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Gofus J, Vojacek J, Karalko M, Zacek P, Kolesar A, Toporcer T, Urban M, Glac F, Cerny S, Homola P, Hlubocky J, Slautin A, Fila P, Zakova D, Sterba J, Rashid H, Van Linden A, Holubec T. Aortic valve performance after remodelling versus reimplantation in a propensity-matched comparison. Eur J Cardiothorac Surg 2024; 66:ezae234. [PMID: 39102871 DOI: 10.1093/ejcts/ezae234] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 05/09/2024] [Accepted: 06/10/2024] [Indexed: 08/07/2024] Open
Abstract
OBJECTIVES Both aortic root remodelling and aortic valve (AV) reimplantation have been used for valve-sparing root replacement in patients with aortic root aneurysm with or without aortic regurgitation. There is no clear evidence to support one technique over the another. This study aimed to compare remodelling with basal ring annuloplasty versus reimplantation on a multicentre level with the use of propensity-score matching. METHODS This was a retrospective international multicentre study of patients undergoing remodelling or reimplantation between 2010 and 2021. Twenty-three preoperative covariates (including root dimensions and valve characteristics) were used for propensity-score matching. Perioperative outcomes were analysed along with longer-term freedom from AV reoperation/reintervention and other major valve-related events. RESULTS Throughout the study period, 297 patients underwent remodelling and 281 had reimplantation. Using propensity-score matching, 112 pairs were selected and further compared. We did not find a statistically significant difference in perioperative outcomes between the matched groups. Patients after remodelling had significantly higher reintervention risk than after reimplantation over the median follow-up of 6 years (P = 0.016). The remodelling technique (P = 0.02), need for decalcification (P = 0.03) and degree of immediate postoperative AV regurgitation (P < 0.001) were defined as independent risk factors for later AV reintervention. After exclusion of patients with worse than mild AV regurgitation immediately after repair, both techniques functioned comparably (P = 0.089). CONCLUSIONS AV reimplantation was associated with better valve function in longer-term postoperatively than remodelling. If optimal immediate repair outcome was achieved, both techniques provided comparable AV function.
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Affiliation(s)
- Jan Gofus
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Jan Vojacek
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Mikita Karalko
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Pavel Zacek
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Adrian Kolesar
- Department of Cardiac Surgery, Faculty of Medicine and East Slovak Institute of Cardiovascular Disease, Pavol Jozef Šafárik University, Košice, Slovakia
| | - Tomas Toporcer
- Department of Cardiac Surgery, Faculty of Medicine and East Slovak Institute of Cardiovascular Disease, Pavol Jozef Šafárik University, Košice, Slovakia
| | - Martin Urban
- Department of Cardiac Surgery, Hospital AGEL Trinec-V Podlesí, Trinec, Czech Republic
| | - Filip Glac
- Department of Cardiac Surgery, Hospital AGEL Trinec-V Podlesí, Trinec, Czech Republic
| | - Stepan Cerny
- Department of Cardiac Surgery, Na Homolce Hospital, Prague, Czech Republic
- Department of Cardiovascular Surgery, University Hospital in Motol, Prague, Czech Republic
| | - Pavel Homola
- Department of Cardiac Surgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jaroslav Hlubocky
- 2nd Department of Surgery, 1st Faculty of Medicine and General University Hospital in Prague, Charles University, Prague, Czech Republic
| | - Andrey Slautin
- 2nd Department of Surgery, 1st Faculty of Medicine and General University Hospital in Prague, Charles University, Prague, Czech Republic
| | - Petr Fila
- Department of Cardiovascular Surgery and Transplantation, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Daniela Zakova
- Department of Cardiovascular Surgery and Transplantation, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jan Sterba
- Department of Cardiovascular Surgery and Transplantation, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Hiwad Rashid
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Arnaud Van Linden
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Tomas Holubec
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, Frankfurt/Main, Germany
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Jahanyar J, Pettinari M, El Khoury G, De Kerchove L. Once again the devil is in the details. Eur J Cardiothorac Surg 2024; 66:ezae261. [PMID: 38960733 DOI: 10.1093/ejcts/ezae261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 07/02/2024] [Indexed: 07/05/2024] Open
Affiliation(s)
- Jama Jahanyar
- Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Matteo Pettinari
- Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Gébrine El Khoury
- Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Laurent De Kerchove
- Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
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Ouzounian M, Lafreniere-Roula M, Elbatarny M, David CM, Chung JCY, David TE. Long-term outcomes following valve-sparing root replacement with concomitant mitral repair. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00189-2. [PMID: 38458348 DOI: 10.1016/j.jtcvs.2024.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 02/03/2024] [Accepted: 02/19/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVES To examine the late outcomes of valve-sparing root replacement and concomitant mitral valve repair in patients who have been followed prospectively for more than 2 decades. METHODS From 1992 to 2020, 54 consecutive patients (mean age, 47 ± 16 years; 80% men) underwent valve-sparing root replacement (45 reimplantation and 9 remodeling) with concomitant repair of the mitral valve. Patients were followed prospectively for a median of 9 years (IQR, 3-14 years). RESULTS No patient experienced perioperative death or stroke. There were 3 late deaths and the 15-year overall survival was 96.0% (95% CI, 74.8%-99.4%), similar to the age- and sex-matched population. Over the follow-up period, 6 patients had reoperation of the aortic valve and 3 on the mitral valve. Of those, 2 had reoperation on both aortic and mitral valves for a total of 7 reoperations in this cohort. The cumulative proportion of reoperation at 10 years of either or both valves were as follows: aortic valve 11.4% (95% CI, 3.9%-33.3%), mitral valve 4.2% (95% CI, 0.6%-28.4%), and both valves 11.4% (95% CI, 3.9%-33.3%). The estimated probability of developing moderate/severe aortic insufficiency at 15 years was 18.5% (95% CI, 9.0%-34.2%). On final echocardiographic follow-up, none of the patients had developed moderate/severe mitral regurgitation. CONCLUSIONS In this single-center series of concomitant valve-sparing root replacement and mitral valve repair, we observed excellent clinical outcomes with a low risk of death or valve-related complications. Continued surveillance of late valve function is necessary.
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Affiliation(s)
- Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Myriam Lafreniere-Roula
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Malak Elbatarny
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Carolyn M David
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C Y Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Tirone E David
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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Burton S, Reynolds AC, King N, Modi A, Asopa S. Midterm Clinical Outcomes of Reimplantation Versus Remodeling Valve-Sparing Aortic Root Replacement in Patients With Connective Tissue Disorders: A Meta-Analysis. Am J Cardiol 2024; 213:28-35. [PMID: 38104753 DOI: 10.1016/j.amjcard.2023.11.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/13/2023] [Accepted: 11/29/2023] [Indexed: 12/19/2023]
Abstract
This meta-analysis aimed to compare the midterm clinical outcomes of reimplantation versus remodeling techniques for valve-sparing aortic root replacement (VSARR) in patients with connective tissue disorders (CTDs). Studies were screened and identified after the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines from the PubMed, Web of Science, and Embase databases. Forest plots were produced using Review Manager 5.3 (Cochrane, UK). Studies comparing early and midterm clinical outcomes of reimplantation versus remodeling VSARR in patients with CTD with a mean age ≥18 years were included. The sensitivity analysis excluded studies and subgroups of patients that received ring or suture annuloplasty in addition to remodeling surgery. The study selection identified 9 eligible studies. After analysis of the study period and location for patient crossover, 7 retrospective studies consisting of 597 patients (301 reimplantation and 296 remodeling) were pooled. The pooling revealed no significant difference in postoperative mortality (estimated mean follow-up of 10.5 years) (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.30 to 1.48, I2 = 30%, p = 0.32), reoperation (OR 0.35, CI 0.04 to 3.30, I2 = 81%, p = 0.36), or occurrence of postoperative aortic regurgitation of ≥2 (OR 0.56, CI 0.31 to 1.02, I2 = 47%, p = 0.06). The sensitivity analysis excluding annuloplasty demonstrated improved mortality (OR 0.19, CI 0.06 to 0.64, I2 = 0%, p = 0.007) and decreased aortic regurgitation of ≥2 (OR 0.23, CI 0.10 to 0.53, I2 = 47%, p = 0.0005) in reimplantation VSARR. The rates of reoperation remained insignificant in the sensitivity analysis (OR 0.43, CI 0.05 to 3.53, I2 = 71%, p = 0.43). In conclusion, this meta-analysis has demonstrated no significant difference in the midterm clinical outcomes of reimplantation versus remodeling techniques of VSARR. The sensitivity analysis excluding studies and patient subgroups that received remodeling and annuloplasty suggests remodeling alone to be inferior to reimplantation in patients with CTDs. Further research is required to assess remodeling and annuloplasty against reimplantation in patients of this demographic because the current body of knowledge does not allow sufficient analysis.
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Affiliation(s)
- Samuel Burton
- Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom.
| | | | - Nicola King
- Faculty of Health, University of Plymouth, Plymouth, United Kingdom
| | - Amit Modi
- Wessex Cardiac Centre, Southampton, United Kingdom
| | - Sanjay Asopa
- Southwest Cardiothoracic Centre, Plymouth, United Kingdom
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Jasinski MJ, Joshua M, Jasinski J, Kosiorowska K, Berezowski M. Valve-sparing operations in patients with Marfan syndrome: There is a room for improvement. J Thorac Cardiovasc Surg 2024; 167:e35-e36. [PMID: 37330730 DOI: 10.1016/j.jtcvs.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 04/26/2023] [Accepted: 05/08/2023] [Indexed: 06/19/2023]
Affiliation(s)
- Marek J Jasinski
- Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Manalo Joshua
- Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Jakub Jasinski
- Department of Cardiac Surgery, Silesian Medical University, Katowice, Poland
| | - Kinga Kosiorowska
- Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Mikolaj Berezowski
- Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
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David TE, Park J, Tatangelo M, Steve Fan CP, Ouzounian M. Cardiovascular Events After Aortic Root Repair in Patients With Marfan Syndrome. J Am Coll Cardiol 2023; 82:1068-1076. [PMID: 37673508 DOI: 10.1016/j.jacc.2023.06.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/12/2023] [Accepted: 06/16/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND The usefulness of aortic valve sparing operations to treat aortic root aneurysm in patients with Marfan syndrome (MS) remains controversial. OBJECTIVES The purpose of this study was to evaluate the occurrence of cardiovascular events in patients with MS who have undergone valve-preserving aortic root replacement. METHODS Patients with MS who had aortic valve sparing operations (reimplantation of the aortic valve or remodeling of the aortic root) from 1988 through 2019 were followed prospectively for a median of 14 years. Pertinent data from clinical, echocardiographic, computed tomography, and magnetic resonance images of the aorta were collected and analyzed. RESULTS There were 189 patients whose mean age was 36 years, and 67% were men. Ten patients presented with acute type A dissection and 29 had mitral regurgitation. There were 52 patients at risk at 20 years. Mortality rate at 20 years was 21.5% (95% CI: 14.7%-30.8%); advancing age and preoperative aortic dissections were associated with increased risk of death by multivariable analysis. At 20 years, the cumulative incidence of moderate or severe aortic insufficiency was 14.5% (95% CI: 9.5%-22.0%), reoperation on the aortic valve was 7.5% (95% CI: 3.9%-14.7%), and new distal aortic dissections was 19.9% (95% CI: 13.9%-28.5%). Remodeling of aortic root was associated with greater risk of developing aortic insufficiency and aortic valve reoperation than reimplantation of the aortic valve. CONCLUSIONS Aortic valve sparing operations provide stable aortic valve function and low rates of valve-related complications during the first 2 decades of follow-up but aortic dissections remain problematic in patients with MS.
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Affiliation(s)
- Tirone E David
- Division of Cardiovascular Surgery of Toronto General Hospital, Peter Munk Cardiac Centre at University Health Network and University of Toronto, Toronto, Ontario, Canada.
| | - Joy Park
- Division of Cardiovascular Surgery of Toronto General Hospital, Peter Munk Cardiac Centre at University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Mark Tatangelo
- Division of Cardiovascular Surgery of Toronto General Hospital, Peter Munk Cardiac Centre at University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Chun-Po Steve Fan
- Division of Cardiovascular Surgery of Toronto General Hospital, Peter Munk Cardiac Centre at University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery of Toronto General Hospital, Peter Munk Cardiac Centre at University Health Network and University of Toronto, Toronto, Ontario, Canada
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Saran N, Pochettino A. Reply From Authors: Aortic annulus in valve-sparing root replacement: Size does matter! J Thorac Cardiovasc Surg 2023; 165:e148-e149. [PMID: 36528431 DOI: 10.1016/j.jtcvs.2022.11.008] [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: 11/06/2022] [Accepted: 11/09/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
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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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