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Urbanski PP, Atieh A, Lehmkuhl L, Irimie V, Zhan X, Thamm T, Ahmidou A, Nasra W, Diegeler A. Selective sinus replacement for aortic root repair in bicuspid aortopathy. J Thorac Cardiovasc Surg 2024; 167:908-917.e6. [PMID: 35461710 DOI: 10.1016/j.jtcvs.2022.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/09/2022] [Accepted: 03/16/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To evaluate the results after selective sinus replacement (SSR) for aortic root remodeling in bicuspid aortopathy. METHODS Among 662 patients who underwent root repair using SSR between 2005 and 2020, there were 114 with bicuspid aortopathy. SSR was performed either as an isolated procedure (31) or as an adjunct to aortic valve repair (83) and was adjusted to the existing aortic annulus diameter rather than a downsized diameter. In valves with asymmetrical commissural orientation, the repair aimed for the achievement of a 180°-commissural orientation. RESULTS Abolishment of aortic insufficiency (AI) ≥2+ using root repair alone was only possible in 2 patients with acute-dissection-related AI, yet isolated root repair was also performed in 29 further patients with no/mild AI. All remaining patients with AI ≥2+ presented cusp-related regurgitation and necessitated an additional valve repair. During the mean follow-up of 91 months (range, 13-196), a relevant valve defect (AI ≥3+ in 8, stenosis in 2) occurred in 10 patients (all after combined repair) resulting in an estimated freedom from a relevant aortic valve defect and/or reoperation of 96 ± 2%, 89 ± 4%, and 82 ± 6% at 5, 10, and 12 years, respectively. Echocardiographically, no patient revealed a considerable change of form or size of the repaired root nor was any root reintervention necessary. CONCLUSIONS Patient-tailored root repair using SSR is a very effective and durable valve-sparing approach for bicuspid aortopathy. Aortic cusp repair is decisive for both abolishment of AI in bicuspid aortopathy and for the functional durability of the repaired aortic valve.
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Affiliation(s)
- Paul P Urbanski
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany.
| | - Alaa Atieh
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Lukas Lehmkuhl
- Department of Radiology, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Vadim Irimie
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Xiaochun Zhan
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Tarvo Thamm
- Department for Medical Statistics, Campus Bad Neustadt, Bad Neustadt, Germany
| | - Akram Ahmidou
- Department for Medical Statistics, Campus Bad Neustadt, Bad Neustadt, Germany
| | - Wasim Nasra
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Anno Diegeler
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
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Zhang H. Bicuspid aortic valve repair-current techniques, outcomes, challenges, and future perspectives. Front Cardiovasc Med 2024; 10:1295146. [PMID: 38235290 PMCID: PMC10791802 DOI: 10.3389/fcvm.2023.1295146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/23/2023] [Indexed: 01/19/2024] Open
Abstract
Bicuspid aortic valve (BAV) is a common congenital heart condition that can lead to some valve-related complications, such as aortic stenosis and/or regurgitation, and is often associated with aortic root dilation. With the development and refinement of BAV repair techniques over the past three decades, surgical repair of BAV has emerged as an effective treatment option, offering symptomatic relief and improved outcomes. This review aims to summarize the current techniques, outcomes, and challenges of BAV repair, and to provide potential future perspectives in the field.
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Affiliation(s)
- Haiyu Zhang
- School of Biological and Behavioural Sciences, Queen Mary University of London, London, United Kingdom
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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Abstract
The clinical outcome of severe aortic regurgitation (AR) remains suboptimal, but surgery has been shown to have survival benefit over medical therapy. Postoperative survival is inferior in patients with reduced left ventricular function, and therefore early surgical intervention is recommended. Aortic valvuloplasty (AVP) is an attractive option to avoid the major drawbacks of prosthetic valves but has not been widely adopted. The etiology of AR is classified functionally into three groups: normal leaflet motion (type I), cusp prolapse (type II), and restriction (type III). Type I with dilatation of the sinus of Valsalva (type Ib) can be repaired by aortic valve reimplantation or aortic root remodeling with similar valve stability. Type I with dilatation of the aortic annulus (type Ic) can be managed by annuloplasty. Type II can be corrected by plication or resuspension techniques. Pericardial patch is necessary in AVP for type Id (perforation/fenestration) and type III but is associated with risk of recurrence. Bicuspid aortic valve is classified according to commissure angle: symmetrical, asymmetrical, and very asymmetrical. Tricuspidization is recommended for repair of very asymmetrical valves to avoid postoperative stenosis. Recent progress has achieved similar reoperation rates between bicuspid and tricuspid aortic valve repair. For Marfan syndrome, valve-sparing root replacement is advantageous compared to Bentall operation regarding late survival, thromboembolic and hemorrhagic events, and endocarditis. Similar findings have been reported in acute aortic dissection. Both remodeling and reimplantation procedures provide similar favorable outcomes in these settings. Recent advances in AVP are summarized by quantitative assessment of cusp configuration (effective height and geometric height), graft size decision, use of template to cut the graft, and videoscopic assessment of post-repair cusp configuration. Due to these advances, AVP shows superior results to replacement surgery. Further concrete evidence with larger case volumes and longer observation periods are necessary to popularize AVP.
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Safari M, Monsefi N, Karimian-Tabrizi A, Miskovic A, Van Linden A, Zacek P, Moritz A, Walther T, Holubec T. Longer-term outcomes after bicuspid aortic valve repair in 142 patients. J Card Surg 2021; 36:4645-4651. [PMID: 34547142 DOI: 10.1111/jocs.16006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/22/2021] [Accepted: 09/06/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the longer-term results of bicuspid aortic valve (BAV) repair with or without aortic root replacement. METHODS From 1999 to 2017, 142 patients with or without aortic root dilatation who underwent repair of a regurgitant BAV were included in the study. Ninety-four patients underwent isolated BAV repair (Group 1; median age 43 years) and 48 patients underwent valve-sparing aortic root replacement plus BAV repair (aortic valve reimplantation-Group 2; median age 48 years). Median clinical follow-up time was 5.9 years (range 0.5-15) in Group 1 and 3 years (range 0.5-16) in Group 2, respectively. RESULTS In-hospital mortality was 1% in Group 1, and 2% in Group 2 (p = .6). The 5- and 10-year survival was 93 ± 2.9% and 81 ± 5.8% in Group 1 and 96 ± 3.1% and 96 ± 3.1% in Group 2, respectively (p = .31). Eleven patients of Group 1 (1.7%/patient-year) and five patients of Group 2 (2.2%/patient-year) underwent reoperation of the aortic valve (p = .5). The 5- and 10-year freedom from reoperation were 93.0 ± 2.1% and 77.1 ± 7.1% in Group 1 and 93.0 ± 5.0% and 76.7 ± 9.6% in Group 2 (p = .83), respectively. At the latest follow-up, only two patients of Group 1 and 1 patient of Group 2 had AV regurgitation = 2° (p = .7). The cumulative linearized incidence of all valve-related complications (bleeding, stroke, endocarditis, and reoperation) was 2.9%/patient-year in Group 1% and 4%/patient-year in Group 2, respectively (p = .6). CONCLUSIONS Isolated BAV repair and combined aortic valve reimplantation plus BAV repair provide good clinical longer-term outcomes with relatively low reoperation rate and durable valve function.
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Affiliation(s)
- Mojyan Safari
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Nadejda Monsefi
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Afsaneh Karimian-Tabrizi
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Alexandra Miskovic
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Arnaud Van Linden
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Pavel Zacek
- Department of Cardiac Surgery, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove and Charles University, Hradec Kralove, Czech Republic
| | - Anton Moritz
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Thomas Walther
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Tomas Holubec
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
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Salem R, Zierer A, Karimian-Tabrizi A, Miskovic A, Moritz A, Risteski P, Monsefi N. Aortic Valve Repair for Aortic Insufficiency or Dilatation: Technical Evolution and Long-term Outcomes. Ann Thorac Surg 2020; 110:1967-1973. [DOI: 10.1016/j.athoracsur.2020.03.105] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 03/21/2020] [Accepted: 03/27/2020] [Indexed: 10/24/2022]
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Wollmann L, Suss P, Mendonça J, Luzia C, Schittini A, Rosa GWXD, Costa F, Tuon FF. Characterization of Decellularized Human Pericardium for Tissue Engineering and Regenerative Medicine Applications. Arq Bras Cardiol 2019; 113:11-17. [PMID: 31271596 PMCID: PMC6684174 DOI: 10.5935/abc.20190094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 09/19/2018] [Indexed: 12/29/2022] Open
Abstract
Background Pericardium tissue allograft can be used for surgical repair in several
procedures. One of the tissue engineering strategies is the process of
decellularization. This process decreases immunogenic response, but it may
modify the natural extracellular matrix composition and behavior. Objective The aim of this study was to evaluate the effectiveness of cell removal,
maintenance of extracellular matrix properties and mechanical integrity of
decellularized human pericardium using a low concentration solution of
sodium dodecyl sulfate. Methods Decellularization was performed with sodium dodecyl sulfate and
ethylenediaminetetraacetic acid. Histological analysis, DNA quantification,
evaluation of glycosaminoglycans and collagen were performed. Biomechanical
assay was performed using tensile test to compare the decellularization
effects on tissue properties of tensile strength, elongation and elastic
modulus. P < 0.05 was considered significant. Results There was reduction in visible nuclei present in pericardium tissue after
decellularization, but it retained collagen and elastin bundles similar to
fresh pericardium. The DNA contents of the decellularized pericardium were
significantly reduced to less than 511.23 ± 120.4 ng per mg of dry
weight (p < 0.001). The biomechanical assay showed no significant
difference for fresh or decellularized tissue. Conclusion The decellularization process reduces cell content as well as extracellular
matrix components without changing its biomechanical properties.
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Affiliation(s)
- Luciana Wollmann
- Pontifícia Universidade Católica do Paraná, Curitiba, PR - Brazil
| | - Paula Suss
- Pontifícia Universidade Católica do Paraná, Curitiba, PR - Brazil
| | - João Mendonça
- Pontifícia Universidade Católica do Paraná, Curitiba, PR - Brazil
| | - Cesar Luzia
- Pontifícia Universidade Católica do Paraná, Curitiba, PR - Brazil
| | | | | | - Francisco Costa
- Pontifícia Universidade Católica do Paraná, Curitiba, PR - Brazil
| | - Felipe F Tuon
- Pontifícia Universidade Católica do Paraná, Curitiba, PR - Brazil
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Miyahara S, Schneider U, Morgenthaler L, Schäfers HJ. (Almost) All Nonstenotic Bicuspid Aortic Valves Should Be Preserved or Repaired. Semin Thorac Cardiovasc Surg 2019; 31:656-660. [DOI: 10.1053/j.semtcvs.2019.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/18/2019] [Indexed: 11/11/2022]
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Abstract
A bicuspid aortic valve is not only a common congenital heart defect but also an enigmatic condition that can cause a large spectrum of diseases, such as aortic valve stenosis and severe heart failure in newborns whereas aortic dissection in adults. On the contrary, a bicuspid aortic valve can also occur with normal function throughout life and never need treatment. Numerous genetic mechanisms are involved in the abnormal cellular functions that may cause abnormal development of the aortic valve during early foetal life. As several chromosomal disorders are also associated with a bicuspid valve, there does not appear to be an apparent common trigger to the abnormal development of the aortic valve. The clinical care of the bicuspid aortic valve patient has been changed by a significant body of evidence that has improved the understanding of the natural history of the disease, including when to best intervene with valve replacement and when to provide prophylactic aortic root surgery. Moreover, as bicuspid valve disease is also part of various syndromes, we can identify high-risk patients in whom a bicuspid valve is much more unfavourable than in the normal population. This review provides an overview of all aspects of the bicuspid aortic valve condition and gives an updated perspective on issues from pathophysiology to clinical care of bicuspid aortic valve disease and associated aortic disease in asymptomatic, symptomatic, and pregnant patients, as well as our viewpoint on population screening.
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Cakir H, Yurekli I, Donmez K, Kestelli M, Asar K. Property of Tricuspid Leaflets in Ventriculoarterial Valves. Ann Thorac Surg 2018; 108:313. [PMID: 30586581 DOI: 10.1016/j.athoracsur.2018.11.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 11/27/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Habib Cakir
- Department of Cardiovascular Surgery, Izmir Katip Celebi University, Ataturk Education and Training Hospital, Flat 7, 35000, Karabaglar, Izmir, Turkey.
| | - Ismail Yurekli
- Department of Cardiovascular Surgery, Izmir Katip Celebi University, Ataturk Education and Training Hospital, Flat 7, 35000, Karabaglar, Izmir, Turkey
| | - Koksal Donmez
- Department of Cardiovascular Surgery, Izmir Katip Celebi University, Ataturk Education and Training Hospital, Flat 7, 35000, Karabaglar, Izmir, Turkey
| | - Mert Kestelli
- Department of Cardiovascular Surgery, Izmir Katip Celebi University, Ataturk Education and Training Hospital, Flat 7, 35000, Karabaglar, Izmir, Turkey
| | - Kamil Asar
- Department of Anesthesia, Izmir Katip Celebi University, Ataturk Education and Training Hospital, Karabaglar, Izmir, Turkey
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Kunihara T. Aortic valve repair for aortic regurgitation and preoperative echocardiographic assessment. J Med Ultrason (2001) 2018; 46:51-62. [PMID: 30232651 DOI: 10.1007/s10396-018-0903-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 08/01/2018] [Indexed: 12/26/2022]
Abstract
Aortic valvuloplasty (AVP) has been performed less frequently than mitral valvuloplasty. The survival benefit of AVP over replacement has been demonstrated. Therefore, standardization of AVP is crucial for its widespread adoption. The hemodynamic advantage of AVP of preserving the native aortic valve may be one reason for the survival benefit. Recent guidelines still recommend AVP in selected cases compared with the less restricted recommendation for mitral valvuloplasty, although recent studies have proposed earlier indication for surgical intervention. Indication for aortic root replacement is also still conservative, especially in Japan. However, more liberal root replacement should be recommended for better repair when AVP is indicated. Theoretically, all aortic regurgitation lesions can be repaired with acceptable durability. However, restricted cusp should be extended by a pericardial patch, which itself has emerged as a risk of recurrence. Therefore, indications for aortic regurgitation for type III lesions should be determined carefully. Special consideration is crucial for bicuspid aortic valve repair; prevention of postoperative stenosis is especially important. Arrangement of the commissure position is the most important consideration for this purpose, although it remains controversial. Therefore, detailed diagnosis is important in planning AVP, and echocardiography plays a key role in this process.
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Affiliation(s)
- Takashi Kunihara
- Department of Cardiac Surgery, Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan.
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Klotz S, Stock S, Sievers HH, Diwoky M, Petersen M, Stierle U, Richardt D. Survival and reoperation pattern after 20 years of experience with aortic valve–sparing root replacement in patients with tricuspid and bicuspid valves. J Thorac Cardiovasc Surg 2018; 155:1403-1411.e1. [DOI: 10.1016/j.jtcvs.2017.12.039] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 11/15/2017] [Accepted: 12/05/2017] [Indexed: 11/26/2022]
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