Aortic Valve-Sparing Procedure With Cusp Elongation and Free Edge Reinforcement for Bicuspid Aortic Valve

The role of transesophageal echocardiography in aortic valve preserving procedures

In selected cases of aortic regurgitation, aortic valve (AV) repair and AV sparing root reconstruction viable alternatives to aortic valve replacement. Repair and preservation of the native valve avoids the use of long-term anticoagulation, lowers the incidence of subsequent thromboembolic events and reduces the risk of endocarditis. Additionally repair has a low operative mortality with reasonable mid-term durability. The success and longer term durability of AVPP has improved with surgical experience. An understanding of the mechanism of the AR is integral to determining feasibility and success of an AVPP. Assessment of AV morphology, anatomy of the functional aortic annulus (FAA) and the aortic root with transesophageal echocardiography (TEE) improves the understanding of the mechanisms of AR. Pre- and intra-operative TEE plays a pivotal role in guiding case selection, surgical planning, and in evaluating procedural success. Post-operative transthoracic echocardiography is useful to determine long-term success and monitor for recurrence of AR.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

On the multiscale modeling of heart valve biomechanics in health and disease

Theoretical models of the human heart valves are useful tools for understanding and characterizing the dynamics of healthy and diseased valves. Enabled by advances in numerical modeling and in a range of disciplines within experimental biomechanics, recent models of the heart valves have become increasingly comprehensive and accurate. In this paper, we first review the fundamentals of native heart valve physiology, composition and mechanics in health and disease. We will then furnish an overview of the development of theoretical and experimental methods in modeling heart valve biomechanics over the past three decades. Next, we will emphasize the necessity of using multiscale modeling approaches in order to provide a comprehensive description of heart valve biomechanics able to capture general heart valve behavior. Finally, we will offer an outlook for the future of valve multiscale modeling, the potential directions for further developments and the challenges involved.