aortopathy

Bicuspid aortic valve (BAV) is a common congenital cardiac malformation affecting 1–2% of people. BAV results from fusion of two adjacent aortic valve cusps, and is associated with dilatation of the aorta, known as bicuspid valve associated aortopathy. Bicuspid valve aortopathy is progressive and associated with catastrophic clinical events, such as aortic dissection and rupture. Therefore, frequent monitoring and early intervention with prophylactic surgical resection of the proximal aorta is often recommended. However, the specific pattern of aortopathy is highly variable among patients, with different segments of the ascending aorta being affected. Individual patient risks are sometimes difficult to predict. Resection strategies are informed by current surgical guidelines which are primarily based on aortic size and growth criteria. These criteria may not optimally reflect the risk of important aortic events. To address these issues in the care of patients with bicuspid valve aortopathy, our translational research group has focused on validating use of novel imaging techniques to establish non-invasive hemodynamic biomarkers for risk-stratifying BAV patients. In this article, we review recent efforts, successes, and ongoing challenges in the development of more precise and individualized surgical approaches for patients with bicuspid aortic valves and associated aortic disease.

Surgery for Diseases of the Aortic Root

The aortic root is the junction between the heart and aorta, containing the aortic valve and the coronary artery ostia. Various pathologic conditions arise in this region requiring complex surgical correction. These include aneurysmal dilatation with and without aortic regurgitation, acute aortic dissection extending below the sinotubular junction, and infective endocarditis with valve and periannular destruction. Multiple strategies for correction of these complex surgical issues exist, with excellent early results and long-term survival.

Comparing American, European and Asian practice guidelines for aortic diseases

The aortic disease comprises a group of different pathologies of high prevalence, seriousness and ever changing by the medical and surgical investigations. Therefore cardiovascular scientific societies in USA, Europe and Asia have created Task Force on practice guidelines (PG) to develop, update and revise PG for aortic diseases. These documents issue recommendations on the diagnosis and management of different aortic diseases. The three societies agree on the recommendations about diagnostic tests and on the value of computed tomography and magnetic resonance as the main tools for the diagnosis and follow-up of aortic disease. Concerning to acute aortic syndromes (AAS), American and European GPs recognize intramural hematoma (IMH) as a type of AAS with surgery indication; however Asian guidelines consider IMH a pathological process different from AAS and indicate medical treatment. In thoracic aortic aneurysms (TAA), all express the need for an adequate control of cardiovascular risk factors, emphasizing strict control of blood pressure, smoking cessation and recommend the use of beta-blockers and statins. The threshold for asymptomatic repair is 5.5 cm in European and American and 6 cm for Asian PG, with lower thresholds in Marfan and bicuspid aortic valve (BAV). As regards the abdominal aortic aneurysms (AAA), the PGs recognize the adequate control of cardiovascular risk factors, but there are differences in class of recommendation on statins, angiotensin-converting enzyme inhibitors or beta-blockers to prevent progression of AAA. For intervention, the threshold diameter in asymptomatic is 5.5 cm but can be reduced to 5 cm in women as recommended by Asian PG. Moreover the specific diseases such as Marfan, BAV, pregnancy or atherosclerosis aortic present specific recommendations with small differences between PGs. In conclusion, PGs are interesting and appropriate documents at present. They issue recommendations based on evidence that help the clinician and surgeon in their daily approach to aortic pathology.

Aortic Volumetry at Contrast-Enhanced Magnetic Resonance Angiography: Feasibility as a Sensitive Method for Monitoring Bicuspid Aortic Valve Aortopathy

OBJECTIVES

Bicuspid aortic valve patients can develop thoracic aortic aneurysms and therefore require serial imaging to monitor aortic growth. This study investigates the reliability of contrast-enhanced magnetic resonance angiography (CEMRA) volumetry compared with 2-dimensional diameter measurements to identify thoracic aortic aneurysm growth.

MATERIALS AND METHODS

A retrospective, institutional review board-approved, and Health Insurance Portability and Accountability Act-compliant study was conducted on 20 bicuspid aortic valve patients (45 ± 8.9 years, 20% women) who underwent serial CEMRA with a minimum imaging follow-up of 11 months. Magnetic resonance imaging was performed at 1.5 T with electrocardiogram-gated, time-resolved CEMRA. Independent observers measured the diameter at the sinuses of Valsalva (SOVs) and mid ascending aorta (MAA) as well as ascending aorta volume between the aortic valve annulus and innominate branch. Intraobserver/interobserver coefficient of variation (COV) and intraclass correlation coefficient (ICC) were computed to assess reliability. Growth rates were calculated and assessed by Student t test (P < 0.05, significant). The diameter of maximal growth (DMG), defined as the diameter at SOV or MAA with the faster growth rate, was recorded.

RESULTS

The mean time of follow-up was 2.6 ± 0.82 years. The intraobserver COV was 0.01 for SOV, 0.02 for MAA, and 0.02 for volume (interobserver COV: 0.02, 0.03, 0.04, respectively). The ICC was 0.83 for SOV, 0.86 for MAA, 0.90 for DMG, and 0.95 for volume. Average aortic measurements at baseline and (follow-up) were 42 ± 3 mm (42 ± 3 mm, P = 0.11) at SOV, 46 ± 4 mm (47 ± 4 mm, P < 0.05) at MAA, and 130 ± 23 mL (144 ± 24 mL, P < 0.05). Average size changes were 0.2 ± 0.6 mm/y (1% ± 2%) at SOV, 0.5 ± 0.8 mm/y (1% ± 2%) at MAA, 0.7 ± 0.7 mm/y (2% ± 2%) at DMG, and 6 ± 3 mL/y (4% ± 3%) with volumetry.

CONCLUSIONS

Three-dimensional CEMRA volumetry exhibited a larger effect when examining percentage growth, a better ICC, and a marginally lower COV. Volumetry may be more sensitive to growth and possibly less affected by error than diameter measurements.