Does the Aortic Annulus Dilate After Aortic Root Remodeling?

Outcomes of Valve-Sparing Surgery in Heritable Aortic Disorders: Results from the AVIATOR Registry

OBJECTIVES

Root reimplantation has been the favored approach for patients with heritable aortic disorder (HAD) requiring valve-sparring root replacement (VSRR). In the past few years, root remodelling with annuloplasty has emerged as an alternative to root reimplantation in the general population. The aim of this study was to examine the late outcomes of patients with HAD undergoing VSRR and compare different techniques.

METHODS

Using the AVIATOR registry, data were collected from 5 North American and European centers. Patients were divided in 4 groups according to the technique of valve-sparing used (root reimplantation, root remodelling with ring annuloplasty, root remodelling with suture annuloplasty and root remodelling alone). The primary end-points were freedom from aortic regurgitation (AR) ≥2 and freedom from reintervention on the aortic valve. Secondary end-points were survival and changes in annular dimensions over time.

RESULTS

A total of 237 patients were included in the study (reimplantation= 100, remodelling + ring annuloplasty= 76, remodelling + suture annuloplasty= 34, remodelling alone= 27). The majority of patients had Marfan syndrome (82%). Preoperative AR ≥ 2 was present in 41% of the patients. Operative mortality was 0.4% (n = 1). No differences were found between techniques in terms of postoperative AR ≥ 2 (p = 0.58), reintervention (p = 0.52) and survival (p = 0.59). Changes in aortic annulus dimension were significantly different at 10 years (p < 0.05), a difference that started to emerge 4 after years surgery.

CONCLUSIONS

Overall, VSRR are safe and durable procedures in patients with HAD. Nevertheless, root remodelling alone is associated with late annular dilatation. Addition of an annuloplasty, however, results in similar freedom from AR, reintervention, survival, and changes in annulus size compared to reimplantation.

Early and long-term outcomes of conventional and valve-sparing aortic root replacement

OBJECTIVE

To determine the early and long-term outcomes of conventional aortic root (ARR) and valve-sparing root replacement (VSRR) using a standard perioperative and operative approach.

METHODS

We present prospectively collected data of 609 consecutive patients undergoing elective and urgent aortic root surgery (470 ARR, 139 VSRR) between 2006 and 2020. Primary outcomes were operative mortality and incidence of postoperative complications. Secondary outcomes were long-term survival and requirement for reintervention. Median follow-up was 7.6 years (range 0.5-14.5).

RESULTS

189 patients (31%) had bicuspid aortic valves and 17 (6.9%) underwent redo procedures. Median cross-clamp time was 88 (range 54-208) min with cardiopulmonary bypass of 108 (range 75-296) min. In-hospital mortality was 10 (1.6%), with transient ischaemic attacks/strokes occurring in 1.1%. In-hospital mortality for VSRR was 0.7%. 12 patients (2.0%) required a resternotomy for bleeding and 14 (2.3%) received haemofiltration. Intensive care unit and hospital stay were 1.7 and 7.0 days, respectively. During follow-up, redo surgery for native aortic valve replacement was required in 1.4% of the VSRR group. Overall survival was 95.1% at 3 years, 93.1% at 5 years, 91.2% at 7 years and 88.6% at 10 years.

CONCLUSIONS

ARR and VSRR can be performed with low mortality and morbidity as well as a low rate of reintervention during the period of long-term follow-up, if performed by an experienced team with a consistent perioperative approach. This series provides contemporary evidence to balance the risks of aortic aneurysms and their rupture at diameters of <5.5 cm against the risks and benefits of surgery.

Reimplantation valve-sparing aortic root replacement is the most durable approach to facilitate aortic valve repair

Reimplantation of the aortic valve has been performed for 3 decades, and experience shows that patient selection and meticulous operative technique are crucial to provide excellent clinical outcomes and stable aortic valve function for decades. More than the type of the Dacron graft used for the reimplantation (straight graft or Valsalva graft), we believe that attention to certain technical aspects of this operation is key to a successful and durable aortic valve reconstruction. This article describes the operative procedure as we believe it should be performed based on a learned experience with several hundred cases and summarizes the latest outcomes in a large cohort of patients followed prospectively during the past 3 decades.