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Argaw S, Azizgolshani N, Blitzer D, Takayama H, George I, Pirelli L. Treatment options for isolated aortic valve insufficiency: a review. Front Cardiovasc Med 2024; 11:1381102. [PMID: 38665234 PMCID: PMC11043486 DOI: 10.3389/fcvm.2024.1381102] [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: 02/02/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Aortic insufficiency (AI) is a valvular disease with increasing prevalence in older patients. The modern era provides numerous options for the management of AI which is explored here. Traditional interventions included aortic valve replacement with either mechanical or bioprosthetic aortic valves. While the former is known for its durability, it has grown out of favor due to the potential complications of anticoagulation. The preference for bioprosthetic valves is thus on the rise, especially with the advancements of transcatheter technology and the use of valve-in-valve therapy. Surgical options are also no longer limited to replacement but include complex techniques such as those required for aortic valve repair, Ozaki neocuspidization, Ross procedure and valve-sparring aortic root repair. Transcatheter options for the management of AI are not commercially available currently; however, preliminary data from ad-hoc trials, showed promising results and potential use of transcatheter technology in a variety of patients with pure AI.
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Affiliation(s)
| | | | | | | | | | - Luigi Pirelli
- Division of Cardiovascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, United States
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2
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Salehi Omran A, Aeen A, Nayebirad S, Vakili-Basir A, Najafi MS, Mohseni-Badalabadi R, Shirani S, Zoroufian A, Jalali A, Mostafanejad FA, Sahebjam M. Short and mid-term outcomes of valve-sparing, aortic root reimplantation (David's procedure). J Cardiothorac Surg 2024; 19:36. [PMID: 38297332 PMCID: PMC10829203 DOI: 10.1186/s13019-024-02546-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 01/28/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND In the current study, we aimed to report the short- and mid-term outcomes of patients undergoing valve-sparing aortic root reimplantation (VSARR) and our center's experience with the procedure. METHODS Forty patients with aortic root aneurysms underwent VSARR at our center from 2010 until 2022. We retrospectively reviewed the medical records of these patients and extracted the relevant data. After carefully examining the aortic valve, the surgeon decided to perform Bentall or David's procedure during the operation. RESULTS The study population comprised 31 (77.5%) men and nine (22.5%) women, with a mean age of 55.35 ± 15.40. One patient developed hemodynamic instability post-surgery in the hospital and died from multi-organ failure. Another patient had severe AI in the intraoperative echocardiography, and aortic valve replacement with a prosthetic graft was performed during the same operation. In pre-operation echocardiography, 25 (62.5%) patients had severe, nine (22.5%) had moderate, and six (15%) had mild AI. In the in-hospital post-operation follow-up echo, AI was improved, and no patients had severe AI (P < 0.001). Only eight patients had moderate AI in post-one-year follow-up echo exams, while the rest had mild AI. CONCLUSION David's procedure showed excellent mid-term results in our center, with only one in-hospital mortality.
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Affiliation(s)
- Abbas Salehi Omran
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Aeen
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sepehr Nayebirad
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Vakili-Basir
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Sadeq Najafi
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Mohseni-Badalabadi
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Shapour Shirani
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Arezou Zoroufian
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Jalali
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Alsadat Mostafanejad
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Sahebjam
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
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3
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Shrestha M, Kaufeld T, Shrestha P, Martens A, Rustum S, Rudolph L, Krüger H, Arar M, Haverich A, Beckmann E. Valve-sparing David procedure via minimally invasive access does not compromise outcome. Front Cardiovasc Med 2022; 9:966126. [PMID: 36312253 PMCID: PMC9614069 DOI: 10.3389/fcvm.2022.966126] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/01/2022] [Indexed: 11/19/2022] Open
Abstract
Objectives Aortic valve sparing-aortic root replacement (David procedure) has not been routinely performed via minimally invasive access due to its complexity. We compared our results of elective David procedure via minimally invasive access to those via a full sternotomy. Methods Between 1993 and 2019, a total of 732 patients underwent a valve sparing root replacement (David) procedure. Out of these, 220 patients underwent elective David-I procedure (isolated) without any other concomitant procedures at our center. Patients were assigned to either group A (n = 42, mini-access) or group B (n = 178, full sternotomy). Results Cardiopulmonary bypass time were 188.5 ± 35.4 min in group A and 149.0 (135.5–167.5) in group B (p < 0.001). Aortic cross-clamp time were 126.2 ± 27.2 min in group A and 110.0 (97.0–126.0) in group B (p < 0.001). Post-operative echocardiography showed aortic insufficiency ≤ I° in 41 (100%) patients of group A and 155 (95%) of group B. In-hospital mortality was 2.4% (n = 1) in group A and 0% (n = 0) in group B (p = 0.191). Perioperative stroke occurred in 1 (2.4%) patient of group A and 2 (1.1%) patients of group B (p = 0.483). Reexploration for bleeding was necessary in 4 (9.5%) patients of group A and 7 (3.9%) of group B (p = 0.232). Follow-up was complete for 98% of all patients. The 1-, 2-, 4-, and 6-year survival rates were: 97, 97, 97, and 97%, in group A (mini-access) and 99, 96, 95, and 92% in group B (full sternotomy), respectively. The rates for freedom from valve-related re-operation at 1, 2, 4, and 6 years after initial surgery were: 97, 95, 95, and 84% in group A and 97, 95, 91, and 90% in group B, respectively. Conclusion Early post-operative results after David procedure via minimally invasive access are comparable to conventional full sternotomy. Meticulous attention to hemostasis is a critical factor during minimally access David procedures. Long-term outcome including the durability of the reimplanted aortic valve seems to be comparable, too.
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4
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Vervoort D, El-Hamamsy I, Chu MWA, Peterson MD, Ouzounian M. The Ross procedure and valve-sparing root replacement procedures in the adult patient: do guidelines follow the evidence? Ann Cardiothorac Surg 2021; 10:433-443. [PMID: 34422555 DOI: 10.21037/acs-2021-rp-24] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 04/15/2021] [Indexed: 12/16/2022]
Abstract
Prosthetic aortic valve replacements have long been the mainstay of valvular surgery due to their favorable outcomes and low operative complexity. Yet, mechanical valves require lifelong anticoagulation, whereas bioprosthetic valves increase the risk for earlier and more frequent reoperation. Alternative reconstructive techniques have been proposed to address these challenges. These include valve-sparing root replacement procedures if the native aortic valve can be salvaged, and the Ross procedure, which nearly eliminates prosthetic valve-related thromboembolism, anticoagulation-related hemorrhage and endocarditis. Both procedures are technically more complex and thus subject to surgeons' volume and expertise compared to conventional aortic valve replacements. However, they are associated with more favorable outcomes compared to aortic valve replacements if performed by experienced surgeons, especially in younger patients. Nevertheless, despite the growing high-quality literature supporting both procedures, existing multi-society guidelines fail to acknowledge the strength of evidence in support of valve-sparing root replacement procedures and the Ross procedure. In this review, we summarize the existing long-term evidence for the use of each procedure, describe the current guidelines for the treatment of aortic valve pathology, and propose the reevaluation of guidelines based on the available clinical evidence.
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Affiliation(s)
- Dominique Vervoort
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, USA
| | - Michael W A Chu
- Division of Cardiac Surgery, Western University, London, Canada
| | - Mark D Peterson
- Division of Cardiovascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, University of Toronto, Toronto, Ontario, Canada
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5
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Pitts L, Montagner M, Kofler M, Van Praet KM, Heck R, Buz S, Kurz SD, Sündermann S, Hommel M, Falk V, Kempfert J. State of the Art Review: Surgical Treatment of Acute Type A Aortic Dissection. Surg Technol Int 2021; 38:279-288. [PMID: 33823055 DOI: 10.52198/21.sti.38.cv1413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Acute type A aortic dissection (ATAAD) is a life-threatening event that requires immediate surgical treatment. Improvements in surgical treatment, graft technology, organ protection and imaging techniques have led to improved clinical outcomes. Individualized treatment concepts have emerged based on more advanced planning tools that allow for a tailored approach even in complex situations such as multi-level malperfusion. This review provides an overview of the current surgical treatment of ATAAD, focusing on new disease classifications, preoperative computed tomography angiography (CTA) assessment, new prosthesis and stent technologies, and organ-protection strategies.
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Affiliation(s)
- Leonard Pitts
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Matteo Montagner
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Markus Kofler
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Karel M Van Praet
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
| | - Roland Heck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Semih Buz
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
| | - Stephan D Kurz
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- Charité - Universitätsmedizin Berlin, Department of Cardiovascular Surgery, Berlin, Germany
| | - Simon Sündermann
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
- Charité - Universitätsmedizin Berlin, Department of Cardiovascular Surgery, Berlin, Germany
| | - Matthias Hommel
- Department of Anesthesiology, German Heart Center Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
- Charité - Universitätsmedizin Berlin, Department of Cardiovascular Surgery, Berlin, Germany
- Translational Cardiovascular Technologies, Institute of Translational Medicine, Department of Health Sciences and Technology, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
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6
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Yiğit G, Özen A, Çetinkaya F, Ünal EU, İşcan HZ, Birincioğlu CL, Sarıtaş A. Early and Late-Term Follow-Up Results of Patients Diagnosed with Aortic Aneurysm or Aortic Dissection with Aortic Regurgitation Undergoing Aortic Valve Repair or Valve-Sparing Aortic Surgery. Braz J Cardiovasc Surg 2021; 36:192-200. [PMID: 33113319 PMCID: PMC8163274 DOI: 10.21470/1678-9741-2020-0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Valve-reimplantation and remodelling techniques used in aortic reconstruction provide successful early, mid, and long-term results. We present our early and late-term experience with 110 patients with aortic regurgitation (AR) who underwent aortic valve repair (AVr) or valve-sparing aortic root surgeries (VSARS) due to aortic dissection or aortic aneurysm. METHODS Nine hundred eighty-two patients who underwent aneurysm or dissection surgery and aortic valve surgery between April 1997 and January 2017 were analysed using the patient database. A total of 110 patients with AR who underwent AVr or VSARS due to aortic dissection or aortic aneurysm were included in the study. RESULTS In the postoperative period, a decrease was observed in AR compared to the preoperative period (P<0.001); there was an increase in postoperative ejection fraction (EF) compared to the preoperative values (P<0.005) and a significant decrease in postoperative left ventricle diameters compared to the preoperative values (P<0.001). Kaplan-Meier analysis revealed one, two, four, and five-year freedom from moderate-severe AR as 95%, 91%, 87%, and 70%, respectively. Freedom from reoperation in one, two, and five years were 97.9%, 93.6%, and 81%, respectively. Eight patients (7.4%) underwent AVr during follow-up. Out of the remaining 100 patients, 13 (12%) had minimum AR, 52 (48%) had 1st-2nd degree AR, and 35 (32%) had 2nd-3rd degree AR during follow-up. CONCLUSION For the purpose of maintaining the native valve tissue, preserving the EF and the left ventricular end-diastolic diameter, valve-sparing surgeries should be preferred for appropriate patients.
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Affiliation(s)
- Görkem Yiğit
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Anıl Özen
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Ferit Çetinkaya
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Ertekin Utku Ünal
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Hakki Zafer İşcan
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | | | - Ahmet Sarıtaş
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
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7
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Adamson C, Rocchiccioli P, Brogan R, Berry C, Ford TJ. Post-operative myocardial infarction following aortic root surgery with coronary reimplantation: a case series treated with percutaneous coronary intervention. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 3:1-6. [PMID: 32123801 PMCID: PMC7042144 DOI: 10.1093/ehjcr/ytz181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/17/2019] [Accepted: 09/25/2019] [Indexed: 11/24/2022]
Abstract
Background Coronary ostial stenosis is an uncommon but potentially lethal complication following aortic root replacement with or without aortic valve replacement (including Bentall and David procedures). This manifests clinically as acute myocardial ischaemia in the early or late post-operative period. Traditionally, this might be managed with redo open-heart surgery. Case summary This case series describes two presentations where urgent percutaneous coronary intervention was used to manage myocardial infarction complicating aortic root surgery with coronary reimplantation. Discussion This series highlights the risk of acute myocardial infarction after cardiac surgery involving coronary reimplantation. Emergency percutaneous coronary intervention is feasible and illustrates the importance of shared post-operative care involving the cardiac surgeons and the cardiology team.
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Affiliation(s)
- Carly Adamson
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, G81 4DY, UK
| | - Paul Rocchiccioli
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, G81 4DY, UK.,British Heart Foundation, Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, G12 8TA, UK
| | - Richard Brogan
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, G81 4DY, UK
| | - Colin Berry
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, G81 4DY, UK.,British Heart Foundation, Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, G12 8TA, UK
| | - Thomas J Ford
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, G81 4DY, UK.,British Heart Foundation, Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, G12 8TA, UK.,Department of Cardiology, Gosford Hospital, NSW, Australia.,University of New South Wales, Sydney, Australia
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8
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Aalaei-Andabili SH, Martin TD, Hess PJ, Karimi A, Bavry AA, Arnaoutakis GJ, Beaver TM. The Florida Sleeve Procedure Is Durable and Improves Aortic Valve Function. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2019; 7:49-55. [PMID: 31529428 PMCID: PMC6748854 DOI: 10.1055/s-0039-1687854] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background
The Florida (FL) Sleeve procedure was introduced as a simplified approach for valve-sparing correction of functional Type I aortic insufficiency (AI) associated with aortic root aneurysms. In this study, short- and long-term outcomes after the FL Sleeve procedure were investigated.
Methods
From May 2002 to January 2016, 177 patients underwent the FL Sleeve procedure. Left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter, left ventricular ejection fraction, and degree of AI (none = 0, minimal = 1, mild = 2, moderate = 3, severe = 4) were evaluated by echocardiography.
Results
Mean ± standard deviation of age was 49.41 ± 15.37 years. Survival rate was 98% at 1 year, 97% at 5 years, and 93% at 8 years. Freedom from reoperation was 99% at 1 year and 98% at 2 to 8 years. Three patients (1.69%) died during hospitalization. Three patients (1.69%) developed periprocedural stroke. Postoperative follow-up echocardiography was available in 140 patients at 30 days, and 31 patients at 5 years. AI grade significantly improved from baseline at 30 days (2.18 ± 1.26 vs. 1.1 ± 0.93,
p
< 0.001) and at 5 years (2.0 ± 1.23 vs. 1.45 ± 0.88,
p
= 0.04). Preoperative mean LVEDD significantly decreased from 52.20 ± 6.73 to 46.87 ± 8.40 (
p
< 0.001) at 30 days, and from 53.22 ± 7.07 to 46.61 ± 10.51 (
p
= 0.01) at 5 years.
Conclusions
The FL Sleeve procedure is a safe, effective, and durable treatment of aortic root aneurysm and Type I AI. Long-term survival and freedom from reoperation rates are encouraging.
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Affiliation(s)
- Seyed Hossein Aalaei-Andabili
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida.,Division of Cardiology, Department of Medicine, University of Florida, Gainesville, Florida
| | - Tomas D Martin
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Philip J Hess
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Indiana University, Indianapolis, Indiana
| | - Ashkan Karimi
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, Florida
| | - Anthony A Bavry
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, Florida.,North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - George J Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
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9
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Aortic root surgery in Marfan syndrome. Indian J Thorac Cardiovasc Surg 2019; 35:79-86. [PMID: 33061070 DOI: 10.1007/s12055-018-0761-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 10/10/2018] [Accepted: 10/11/2018] [Indexed: 10/27/2022] Open
Abstract
Marfan syndrome (MFS) is an autosomal dominant connective disease etiologically related with FBN-1 gene mutation. The altered microfibril protein structure result in characteristic cardiovascular abnormalities including aortic root dilatation, aortic root aneurysms, and aortic dissections. Aortic root aneurysms and subsequent dissection are the major causes of reduced life expectancy in MFS patients. Prophylactic aortic root replacement has improved the survival of patients with MFS. Elective root replacement carries very low mortality and morbidity. Emergency root replacement for dissection is accompanied with higher early mortality and late deaths/interventions. Both the techniques of aortic root replacement, total root replacement (TRR) with a prosthetic valved conduit, and valve-sparing root replacement (VSRR) yield excellent early and late results. Considering the low risk of prosthetic valve-related events, the improved long-term survival, and event-free survival, TRR continues to be a very effective surgical option. VSSR also seems to be a good option for the first 10 to 15 years following surgery in MFS patients. The choice of procedure depends upon available expertise, patients' choice, feasibility of anticoagulation, possibility of pregnancy, and lifestyle of the patient. Aortic root morphology and state of valve cusps also affect the decision making. In recent times, personalized external aortic root support (PEARS) with a macroporous mesh sleeve has also emerged as a promising alternative to aortic root replacement. All these patients need close monitoring for whole life after surgical intervention.
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10
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Treasure T, King A, Hidalgo Lemp L, Golesworthy T, Pepper J, Takkenberg JJM. Developing a shared decision support framework for aortic root surgery in Marfan syndrome. Heart 2018; 104:480-486. [PMID: 28780581 PMCID: PMC5861390 DOI: 10.1136/heartjnl-2017-311598] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/28/2017] [Accepted: 06/28/2017] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE The study is an early phase of development of a decision support framework for people with Marfan syndrome who are anticipating prophylactic aortic root surgery. Implications of the timing and the nature of the operation chosen were previously elicited in focus groups. In this step, we explored the range of relative values placed by individuals on the implications of decisions made about surgery. METHODS Following the principles of the Ottawa Decision Support Framework, eight questions in the general form 'How important is it to you …' were framed by a panel. Marfan people, families and specialist doctors answered online. Quantitative and qualitative analyses were performed. RESULTS Worldwide, 142 responses were received including 25 specialist doctors. Respondents were 55% female and 46% had previous aortic root surgery. Overall, active lifestyle was more important to males (p=0.03). Patients placed more importance than doctors on not deferring surgery (p=0.04) and on avoidance of anticoagulation in the interests of childbearing (p=0.009). Qualitative analysis showed differing but cogently reasoned values that were sometimes polarised, and mainly driven by the wish to maintain a good quality of life and active lifestyle. CONCLUSIONS Given the cogency of these viewpoints, people anticipating root replacement surgery should have ample opportunity to express them and to have them acknowledged ahead of a consultation when they can then be fully explored in a mutually informed forum. If they differ from local medical practice, they can then be discussed in the process of reaching shared and individualised decisions.
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Affiliation(s)
- Tom Treasure
- Operational Research Unit, Department of Mathematics, University College London, London, UK
| | - Annette King
- Centre for Health Services Studies, University of Kent, Canterbury, Kent, UK
| | | | | | - John Pepper
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK
| | - Johanna JM Takkenberg
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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11
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Tavakoli R, Lebreton G, Gassmann M, Jamshidi P, Leprince P. Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement. J Vis Exp 2017. [PMID: 29286413 DOI: 10.3791/56790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures prevents a number of cardiac surgeons from incorporating them into their practice. The aim of this protocol is to describe a simplified and user-friendly technique of an aortic valve-sparing root replacement (VSRR) procedure by re-implantation of the aortic valve. Proper selection of patients and limitations of the technique are discussed. In 54 consecutive patients, normal appearing aortic valves were re-implanted in a commercially available polyester prosthesis with pre-shaped sinuses by a simplified and standardized technique. Placement of the first row of the proximal suture line, choice of the prosthesis size, and adjustment of the height of the commissures of the patient to the fixed height of the sinus portion of the prosthesis were slightly modified from the reference techniques with the aim of increasing its feasibility for use by other cardiac surgeons. Early mortality and morbidity as well as 5-year survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were collected in all patients. Thirty-day mortality, re-sternotomy for bleeding, re-sternotomy for mediastinitis, and the incidence of stroke were very low, 1.8% for each (1 of 54). No patient required permanent pace-maker implantation. At 5 years, survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were 97.5%, 95.2%, and 91.6%, respectively. Mid-term results of our standardized technique of re-implantation of the aortic valve for valve-sparing aortic root replacement are very good and compare with more complex techniques reported by experienced surgeons. By following the present protocol of the standardized re-implantation technique, a greater number of cardiac surgeons can perform this procedure with comparable good results.
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Affiliation(s)
- Reza Tavakoli
- Department of Cardiovascular and Thoracic Surgery, Pitie Salpetriere University Hospital, Assistance Publique, Hopitaux de Paris (APHP), Institut de Cardiologie; Institute of Veterinary Physiology and Zurich Center for Integrative Human Physiology, University of Zurich;
| | - Guillaume Lebreton
- Department of Cardiovascular and Thoracic Surgery, Pitie Salpetriere University Hospital, Assistance Publique, Hopitaux de Paris (APHP), Institut de Cardiologie
| | - Max Gassmann
- Institute of Veterinary Physiology and Zurich Center for Integrative Human Physiology, University of Zurich
| | | | - Pascal Leprince
- Department of Cardiovascular and Thoracic Surgery, Pitie Salpetriere University Hospital, Assistance Publique, Hopitaux de Paris (APHP), Institut de Cardiologie
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12
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Liu L, Qin C, Hou J, Zhu D, Zhang B, Ma H, Guo Y. One-stage hybrid surgery for acute Stanford type A aortic dissection with David operation, aortic arch debranching, and endovascular graft: a case report. J Thorac Dis 2017; 8:E1597-E1601. [PMID: 28149590 DOI: 10.21037/jtd.2016.12.81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Acute Stanford type A aortic dissection requires an extremely complex surgical strategy and presents high risk of complications. Although many different procedures were reported to treat this aortic dissection, high mortality rate and incidences of complications still exist. This study presents a 59-year-old lady with acute Stanford type A aortic dissection, which originated from the aortic root to proximal part of right external iliac artery and involved the brachiocephalic trunk, left carotid artery, celiac trunk, and left renal artery. The patient underwent one-stage hybrid surgery of David procedures, debranching, and endovascular aortic repair under ultrasound-guided aortic arch cannulation cardiopulmonary bypass (CPB). The surgery was successfully performed, and the patient showed no post-operative complication. The one-staged hybrid surgery of David procedures, debranching, and endovascular aortic repair provides novel and well-designed combined techniques for treating complex acute Stanford type A aortic dissection. Our techniques significantly lowered the risks, thereby expanding the indications of surgical intervention for acute Stanford type A aortic dissection.
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Affiliation(s)
- Lulu Liu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Chaoyi Qin
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jianglong Hou
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Da Zhu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Bengui Zhang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Hao Ma
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yingqiang Guo
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
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Nappi F, Carotenuto AR, Cutolo A, Fouret P, Acar C, Chachques JC, Fraldi M. Compliance mismatch and compressive wall stresses drive anomalous remodelling of pulmonary trunks reinforced with Dacron grafts. J Mech Behav Biomed Mater 2016; 63:287-302. [PMID: 27442920 DOI: 10.1016/j.jmbbm.2016.06.023] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/20/2016] [Accepted: 06/26/2016] [Indexed: 11/18/2022]
Abstract
Synthetic grafts are often satisfactory employed in cardiac and vascular surgery, including expanded poly(ethylene terephthalate) or expanded poly(tetrafluoroethylene). However, accumulating evidences suggest the emergence of worrisome issues concerning the long-term fate of prosthetic grafts as large vessel replacement. Disadvantages related to the use of synthetic grafts can be traced in their inability of mimicking the elasto-mechanical characteristics of the native vascular tissue, local suture overstress leading to several prosthesis-related complications and retrograde deleterious effects on valve competence, cardiac function and perfusion. Motivated by this, in the present work it is analyzed - by means of both elemental biomechanical paradigms and more accurate in silico Finite Element simulations - the physical interaction among aorta, autograft and widely adopted synthetic (Dacron) prostheses utilized in transposition of pulmonary artery, highlighting the crucial role played by somehow unexpected stress fields kindled in the vessel walls and around suture regions, which could be traced as prodromal to the triggering of anomalous remodelling processes and alterations of needed surgical outcomes. Theoretical results are finally compared with histological and surgical data related to a significant experimental animal campaign conducted by performing pulmonary artery transpositions in 30 two-month old growing lambs, followed up during growth for six months. The in vivo observations demonstrate the effectiveness of the proposed biomechanical hypothesis and open the way for possible engineering-guided strategies to support and optimize surgical procedures.
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Affiliation(s)
- Francesco Nappi
- Cardiac Surgery Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Angelo Rosario Carotenuto
- Department of Chemical, Materials and Production Engineering of the University of Naples Federico II, Italy
| | - Arsenio Cutolo
- Department of Structures for Engineering and Architecture of the University of Naples Federico II, Italy
| | - Pierre Fouret
- Department of Pathology, Hôpital de la Salpétriere, Paris, France
| | - Christophe Acar
- Department of Cardiovascular Surgery, Hôpital de la Salpétriere, Paris, France
| | - Juan Carlos Chachques
- Laboratory of Biosurgical Research "Carpentier Foundation", Pompidou Hospital, University Paris Descartes, France
| | - Massimiliano Fraldi
- Department of Structures for Engineering and Architecture and Interdisciplinary Research Center for Biomaterials, University of Napoli Federico II, Italy.
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Old Myths, New Concerns: the Long-Term Effects of Ascending Aorta Replacement with Dacron Grafts. Not All That Glitters Is Gold. J Cardiovasc Transl Res 2016; 9:334-42. [PMID: 27245785 PMCID: PMC4990605 DOI: 10.1007/s12265-016-9699-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 05/18/2016] [Indexed: 02/07/2023]
Abstract
Synthetic grafts are widely used in cardiac and vascular surgery since the mid-1970s. Despite their general good performance, inability of mimicking the elastomechanical characteristics of the native arterial tissue, and the consequent lack of adequate compliance, leads to a cascade of hemodynamic and biological alterations deeply affecting cardiovascular homeostasis. Those concerns have been reconsidered in more contemporaneous surgical and experimental reports which also triggered some research efforts in the tissue engineering field towards the realization of biomimetic arterial surrogates. The present review focuses on the significance of the “compliance mismatch” phenomenon occurring after aortic root or ascending aorta replacement with prosthetic grafts and discusses the clinical reflexes of this state of tissue incompatibility, as the loss of the native elastomechanical properties of the aorta can translate into detrimental effects on the normal efficiency of the aortic root complex with impact in the long-term results of patients undergoing aortic replacement.
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15
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Treasure T, Takkenberg JJM, Pepper J. Republished review: Surgical management of aortic root disease in Marfan syndrome and other congenital disorders associated with aortic root aneurysms. Postgrad Med J 2016; 92:112-7. [PMID: 26811510 PMCID: PMC4752614 DOI: 10.1136/postgradmedj-2013-305132rep] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Elective root replacement in Marfan syndrome has improved life expectancy in affected patients. Three forms of surgery are now available: total root replacement (TRR) with a valved conduit, valve sparing root replacement (VSRR) and personalised external aortic root support (PEARS) with a macroporous mesh sleeve. TRR can be performed irrespective of aortic dimensions and a mechanical replacement valve is a secure and near certain means of correcting aortic valve regurgitation but has thromboembolic and bleeding risks. VSRR offers freedom from anticoagulation and attendant risks of bleeding but reoperation for aortic regurgitation runs at 1.3% per annum. A prospective multi-institutional study has found this to be an underestimate of the true rate of valve-related adverse events. PEARS conserves the aortic root anatomy and optimises the chance of maintaining valve function but average follow-up is under 5 years and so the long-term results are yet to be determined. Patients are on average in their 30s and so the cumulative lifetime need for reoperation, and of any valve-related complications, are consequently substantial. With lowering surgical risk of prophylactic root replacement, the threshold for intervention has reduced progressively over 30 years to 4.5 cm and so an increasing number of patients who are not destined to have a dissection are now having root replacement. In evaluation of these three forms of surgery, the number needed to treat to prevent dissection and the balance of net benefit and harm in future patients must be considered.
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Affiliation(s)
- Tom Treasure
- Clinical Operational Research Unit, University College London, London, UK
| | - J J M Takkenberg
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - John Pepper
- NIHR Cardiovascular BRU, Royal Brompton Hospital, London, UK Institute of Cardiovascular Medicine and Science (ICMS), London, UK
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16
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Berdajs D, Mosbahi S, Forro Z, Burki M, von Segesser LK. Aortic root haemodynamics following David procedure: numerical analysis of 3-dimensional haemodynamics. Eur J Cardiothorac Surg 2016; 49:1588-98. [DOI: 10.1093/ejcts/ezv427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 11/09/2015] [Indexed: 11/13/2022] Open
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17
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Kari FA, Doll KN, Hemmer W, Liebrich M, Sievers HH, Richardt D, Reichenspurner H, Detter C, Siepe M, Czerny M, Beyersdorf F. Survival and freedom from aortic valve-related reoperation after valve-sparing aortic root replacement in 1015 patients. Interact Cardiovasc Thorac Surg 2015; 22:431-8. [DOI: 10.1093/icvts/ivv354] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 11/16/2015] [Indexed: 11/14/2022] Open
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18
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Xu L, Gao F, Li P, Xu Y, Liu S, You B, Sun LZ. Early and Midterm Outcomes of the VSSR procedure with De Paulis valsalva graft: A Chinese single-Center Experience in 38 patients. J Cardiothorac Surg 2015; 10:167. [PMID: 26584742 PMCID: PMC4652352 DOI: 10.1186/s13019-015-0347-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 10/28/2015] [Indexed: 11/15/2022] Open
Abstract
Background This study investigated early and midterm outcomes after valve-sparing aortic root replacement (VSSR procedure with De Paulis Valsalva graft) for acute aortic dissection or ascending aortic aneurysm in a single Chinese hospital center. Methods Between September 2005 to July 2013, 38 patients (84.2 % male; mean age, 45.5 ± 12.4) underwent VSSR procedure with De Paulis valsalva graft for acute aortic dissection or ascending aortic aneurysm and were followed up clinically and echocardiographically. Results Among the 38 cases studied, intensive care unit stay duration was 34.5 (interquartile range, 16–34.6) days; hospital stay duration was 11.7 ± 7.9 days; operation time was 6.8 ± 1.9 h; and cross-clamping time was 154.4 ± 42.0 min. There was one intraoperative conversion to Bentall procedure; one re-operation for bleeding; one operative death and one case who developed complications. Mean follow-up was 39.7 ± 21.7 months (range, 12–108 months; cumulative rate, 1483 patients-months; follow-up rate, 94 %). At 5 and 10 years, overall freedom from valve replacement was 94 % and 87 %; freedom from aortic regurgitation grade II or higher was 94 % and 91 %; and freedom from reoperation was 94 % and 90 % years, respectively. Conclusions The reimplantation type of valve-sparing procedure appears to be facilitated by the use of the De Paulis valsalva graft with satisfactory perioperative and midterm results.
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Affiliation(s)
- Lili Xu
- Department of Cardiovascular Surgery, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Beijing, 100029, China.
| | - Feng Gao
- Department of Cardiovascular Surgery, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Beijing, 100029, China.
| | - Ping Li
- Department of Cardiovascular Surgery, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Beijing, 100029, China.
| | - Yi Xu
- Department of Cardiovascular Surgery, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Beijing, 100029, China.
| | - Shuo Liu
- Department of Cardiovascular Surgery, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Beijing, 100029, China.
| | - Bing You
- Department of Cardiovascular Surgery, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Beijing, 100029, China.
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Beijing, 100029, China.
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Shrestha M, Krueger H, Umminger J, Koigeldiyev N, Beckmann E, Haverich A, Martens A. Minimally invasive valve sparing aortic root replacement (David procedure) is safe. Ann Cardiothorac Surg 2015; 4:148-53. [PMID: 25870810 DOI: 10.3978/j.issn.2225-319x.2014.08.04] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 08/13/2014] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Even though minimally invasive cardiac surgery may reduce morbidity, this approach is not routinely performed for aortic root replacements. The purpose of this pilot study was to assess the safety and feasibility of valve sparing aortic root replacement via an upper mini-sternotomy up to the 3(rd) intercostal space. METHODS Between April 2011 and March 2014, 26 patients (22 males, age 47.6±13 years) underwent elective minimally invasive aortic valve sparing root replacement (David procedure, group A). Twelve patients underwent additional leaflet repair. Concomitant procedures were: four proximal aortic arch replacements and one coronary artery bypass grafting (CABG) to the proximal right coronary artery (RCA). During the same time period, 14 patients (ten males, age 64.2±9.5 years) underwent elective David procedure via median full sternotomy (group B). Concomitant procedures included six proximal aortic arch replacements. Although the patient cohorts were small, the results of these two groups were compared. RESULTS In group A, there were no intra-operative conversions to full sternotomy. The aortic cross-clamp and cardiopulmonary bypass (CPB) times were 115.6±30.3 and 175.8±41.9 min, respectively. One patient was re-opened (via same access) due to post-operative bleeding. The post-operative ventilation time and hospital stay were 0.5±0.3 and 10.4±6.8 days, respectively. There was no 30-day mortality. The patient questionnaire showed that the convalescence time was approximately two weeks. In group B: the cross-clamp and CPB times were 114.1±19.9 and 163.0±24.5 min, respectively. One patient was re-opened (7.1%) due to post-operative bleeding. The post-operative ventilation time and hospital stay were 0.6±0.7 and 14.2±16.7 days, respectively. There was no 30-day mortality. CONCLUSIONS Minimally invasive valve sparing aortic root replacement can be safely performed in selected patients. The results are comparable to those operated via a full sternotomy. The key to success is a 'step by step' technique of moving from minimally invasive aortic valve replacements (AVR) to more demanding aortic root replacements. Meticulous hemostasis & attention to surgical details is of utmost importance to prevent perioperative complications.
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Affiliation(s)
- Malakh Shrestha
- Division of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Heike Krueger
- Division of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Julia Umminger
- Division of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Nurbol Koigeldiyev
- Division of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Erik Beckmann
- Division of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Division of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Andreas Martens
- Division of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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20
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Kari FA, Siepe M, Rylski B, Kueri S, Beyersdorf F. Aortic valve reimplantation for large root aneurysm and high-grade aortic regurgitation: incidence and implications of additional cusp and commissure repair. Interact Cardiovasc Thorac Surg 2015; 20:611-5. [DOI: 10.1093/icvts/ivv020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 01/14/2015] [Indexed: 11/14/2022] Open
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21
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Treasure T, Takkenberg JJM, Pepper J. Surgical management of aortic root disease in Marfan syndrome and other congenital disorders associated with aortic root aneurysms. Heart 2015; 100:1571-6. [PMID: 24986892 PMCID: PMC4215278 DOI: 10.1136/heartjnl-2013-305132] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Elective root replacement in Marfan syndrome has improved life expectancy in affected patients. Three forms of surgery are now available: total root replacement (TRR) with a valved conduit, valve sparing root replacement (VSRR) and personalised external aortic root support (PEARS) with a macroporous mesh sleeve. TRR can be performed irrespective of aortic dimensions and a mechanical replacement valve is a secure and near certain means of correcting aortic valve regurgitation but has thromboembolic and bleeding risks. VSRR offers freedom from anticoagulation and attendant risks of bleeding but reoperation for aortic regurgitation runs at 1.3% per annum. A prospective multi-institutional study has found this to be an underestimate of the true rate of valve-related adverse events. PEARS conserves the aortic root anatomy and optimises the chance of maintaining valve function but average follow-up is under 5 years and so the long-term results are yet to be determined. Patients are on average in their 30s and so the cumulative lifetime need for reoperation, and of any valve-related complications, are consequently substantial. With lowering surgical risk of prophylactic root replacement, the threshold for intervention has reduced progressively over 30 years to 4.5 cm and so an increasing number of patients who are not destined to have a dissection are now having root replacement. In evaluation of these three forms of surgery, the number needed to treat to prevent dissection and the balance of net benefit and harm in future patients must be considered.
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Affiliation(s)
- Tom Treasure
- Clinical Operational Research Unit, University College London, London, UK
| | - J J M Takkenberg
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - John Pepper
- NIHR Cardiovascular BRU, Royal Brompton Hospital, London, UK
- Institute of Cardiovascular Medicine and Science (ICMS), London, UK
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22
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Personalised External Aortic Root Support (PEARS) Compared with Alternatives for People with Life-Threatening Genetically Determined Aneurysms of the Aortic Root. Diseases 2015; 3:2-14. [PMID: 28943604 PMCID: PMC5548228 DOI: 10.3390/diseases3010002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 01/04/2015] [Indexed: 12/02/2022] Open
Abstract
Personalised external aortic support was first proposed in 2000 by Tal Golesworthy, an engineer with familial Marfan syndrome and an aortic root aneurysm. After putting together a research and development team, and finding a surgeon to take on the challenge to join him in this innovative approach, he was central to the manufacture of the device, custom made for his own aorta. He was the patient for the ‘first in man’ operation in 2004. Ten years later he is well and 45 other people have had their own personalised device implanted. In this account, the stepwise record of proof of principle, comparative quantification of the surgical and perioperative requirements, 10 years of results, and development and research plans for the future are presented.
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23
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Jasinski MJ, Gocol R, Malinowski M, Hudziak D, Duraj P, Frackiewicz J, Kargul T, Deja MA, Woś S. Different techniques for aortic valve repair and the associated root reconstruction - prospective long-term follow-up of the first 100 patients. KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2014; 11:373-80. [PMID: 26336452 PMCID: PMC4349031 DOI: 10.5114/kitp.2014.47335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 05/06/2014] [Accepted: 09/01/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The advantages of aortic valve and aortic root reconstructive surgery include the provision of natural postoperative valve hemodynamics and the avoidance of prosthetic valve-related complications. A systematic approach based on functional classification of aortic regurgitation allows standardization and reproducibility. Its potential applicability, however, is limited by the relative lack of long-term follow-up data. AIM To achieve the long term results of aortic valve and root repair in prospectively recruited group of 100 patients operated on during first seven years. MATERIAL AND METHODS Between the years 2003 and 2013, 225 consecutive patients (175 male, 50 female, mean age 51.3 years) with severe aortic regurgitation and aortic root enlargement underwent aortic valve repair or sparing surgery. The first 100 patients operated between 2003 and 2009 were prospectively enrolled in the study in order to achieve a 105-month follow-up. They underwent aortic valve repair and associated aortic root reconstruction. This prospective study is aimed at assessing the major endpoints of overall survival and freedom from reoperation. Additionally, log-rank testing for the risk factors associated with overall mortality, reoperation, and aortic valve repair failure was performed. RESULTS Among 225 patients, early mortality occurred in the case of 5 patients (2.2%), while 6 (2.5%) patients experienced early valve failure. In a prospective analysis performed on the first 100 patients, long-term results achieved with Kaplan-Meier analysis showed a survival rate of 93% and freedom from reoperation at the level of 91.3%. The risk factors for overall mortality included NYHA class, creatinine level, and perioperative root replacement as reimplantation. Redo operation was associated with bicuspid aortic valve and perioperative leaflet resection with pericardial patch repair. CONCLUSIONS One hundred and five month follow-up data from this prospectively analyzed cohort of patients prove that aortic valve repair associated with aortic root reconstruction can be performed with satisfactory results.
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Affiliation(s)
- Marek J Jasinski
- School of Medicine, Medical University of Silesia, Chair and Department of Cardiac Surgery, Katowice, Poland
| | - Radosław Gocol
- School of Medicine, Medical University of Silesia, Chair and Department of Cardiac Surgery, Katowice, Poland
| | - Marcin Malinowski
- School of Medicine, Medical University of Silesia, Chair and Department of Cardiac Surgery, Katowice, Poland
| | - Damian Hudziak
- School of Medicine, Medical University of Silesia, Chair and Department of Cardiac Surgery, Katowice, Poland
| | - Piotr Duraj
- School of Medicine, Medical University of Silesia, Chair and Department of Cardiac Surgery, Katowice, Poland
| | - Joanna Frackiewicz
- Department of Rehabilitation, Medical University of Silesia, Katowice, Poland
| | - Tomasz Kargul
- School of Medicine, Medical University of Silesia, Chair and Department of Cardiac Surgery, Katowice, Poland
| | - Marek A Deja
- School of Medicine, Medical University of Silesia, Chair and Department of Cardiac Surgery, Katowice, Poland
| | - Stanisław Woś
- School of Medicine, Medical University of Silesia, Chair and Department of Cardiac Surgery, Katowice, Poland
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Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RSV, Vrints CJM. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014; 35:2873-926. [PMID: 25173340 DOI: 10.1093/eurheartj/ehu281] [Citation(s) in RCA: 2823] [Impact Index Per Article: 282.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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25
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Boldyrev S, Barbukhatty K, Porhanov V. A Novel Tool to Facilitate Crimping Suture Placement for a Modified David V/Miller Aortic Root Replacement. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2014; 2:161-6. [PMID: 26798736 DOI: 10.12945/j.aorta.2014.14-024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 07/29/2014] [Indexed: 11/18/2022]
Abstract
Surgical treatment of aortic root and ascending aorta aneurysms with aortic insufficiency is still controversial. A valve-sparing operation is the procedure of choice for such patients, and the reimplantation technique is preferable. We describe a simple technique for aortic root reconstruction that has been successfully performed for patients with aneurysms of aortic root and ascending aorta with aortic insufficiency.
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Affiliation(s)
- Sergey Boldyrev
- Department of Adult Cardiac Surgery, Regional Clinical Hospital #1, Krasnodar, Russian Federation
| | - Kirill Barbukhatty
- Department of Adult Cardiac Surgery, Regional Clinical Hospital #1, Krasnodar, Russian Federation
| | - Vladimir Porhanov
- Department of Adult Cardiac Surgery, Regional Clinical Hospital #1, Krasnodar, Russian Federation
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26
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Kari FA, Beyersdorf F, Rylski B, Stephens EH, Russe M, Siepe M. David I reimplantation procedure for aortic root replacement in Marfan patients: medium-term outcome. Interact Cardiovasc Thorac Surg 2014; 19:743-8. [DOI: 10.1093/icvts/ivu244] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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27
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Edelman JJB, Seco M, Dunne B, Matzelle SJ, Murphy M, Joshi P, Yan TD, Wilson MK, Bannon PG, Vallely MP, Passage J. Custodiol for myocardial protection and preservation: a systematic review. Ann Cardiothorac Surg 2014; 2:717-28. [PMID: 24349972 DOI: 10.3978/j.issn.2225-319x.2013.11.10] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 11/10/2013] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Custodiol cardioplegia is attractive for minimally invasive cardiac surgery, as a single dose provides a long period of myocardial protection. Despite widespread use in Europe, there is little data confirming its efficacy compared with conventional (blood or crystalloid) cardioplegia. There is similar enthusiasm for its use in organ preservation for transplant, but also a lack of data. This systematic review aimed to assess the evidence for the efficacy of Custodiol in myocardial protection and as a preservation solution in heart transplant. METHODS Electronic searches were performed of six databases from inception to October 2013. Reviewers independently identified studies that compared Custodiol with conventional cardioplegia (blood or extracellular crystalloid) in adult patients for meta-analysis; large case series that reported results using Custodiol were analyzed. Next, we identified studies that compared Custodiol with other organ preservation solutions for organ preservation in heart transplant. RESULTS Fourteen studies compared Custodiol with conventional cardioplegia for myocardial protection in adult cardiac surgery. No difference was identified in mortality; there was a trend for increased incidence of ventricular fibrillation in the Custodiol group that did not reach statistical significance. No difference was identified in studies that compared Custodiol with other solutions for heart transplant. CONCLUSIONS Despite widespread clinical use, the evidence supporting the superiority of Custodiol over other solutions for myocardial protection or organ preservation is limited. Large randomised trials are required.
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Affiliation(s)
- J James B Edelman
- Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Nedlands, Australia; ; The Baird Institute; Sydney Medical School, University of Sydney, Sydney, Australia
| | - Michael Seco
- The Baird Institute; Sydney Medical School, University of Sydney, Sydney, Australia
| | - Ben Dunne
- Department of Cardiothoracic Surgery, Royal Perth Hospital, Perth, Australia
| | - Shannon J Matzelle
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Michelle Murphy
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Pragnesh Joshi
- Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Tristan D Yan
- The Baird Institute; Sydney Medical School, University of Sydney, Sydney, Australia; ; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael K Wilson
- The Baird Institute; Sydney Medical School, University of Sydney, Sydney, Australia; ; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia; ; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
| | - Paul G Bannon
- The Baird Institute; Sydney Medical School, University of Sydney, Sydney, Australia; ; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael P Vallely
- The Baird Institute; Sydney Medical School, University of Sydney, Sydney, Australia; ; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia; ; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
| | - Jurgen Passage
- Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Nedlands, Australia; ; Notre Dame Medical School, Fremantle, Australia
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Caceres M, Ma Y, Rankin JS, Saha-Chaudhuri P, Englum BR, Gammie JS, Suri RM, Thourani VH, Esmailian F, Czer LS, Puskas JD, Svensson LG. Mortality characteristics of aortic root surgery in North America. Eur J Cardiothorac Surg 2014; 46:887-93. [PMID: 24639452 DOI: 10.1093/ejcts/ezu083] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES Aortic root surgery is transitioning to aortic valve sparing (AVS), but little is known about the relative early outcomes of AVS versus composite graft-valve replacement (CVR). This study assessed mortality differences for AVS versus CVR to guide future practice decisions. METHODS From January 2000 to June 2011, 31 747 patients had aortic root replacement with AVS (n = 3585; 11%) or CVR (n = 28 162; 89%). The cohort of Overall patients was divided into two subgroups: high-risk patients (n = 20 356; 6% AVS) having age >75 years, endocarditis, aortic stenosis, dialysis, multiple valves, reoperation or emergency/salvage status, and the remaining low-risk patients (n = 11 388; 21% AVS). Using logistic regression analysis, outcomes were presented as unadjusted operative mortality (UOM), risk-adjusted operative mortality (AOM) and adjusted odds ratio (AOR) for mortality. RESULTS Baseline characteristics for the Overall group (AVS versus CVR) were: mean age (52 vs 57 years), endocarditis (1 vs 11%), aortic stenosis (4 vs 36%), dialysis (1 vs 2%), multiple valves (7 vs 10%), reoperation (6 vs 17%) and emergency status (14 vs 12%) (all P < 0.0001). In high- and low-risk groups, baseline differences narrowed, and lower mortality was generally observed with AVS: (AVS versus CVR) UOM group Overall (4.5 vs 8.9%)*, group High-risk (10.5 vs 11.7%), group Low-risk (1.4 vs 3.1%)*; AOM group Overall (6.2 vs 8.6%), group High-risk (10.1 vs 11.7%), group Low-risk (2.2 vs 2.8%); AOR group Overall (0.59)*, group High-risk (0.62)*, group Low-risk (0.69). *P < 0.05. CONCLUSIONS Relative risk-adjusted mortality seemed comparable with AVS versus CVR in low- and high-risk subgroups. These data support judicious expansion of aortic valve repair in patients having aortic root replacement.
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Affiliation(s)
- Manuel Caceres
- Division of Cardiothoracic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA Department of Cardiac Surgery, Veterans Affairs Medical Center, Memphis, TN, USA
| | - Yicheng Ma
- Duke Clinical Research Institute, Durham, NC, USA
| | - J Scott Rankin
- Department of Cardiac Surgery, Vanderbilt University, Nashville, TN, USA
| | | | | | - James S Gammie
- Division of Cardiac Surgery, University of Maryland, Baltimore, MD, USA
| | - Rakesh M Suri
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Vinod H Thourani
- Division of Cardiothoracic Surgery, Emory University, Atlanta, GA, USA
| | - Fardad Esmailian
- Division of Cardiothoracic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Lawrence S Czer
- Division of Cardiothoracic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - John D Puskas
- Division of Cardiothoracic Surgery, Emory University, Atlanta, GA, USA
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
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Treasure T, Takkenberg JJM, Golesworthy T, Rega F, Petrou M, Rosendahl U, Mohiaddin R, Rubens M, Thornton W, Lees B, Pepper J. Personalised external aortic root support (PEARS) in Marfan syndrome: analysis of 1-9 year outcomes by intention-to-treat in a cohort of the first 30 consecutive patients to receive a novel tissue and valve-conserving procedure, compared with the published results of aortic root replacement. Heart 2014; 100:969-75. [PMID: 24395977 PMCID: PMC4033204 DOI: 10.1136/heartjnl-2013-304913] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Among people with Marfan syndrome who have a typical aortic root aneurysm, dissection is a characteristic cause of premature death. To pre-empt Type A dissection, composite root replacement with a mechanical valve became the standard of care in the 1980s and 1990s. This is being superseded by valve-sparing aortic root replacement to avoid lifelong anticoagulation. In 2004, a total root and valve-sparing procedure, personalised external aortic support, was introduced. We report here results among the first 30 recipients. METHODS From cross-sectional digital images, the patient's own aorta is modelled by computer aided design and a replica is made in thermoplastic by rapid prototyping. On this, a personalised support of a macroporous polymer mesh is manufactured. The mesh is positioned around the aorta, closely applied from the aortoventricular junction to beyond the brachiocephalic artery. The operation is performed with a beating heart and usually without cardiopulmonary bypass. RESULTS Between 2004 and 2011, 30 patients, median age 28 years (IQR 20-44) had this operation and have been prospectively followed for 1.4-8.8 years by February 2013. During a total of 133 patient-years there were no deaths or cerebrovascular, aortic or valve-related events. These early outcomes are better than published results for the more radical extirpative root replacement operations. CONCLUSIONS The aortic valve, the root architecture, and the blood/endothelia interface are conserved. The perioperative burden is less and there has been freedom from aortic and valvular events. A prospective comparative study is planned.
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Affiliation(s)
- Tom Treasure
- Clinical Operational Research Unit, UCL, London, UK
| | - Johanna J M Takkenberg
- Department of CardioThoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Ulrich Rosendahl
- Department of Cardiac Surgery, Royal Brompton Hospital, London, UK
| | - Raad Mohiaddin
- Department of Cardiac MRI, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael Rubens
- Department of Radiology, Royal Brompton Hospital, London, UK
| | | | | | - John Pepper
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK
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Fattouch K, Castrovinci S, Murana G, Nasso G, Guccione F, Dioguardi P, Salardino M, Bianco G, Speziale G. Functional annulus remodelling using a prosthetic ring in tricuspid aortic valve repair: mid-term results. Interact Cardiovasc Thorac Surg 2013; 18:49-54; discussion 54-5. [PMID: 24065345 DOI: 10.1093/icvts/ivt410] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES The functional aortic valve annulus (FAVA) is a complex unit with proximal (aorto-ventricular junction) and distal (sinotubular junction) components. The aim of our study was to evaluate the impact of the total FAVA remodelling, using a prosthetic ring, on mid-term clinical and echocardiographic results after aortic valve repair. METHODS Since February 2003, 250 patients with tricuspid aortic valve insufficiency (AI) underwent aortic valve repair. FAVA dilatation was treated by prosthetic ring in 52 patients, by isolated subcommissural plasty in 62, by subcommissural plasty plus ascending aortic replacement in 57 and by David's reimplantation procedure in 79. Survival rate and freedom from recurrent AI greater than or equal to moderate were evaluated by Kaplan-Meier. RESULTS Overall late survival was 90.4%. Late cardiac-related deaths occurred in 15 patients. At follow-up, 36 (16%) patients had recurrent AI greater than or equal to moderate because of cusp reprolapse and/or FAVA redilatation. Freedom from recurrent AI was significantly higher for patients who underwent David's procedure or FAVA remodelling by prosthetic ring than those who underwent isolated subcommissural plasty (P < 0.01) or subcommissural plasty plus ascending aortic replacement (P = 0.02). There was no statistical difference between David's procedure and prosthetic ring annuloplasty (P = 0.26). CONCLUSION FAVA remodelling using a prosthetic ring is a safe procedure in aortic valve repair surgery thanks to long-term annulus stabilization and it is a pliable alternative to David's procedure in selected patients. This technique may be used in all patients with slight root dilatation to avoid aggressive root reimplantation. We also recommended total FAVA annuloplasty in all patients who underwent aortic valve repair to improve long-term repair results.
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Affiliation(s)
- Khalil Fattouch
- Department of Cardiovascular Surgery, GVM Care and Research, Maria Eleonora Hospital, Palermo, Italy
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Kvitting JPE, Kari FA, Fischbein MP, Liang DH, Beraud AS, Stephens EH, Mitchell RS, Miller DC. David valve-sparing aortic root replacement: equivalent mid-term outcome for different valve types with or without connective tissue disorder. J Thorac Cardiovasc Surg 2012; 145:117-26, 127.e1-5; discussion 126-7. [PMID: 23083792 DOI: 10.1016/j.jtcvs.2012.09.013] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 08/13/2012] [Accepted: 09/12/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Although implicitly accepted by many that the durability of valve-sparing aortic root replacement in patients with bicuspid aortic valve disease and connective tissue disorders will be inferior, this hypothesis has not been rigorously investigated. METHODS From 1993 to 2009, 233 patients (27% bicuspid aortic valve, 40% Marfan syndrome) underwent Tirone David valve-sparing aortic root replacement. Follow-up averaged 4.7 ± 3.3 years (1102 patient-years). Freedom from adverse outcomes was determined using log-rank calculations. RESULTS Survival at 5 and 10 years was 98.7% ± 0.7% and 93.5% ± 5.1%, respectively. Freedom from reoperation (all causes) on the aortic root was 92.2% ± 3.6% at 10 years; 3 reoperations were aortic valve replacement owing to structural valve deterioration. Freedom from structural valve deterioration at 10 years was 96.1% ± 2.1%. No significant differences were found in survival (P = .805, P = .793, respectively), reoperation (P = .179, P = .973, respectively), structural valve deterioration (P = .639, P = .982, respectively), or any other functional or clinical endpoints when patients were stratified by valve type (tricuspid aortic valve vs bicuspid aortic valve) or associated connective tissue disorder. At the latest echocardiographic follow-up (95% complete), 202 patients (94.8%) had none or trace aortic regurgitation, 10 (4.7%) mild, 0 had moderate to severe, and 1 (0.5%) had severe aortic regurgitation. Freedom from greater than 2+ aortic regurgitation at 10 years was 95.3% ± 2.5%. Six patients sustained acute type B aortic dissection (freedom at 10 years, 90.4% ± 5.0%). CONCLUSIONS Tirone David reimplantation valve-sparing aortic root replacement in carefully selected young patients was associated with excellent clinical and echocardiographic outcome in patients with either a tricuspid aortic valve or bicuspid aortic valve. No demonstrable adverse influence was found for Marfan syndrome or connective tissue disorder on durability, clinical outcome, or echocardiographic results.
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Affiliation(s)
- John-Peder Escobar Kvitting
- Department of Cardiovascular and Thoracic Surgery, Stanford University School of Medicine, Stanford, Calif. 94305-5247, USA
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David TE. Aortic valve sparing operations: a review. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2012; 45:205-12. [PMID: 22880164 PMCID: PMC3413824 DOI: 10.5090/kjtcs.2012.45.4.205] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 07/25/2012] [Accepted: 07/26/2012] [Indexed: 11/16/2022]
Abstract
Aortic valve sparing operations were developed to preserve the native aortic valve during surgery for aortic root aneurysm as well as surgery for ascending aortic aneurysms with associated aortic insufficiency. There are basically two types of aortic valve sparing oprations: remodeling of the aortic root and reimplantation of the aortic valve. These operations have been performed for over two decades and the clinical outcomes have been excellent in experienced hands. Although remodeling of the aortic root is physiologically superior to reimplantation of the aortic valve, long-term follow-up suggests that the latter is associated with lower risk of developing aortic insufficiency. Failure of remodeling of the aortic root is often due to dilatation of the aortic annulus. Thus, this type of aortic valve sparing should be reserved for older patients with ascending aortic aneurysm and normal aortic annulus whereas reimplantation of the aortic valve is more appropriate for young patients with inherited disorders that cause aortic root aneurysms. This article summarizes the published experience with these two operations. They are no longer experimental procedures and should be part of the surgical armamentarium to treat patients with aortic root aneurysm and ascending aortic aneurysms with associated aortic insufficiency.
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Affiliation(s)
- Tirone E David
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Canada
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Leontyev S, Trommer C, Subramanian S, Lehmann S, Dmitrieva Y, Misfeld M, Mohr FW, Borger MA. The outcome after aortic valve-sparing (David) operation in 179 patients: a single-centre experience. Eur J Cardiothorac Surg 2012; 42:261-6; discussion 266-7. [PMID: 22328626 DOI: 10.1093/ejcts/ezs011] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The David aortic valve-sparing reimplantation (AVr-D) operation is increasingly being used in patients with aortic root aneurysmal disease and pliable aortic cusps. The objective of this study was to assess our early and medium-term outcomes with the AVr-D operation. METHODS Between 2003 and 2011, a total of 179 patients underwent AVr-D procedures. The mean patient age was 49.7 ± 15.1 years, and 23.5% (n = 42) were females. Marfan syndrome was present in 17.3% of patients (n = 31), and acute Type A aortic dissection in 15.6% (n = 28). Clinical follow-up was 100% complete and was 1.8 ± 1.6 years (0 days to 7.5 years) long. Echocardiographic follow-up was performed 2.2 ± 1.5 years (0 days to 7.5 years) postoperatively and was 77% complete. RESULTS Early mortality was 1.1% (n = 2), with both deaths occurring in patients with Type A dissection. Pre-discharge echocardiography revealed no patients with >2+ aortic insufficiency (AI), 19.6% of patients (n = 34) with 1+ or 2+ AI and 80.4% of patients (n = 145) with trace or no AI. Left ventricular end-diastolic diameters decreased significantly from 5.6 ± 0.9 to 5.1 ± 0.8 cm early postoperatively (P < 0.01). Transvalvular maximum gradients were similar before discharge and at last follow-up (10.6 ± 5.4 vs. 10.0 ± 8.2 mmHg, P = 0.4). AI grade increased significantly over time (0.3 ± 0.4 before discharge vs. 0.5 ± 0.6 at follow-up, P = 0.01), but remained less than moderate in 93.6% of patients. Four patients required aortic valve re-replacement during follow-up, two due to early endocarditis and two due to non-coronary leaflet prolapse in Marfan patients. Five-year freedom from aortic valve reoperation was 95.9 ± 2.0%. CONCLUSIONS AVr-D is associated with a low mortality and morbidity rate, even in patients with Type A aortic dissection. Although a slightly higher rate of recurrent AI may be present in patients with Marfan syndrome, freedom from recurrent AI and reoperation remains excellent during medium-term follow-up. The David operation should be considered the gold standard for patients with proximal aortic root pathology (aneurysm or dissection) and pliable aortic cusps.
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Affiliation(s)
- Sergey Leontyev
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
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Beyersdorf F, Rylski B. Current state of the reimplantation technique (DAVID Operation): surgical details and results. HSR PROCEEDINGS IN INTENSIVE CARE & CARDIOVASCULAR ANESTHESIA 2012; 4:73-6. [PMID: 23439276 PMCID: PMC3484932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Valve-sparing operations are becoming more and more popular because they allow a repair of the native aortic valve and a replacement of the diseased aortic root and the ascending aorta. Previously these patients were treated with a valved-conduit and needed anticoagulation with warfarin if a mechanical valve was used or were left with uncertain long-term durability if a biological valve was used. There are two different types of valve-sparing operations available (reimplantation and remodeling technique). Of these two techniques, the reimplantation technique has several advantages but is also technically more demanding. Therefore this paper describes surgical details of the reimplantation technique and the potential pitfalls as well as some results.
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D'Ancona G, Ciofalo R, Biondo D, Follis M, Follis F. Midterm follow-up dynamic echocardiography evaluation after ascending aorta replacement and reimplantation of the aortic valve (David operation) in a matched control study. Eur J Cardiothorac Surg 2011; 41:785-8. [DOI: 10.1093/ejcts/ezr114] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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