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Sá MP, Jacquemyn X, Awad AK, Brown JA, Chu D, Serna-Gallegos D, Kari FA, Sultan I. Valve-Sparing Aortic Root Replacement With Reimplantation vs Remodeling: A Meta-analysis. Ann Thorac Surg 2024; 117:501-507. [PMID: 37831047 DOI: 10.1016/j.athoracsur.2023.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/18/2023] [Accepted: 08/15/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Long-term outcomes of valve-sparing aortic root replacement (VSARR) with reimplantation vs remodeling in patients undergoing aortic root surgery remains a controversial subject. METHODS This study was a pooled meta-analysis of Kaplan-Meier-derived data from comparative studies published by December 31, 2022. RESULTS Fifteen studies met our eligibility criteria, comprising 3044 patients (1991 in the reimplantation group and 2018 in the remodeling group). Patients who underwent VSARR with remodeling had a higher risk of all-cause death (hazard ratio [HR], 1.54; 95% CI, 1.16-2.03; P = .002, log-rank test P < .001). Landmark analysis (with 4 years as the landmark time point) demonstrated that survival was lower in patients who underwent VSARR with remodeling (HR, 2.15; 95% CI, 1.43-3.24; P < .001) in the first 4 years. Beyond the 4-year time point, no difference in survival was observed (HR, 1.04; 95% CI, 0.72-1.50; P = .822). The risk for need of aortic valve and/or root reintervention was higher in patients undergoing VSARR with remodeling (HR, 1.49; 95% CI, 1.07-2.07; P = .019, log-rank test P < .001). We did not find statistically significant coefficients for the covariates of age, female sex, connective tissue disorders, bicuspid aortic valve, aortic dissection, coronary bypass surgery, total arch replacement, or annular stabilization, which means that these covariates did not modulate the effects observed in our pooled analyses. CONCLUSIONS VSARR with reimplantation is associated with better overall survival and lower risk of need for reintervention over time compared with VSARR with remodeling. Regarding overall survival, we observed a time-varying effect that favored the reimplantation technique up to 4 years of follow-up, but not beyond this time point.
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Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Ahmed K Awad
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - James A Brown
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Fabian A Kari
- Section of Pediatric and Congenital Cardiac Surgery, European Pediatric Heart Center, Ludwig Maximilian University (LMU) University Hospital and German Heart Center, Munich, Germany
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Stephens EH, Dearani JA, Pochettino A, Vricella LA, Sundt TM, David TE, Bavaria JE, Cameron DE. Valve-Sparing Aortic Root Replacement State-of-the-Art Review, Part I: Anatomy and Physiology. Ann Thorac Surg 2024:S0003-4975(24)00115-2. [PMID: 38360340 DOI: 10.1016/j.athoracsur.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/03/2023] [Accepted: 12/09/2023] [Indexed: 02/17/2024]
Abstract
Aortic valve disease is common, and valve-preserving operations are preferred whenever possible. Valve-sparing aortic root replacement has become an important tool for managing aortic root pathology in children and adults. The learning curve for this operation is challenging, but with increasing experience and technical modifications, early and late outcomes continue to improve. Durable long-term results vary based on the underlying anatomy, pathology, and patient selection, as well as surgeon expertise. The first installment of this Valve-Sparing Aortic Root Replacement State-of-the-Art Review article addresses patient anatomy and physiology as it relates to candidacy for VSRR.
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Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | | | - Luca A Vricella
- Division of Pediatric Cardiovascular Surgery, Department of Surgery, Advocate Children's Heart Institute, Chicago, Illinois
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Tirone E David
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Duke E Cameron
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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3
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Stephens EH, Dearani JA, Pochettino A, Vricella LA, Sundt TM, David TE, Bavaria JE, Cameron DE. Valve-Sparing Aortic Root Replacement State-of-the-Art Review, Part II: Surgical Techniques. Ann Thorac Surg 2024:S0003-4975(24)00116-4. [PMID: 38360342 DOI: 10.1016/j.athoracsur.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 12/03/2023] [Accepted: 12/19/2023] [Indexed: 02/17/2024]
Abstract
Aortic valve disease is common, and valve-preserving operations are preferred whenever possible. Valve-sparing aortic root replacement (VSRR) has become an important tool for managing aortic root pathology in children and adults. The learning curve for this operation is challenging, but with increasing experience and technical modifications, early and late outcomes continue to improve. Durable long term results vary based on underlying anatomy, pathology, and patient selection, as well as surgeon expertise. Part II of this VSRR State-of-the-Art Review article provides technical pearls related to VSRR.
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Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | | | - Luca A Vricella
- Division of Pediatric Cardiovascular Surgery, Department of Surgery, Advocate Children's Heart Institute, Chicago, Illinois
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Tirone E David
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Duke E Cameron
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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4
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Rosinski BF, Hodges K, Vargo PR, Roselli EE, Koprivanac M, Tong M, Rajeswaran J, Blackstone EH, Svensson LG. Outcomes of aortic root replacement with tricuspid aortic valve reimplantation in patients with residual aortic regurgitation. J Thorac Cardiovasc Surg 2024; 167:101-111.e4. [PMID: 37532029 DOI: 10.1016/j.jtcvs.2023.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/22/2023] [Accepted: 07/25/2023] [Indexed: 08/04/2023]
Abstract
OBJECTIVE To characterize residual aortic regurgitation (AR), identify its risk factors, and evaluate outcomes following aortic root replacement with aortic valve reimplantation. METHODS From 2002 to 2020, 756 patients with a tricuspid aortic valve underwent elective reimplantation for aortic root aneurysm. AR on transthoracic echocardiograms before hospital discharge was graded as mild or greater. Machine learning was used to identify risk factors for residual AR and subsequent aortic valve reoperation. RESULTS Sixty-five patients (8.6%) had mild (58 [7.7%]) or moderate (7 [0.93%]) residual postoperative AR. They had more severe preoperative AR (38% vs 12%; P < .0001), thickened cusps (7.7% vs 2.2%; P = .008), aortic valve repair (38% vs 23%; P = .004), and multiple returns to cardiopulmonary bypass for additional repair (11% vs 3.3%; P = .003) than those without AR. Predictors of residual AR were severe preoperative AR, smaller aortic root graft, and concomitant cusp repair. At 10 years, patients with versus without residual AR had more moderate or severe AR (48% vs 7.0%; P < .0001) and freedom from reoperation was worse (89% vs 98%; P < .0001). Residual AR was a risk factor for early reoperation. Concomitant coronary bypass, lower body mass index, and lower ejection fraction were risk factors for late reoperation. Ten-year survival was similar among patients with and without residual AR (97% vs 93%; P = .43). CONCLUSIONS Residual AR after elective reimplantation of a tricuspid aortic valve for aortic root aneurysm is uncommon. Patients with severe preoperative AR and those who undergo valve repair have higher risk for residual AR, which can progress and increase risk of aortic valve reoperation.
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Affiliation(s)
- Brad F Rosinski
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kevin Hodges
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Patrick R Vargo
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Michael Tong
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- The Aorta Center, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio.
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Accord RE, Mecozzi G, Aalberts JJJ, Nijs J, ter Weeme M, van Aarnhem EEHL, Mariani MA, van den Berg MP. Multicentre experience with valve-sparing aortic root replacement by means of combined remodelling and external aortic ring annuloplasty in patients with Marfan syndrome. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad200. [PMID: 38109664 PMCID: PMC10739556 DOI: 10.1093/icvts/ivad200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 11/15/2023] [Accepted: 12/08/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVES The most recent valve-sparing root replacement technique combines the advantages of the reimplantation (David) and remodelling (Yacoub) techniques. The aortic root is reconstructed according to the remodelling technique, the aortic valve is repaired according to the principle of effective height, and an external ring provides annular support. The purpose of this study was to evaluate operative and mid-term outcomes using this technique in patients with Marfan syndrome. METHODS Adult patients with Marfan syndrome who had an indication for aortic root surgery according to European Society of Cardiology guidelines and were operated on using this new root replacement technique were retrospectively evaluated. Follow-up was obtained from standard outpatient visits and included echocardiography. RESULTS The study group comprised 22 patients (mean age 36 years, 68% males). Mean follow-up was 7.5 years. There were no mortalities. Two patients required aortic valve replacement because of aortic regurgitation. In both patients, the aortic root was severely dilated (≥65 mm) preoperatively, with grade III aortic valve regurgitation and aortic valve cusps that were very fragile. Aortic regurgitation was grade ≤I on follow-up in 18 of the remaining 20 patients. CONCLUSIONS Valve-sparing root replacement using remodelling combined with aortic-ring annuloplasty is safe in patients with Marfan syndrome. The mid-term outcome is promising in patients undergoing elective valve-sparing root replacement at recommended root diameters. However, in patients with extremely dilated aortic roots and already severe aortic regurgitation, the technique should be used cautiously as aortic cusps are fragile and might not be suitable for durable repair. CLINICAL REGISTRATION NUMBER UMCG Research registry #11208.
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Affiliation(s)
- Ryan E Accord
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Gianclaudio Mecozzi
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Jan J J Aalberts
- Department of Cardiology, Reinier de Graaf Hospital, Delft, Netherlands
| | - Jan Nijs
- Department of Cardiac Surgery, University Hospital Brussels, Brussels, Belgium
| | - Mimi ter Weeme
- Thorax Centrum Twente, Medisch Spectrum Twente, Enschede, Netherlands
| | | | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Maarten P van den Berg
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Seki M, Kunihara T, Takada J, Sasaki K, Kumazawa R, Seki H, Sasuga S, Fukuda H, Umezu M, Iwasaki K. Comparison of hemodynamics and root configurations between remodeling and reimplantation methods for valve-sparing aortic root replacement: a pulsatile flow study. Surg Today 2023; 53:845-854. [PMID: 36436023 PMCID: PMC10290965 DOI: 10.1007/s00595-022-02622-4] [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] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 10/11/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE To compare the characteristics of reimplantation (RI) using grafts with sinuses and remodeling (RM) with/without external suture annuloplasty using a pulsatile flow simulator. METHODS Porcine aortic roots were obtained from an abattoir, and six models of RM and RI with sinuses were prepared. External suture annuloplasty (ESA) was performed in the RM models to decrease the root diameter to 22 mm (RM-AP22) and 18 mm (RM-AP18). Valve models were tested at mean pulsatile flow and aortic pressure of 5.0 L/min and 120/80 (100) mmHg, respectively, at 70 beats/min. The forward flow, regurgitation, leakage, backflow rates, valve-closing time, and mean and peak pressure gradient (p-PG) were evaluated. Root configurations were examined using micro-computed tomography (micro-CT). RESULTS The backflow rate was larger in the RM models than in the RI models (RI: 8.56% ± 0.38% vs. RM: 12.64% ± 0.79%; p < 0.01). The RM-AP and RI models were comparable in terms of the forward flow, regurgitation, backflow rates, p-PG, and valve-closing time. The analysis using a micro-CT showed a larger dilatation of the sinus of the Valsalva in the RM groups than in the RI group (Valsalva: RI, 26.55 ± 0.40 mm vs. RM-AP22, 31.22 ± 0.55 mm [p < 0.05]; RM-AP18, 31.05 ± 0.85 mm [p < 0.05]). CONCLUSIONS RM with ESA and RI with neo-sinuses showed comparable hemodynamics. ESA to RM reduced regurgitation.
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Affiliation(s)
- Masahiro Seki
- Department of Cardiovascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Takashi Kunihara
- Department of Cardiac Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Jyunpei Takada
- Department of Modern Mechanical Engineering, Graduate School of Creative Science and Engineering, Waseda University, Tokyo, Japan
| | - Kenichi Sasaki
- Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Sayama, Japan
- Cooperative Major in Advanced Biomedical Sciences, Joint Graduate School of Tokyo Women's Medical University and Waseda University, Waseda University, 2-2 Wakamatsucho, Shinjuku, Tokyo, 162-8480, Japan
| | - Ryo Kumazawa
- Department of Modern Mechanical Engineering, Graduate School of Creative Science and Engineering, Waseda University, Tokyo, Japan
| | - Hiroshi Seki
- Division of Cardiovascular Surgery, Yamato Seiwa Hospital, Yamato, Japan
| | - Saeko Sasuga
- Department of Modern Mechanical Engineering, Graduate School of Creative Science and Engineering, Waseda University, Tokyo, Japan
| | - Hirotsugu Fukuda
- Department of Cardiovascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Mitsuo Umezu
- Department of Modern Mechanical Engineering, Graduate School of Creative Science and Engineering, Waseda University, Tokyo, Japan
- Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
- Cooperative Major in Advanced Biomedical Sciences, Joint Graduate School of Tokyo Women's Medical University and Waseda University, Waseda University, 2-2 Wakamatsucho, Shinjuku, Tokyo, 162-8480, Japan
| | - Kiyotaka Iwasaki
- Department of Modern Mechanical Engineering, Graduate School of Creative Science and Engineering, Waseda University, Tokyo, Japan.
- Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan.
- Cooperative Major in Advanced Biomedical Sciences, Joint Graduate School of Tokyo Women's Medical University and Waseda University, Waseda University, 2-2 Wakamatsucho, Shinjuku, Tokyo, 162-8480, Japan.
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7
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Elbatarny M, David TE, David CM, Chung JCY, Lafreniere-Roula M, Ouzounian M. Improved Outcomes of Reimplantation vs Remodeling in Marfan Syndrome: A Propensity-Matched Study. Ann Thorac Surg 2023; 115:576-582. [PMID: 35841950 DOI: 10.1016/j.athoracsur.2022.05.068] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 03/26/2022] [Accepted: 05/08/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Valve-sparing root replacement (VSRR) has excellent outcomes when performed in experienced centers in well-selected patients. It is suggested that reimplantation of the aortic valve may have better durability than remodeling in patients with Marfan syndrome (MFS), although long-term comparative data are limited. METHODS Between 1988 and 2018, 194 patients with MFS underwent VSRR at our institution. From these, we derived a propensity-matched cohort of 68 patients (44 who underwent reimplantation and 24 who had remodeling). Early outcomes included death and perioperative complications. Late outcomes were survival, probability of aortic insufficiency, and reintervention up to 20 years of follow-up. Median follow-up was 17.8 years (interquartile range, 12.0-20.6 years) for the entire matched cohort. RESULTS Baseline variables were similar between reimplantation and remodeling patients after matching: age (39 ± 12 vs 40 ± 13 years, P = .75) and male sex (28 [64%] vs 15 [63%], P = 1.0). Similar 20-year survival was observed after reimplantation compared with remodeling (82% vs 72%, P = .20), whereas the probability of developing greater than mild aortic insufficiency at 20 years was increased after remodeling (5.8% vs 13%, P = .013). More patients underwent reoperation on the aortic valve after a remodeling procedure than after reimplantation of the aortic valve (18% vs 0%, P = .018). CONCLUSIONS VSRR provides excellent long-term survival and freedom from valve-related complications outcomes in patients with MFS. Reimplantation of the aortic valve was associated with a lower risk of aortic valve reoperation and aortic insufficiency than the remodeling procedure after 2 decades of follow-up.
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Affiliation(s)
- Malak Elbatarny
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Tirone E David
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Carolyn M David
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C Y Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Myriam Lafreniere-Roula
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada.
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8
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Burke CR, Bavaria J. Response to: Correspondence on 'The personalized external aortic root support procedure: interesting niche or ready for prime time?' by Anderson. BRITISH HEART JOURNAL 2022; 108:744-745. [PMID: 35264417 DOI: 10.1136/heartjnl-2021-320557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - Joseph Bavaria
- Cardiac Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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9
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de Meester C, Vanovershelde JL, Jahanyar J, Tamer S, Mastrobuoni S, Van Dyck M, Navarra E, Poncelet A, Astarci P, El Khoury G, de Kerchove L. Long-term durability of bicuspid aortic valve repair: a comparison of 2 annuloplasty techniques. Eur J Cardiothorac Surg 2021; 60:286-294. [PMID: 33495781 DOI: 10.1093/ejcts/ezaa471] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/14/2020] [Accepted: 11/22/2020] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES To compare long-term outcomes after bicuspid aortic valve (BAV) repair utilizing the Cabrol annuloplasty versus valve sparing Reimplantation technique. METHODS From 1996 to 2018, 340 consecutive patients underwent BAV repair. Eighty underwent Cabrol annuloplasty and 189 underwent Reimplantation. Exclusion criteria were re-repairs (n = 6), active endocarditis (n = 4), no annuloplasty (n = 41) and ring or suture annuloplasty (n = 20). We compared both groups for survival, reoperations, valve related events and recurrent severe aortic regurgitation (AR > 2+). Inverse probability weighting (IPW) was used to balance the 2 groups. Cox regression analysis was used to identify outcome predictors. RESULTS After weighting, pre- and intraoperative characteristics were similar between groups, except for aorta replacement techniques and operative time, which was longer in the Reimplantation group (P < 0.001). At 12 years, overall survival was similar between groups (IPW: Cabrol 97 ± 2% vs Reimplantation 94 ± 3%, P = 0.52). Freedom from reoperation and freedom from AR > 2+ were significantly lower in the Cabrol group (reoperation IPW: 69 ± 9% vs 91 ± 4%, P = 0.004 and AR > 2+ IPW: 71 ± 8% vs 97 ± 2%, P < 0.001). The Reimplantation technique was the only independent predictor of reoperation (hazard ratio 0.31; confidence interval 0.19-0.7; P = 0.005). CONCLUSIONS In this study, comparing 2 annuloplasty strategies for BAV repair, we found statistically significant differences in long-term durability favouring the Reimplantation technique, and no differences in overall survival. The results support our current strategy of Reimplantation technique and repair of AR in patients with BAV. Cabrol annuloplasty is obsolete and should be generally abandoned in patients undergoing BAV repair for AR.
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Affiliation(s)
- Christophe de Meester
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCL), Louvain-la-Neuve, Belgium
| | - Jean-Louis Vanovershelde
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCL), Louvain-la-Neuve, Belgium.,Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jama Jahanyar
- Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Saadallah Tamer
- Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Stefano Mastrobuoni
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCL), Louvain-la-Neuve, Belgium.,Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Michel Van Dyck
- Division of Anesthesiology, Department of Acute Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Emiliano Navarra
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCL), Louvain-la-Neuve, Belgium.,Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Alain Poncelet
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCL), Louvain-la-Neuve, Belgium.,Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Parla Astarci
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCL), Louvain-la-Neuve, Belgium.,Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Gebrine El Khoury
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCL), Louvain-la-Neuve, Belgium.,Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Laurent de Kerchove
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCL), Louvain-la-Neuve, Belgium.,Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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10
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Toh S, Ang J, George JJ, Jayawardena O, Mahbub S, Harky A. Outcomes in techniques of valve sparing aortic root replacement: A systematic review and meta-analysis. J Card Surg 2020; 36:178-187. [PMID: 33085112 DOI: 10.1111/jocs.15132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To compare clinical outcomes of reimplantation versus remodeling in patients undergoing valve-sparing aortic root replacement (VSRR) surgery. METHOD Electronic database search at PubMed, Scopus, Embase, Ovid, and Google scholar was performed from inception to January 2020. Primary outcomes were aortic valve (AV) reintervention and postoperative grade of aortic insufficiency (AI) while secondary outcomes were 30-day mortality, reoperation for bleeding, and operative times. RESULTS A total of 21 articles met the inclusion criteria. A total of 1283 patients had reimplantation while 1150 had remodeling. No difference in preoperative demographics was noted except reimplantation patients were younger (48 ± 16 vs. 56 ± 15 years; p < .00001). The cardiopulmonary bypass and aortic cross-clamp times were shorter in the remodeling cohort (168 ± 38 vs. 150 ± 37 min; p = .0001 and 133 ± 31 vs. 112 ± 30 min; p = .0002, respectively). No difference in concomitant total arch surgery (14% in reimplantation vs. 15% in remodeling; p = .53). Postoperatively, there were similar stroke rates (3% in both cohorts; p = .54), rates of reoperation for bleeding (9% in reimplantation vs. 12% in remodeling; p = .88), and 30-day mortality (3% in reimplantation vs. 4% in remodeling; p = .96). No difference in early AV reintervention (1% in reimplantation vs. 2% in remodeling; p = .07), and late AV reintervention (4% in reimplantation vs. 7% in remodeling; p = .07). The AI of +2 grade was significantly lower in the reimplantation cohort (5% vs. 8%; p = .01). CONCLUSION Our study shows comparable clinical outcomes between both techniques. The practice of each technique is largely center and surgeon dependent. Larger sample size cohorts with minimal confounding factors are required to confirm the above findings.
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Affiliation(s)
- Steven Toh
- School of Medicine, Faculty of Life Science, University of Liverpool, Liverpool, UK
| | - Juliana Ang
- School of Medicine, Faculty of Life Science, University of Liverpool, Liverpool, UK
| | - Joel Jacob George
- School of Medicine, Faculty of Life Science, University of Liverpool, Liverpool, UK
| | - Ovin Jayawardena
- School of Medicine, Faculty of Life Science, University of Liverpool, Liverpool, UK
| | - Samiha Mahbub
- Department of Medicine, St. George's University of London, London, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Integrative Biology, Faculty of Health Science, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
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11
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Reimplantation for annular stabilization in bicuspid aortic valve repair. Gen Thorac Cardiovasc Surg 2020; 69:260-266. [PMID: 32743727 DOI: 10.1007/s11748-020-01453-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/23/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To review the outcomes of bicuspid aortic valve repair with the reimplantation technique. PATIENTS AND METHODS From 2006 to 2018, 46 patients with bicuspid aortic valve underwent the reimplantation procedure for aortic valve repair. Those patients were included in this study. The mean age was 45 ± 15 years and 44 were male. Preoperative echocardiography showed a mean ventriculoaortic junction diameter of 28 ± 3 mm. The mean diameter at the sinus of Valsalva was 41 ± 9 mm. The minimum cusp height was 19 ± 3 mm. Regarding cusp repair technique, central plication was used in 45 patients, free margin reinforcement in 10 patients, and patch repair in 4 patients. Follow-up was performed by annual echocardiography. RESULTS There were no hospital deaths. All patients were found with either no/trivial or mild AR on postoperative transesophageal echocardiography. The postoperative ventriculoaortic junction diameter was 23 ± 2 mm and 83 ± 17% preoperatively. Freedom from moderate AR was 85 ± 6% at 5 years, and freedom from reoperation was 93 ± 4% at 5 years. CONCLUSIONS Reimplantation for bicuspid aortic valve repair showed acceptable mid-term outcomes.
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12
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Lansac E. Invited Commentary. Ann Thorac Surg 2020; 110:947-948. [PMID: 31982446 DOI: 10.1016/j.athoracsur.2019.12.010] [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: 11/21/2019] [Accepted: 12/01/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Emmanuel Lansac
- Cardiac Surgery, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014 Paris, France.
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13
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Sharghbin M, Benhassen LL, Lading T, Bechsgaard T, Nielsen Skov S, Røpcke DM, Lyager Nielsen S, Hasenkam JM, Johansen P. Comparison of the Dacron ring and suture annuloplasty for aortic root repair: an in vitro evaluation. Interact Cardiovasc Thorac Surg 2018; 27:819-827. [PMID: 29868723 DOI: 10.1093/icvts/ivy175] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 04/29/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Increasing evidence shows that annular stabilization is essential in most aortic valve repair procedures. However, a standardized comparison of the 2 commonly used annuloplasty procedures is lacking. We hypothesized that the Dacron ring is more rigid than the polytetrafluoroethylene suture, whereas both procedures decrease annular dimensions. The aim of this study was to compare the biomechanical properties of the ring and suture techniques with native aortic roots in vitro. METHODS Eighteen aortic roots explanted from 80-kg pigs were randomized into a Dacron ring group, a suture annuloplasty group and a native control group. Each sample was tested in a pulsatile in vitro model with a force transducer attached to the aortic annulus to obtain radial force measurements, and annular dynamics was evaluated using 2-dimensional echography. RESULTS Among the 2 annuloplasty procedures, only the Dacron ring group provided a significant reduction in the annular diameter compared with the native group (P < 0.006). Both annuloplasty procedures significantly reduced the geometric orifice area, tenting area and sinus diameter while increasing the coaptation length compared with the native group. Systolic annular distension was retained between groups, although the total radial forces were significantly reduced in the procedure groups compared with the native group (ring 1.07 ± 0.45 N, suture 1.13 ± 0.39 N and native 3.55 ± 1.34 N, P < 0.001). CONCLUSIONS Although both annuloplasty procedures increase coaptation length and decrease geometric orifice area, a significant downsizing of the annulus was achieved using the Dacron ring only. The systolic annular distension was similar to the native aortic root, whereas the radial annular forces were evenly decreased by both annuloplasty procedures. Long-term studies are needed to disclose any difference in long-term effect of the annuloplasty procedures.
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Affiliation(s)
- Mona Sharghbin
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - Leila L Benhassen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - Troels Lading
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - Tommy Bechsgaard
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Skejby, Aarhus, Denmark
- Department of Engineering, Faculty of Science and Technology, Aarhus University, Aarhus, Denmark
| | - Søren Nielsen Skov
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - Diana M Røpcke
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - Sten Lyager Nielsen
- Department of Cardiothoracic Surgery, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - J Michael Hasenkam
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - Peter Johansen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Skejby, Aarhus, Denmark
- Department of Engineering, Faculty of Science and Technology, Aarhus University, Aarhus, Denmark
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14
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Toward standardization of valve-sparing root replacement and annuloplasty. Gen Thorac Cardiovasc Surg 2018; 66:685-691. [DOI: 10.1007/s11748-018-1015-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 09/11/2018] [Indexed: 12/14/2022]
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15
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Tanaka H, Takahashi H, Inoue T, Matsueda T, Oda T, Abe N, Nomura Y, Gotake Y, Okita Y. Which technique of cusp repair is durable in reimplantation procedure? Eur J Cardiothorac Surg 2018; 52:112-117. [PMID: 28498897 DOI: 10.1093/ejcts/ezx034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 01/18/2017] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES We aimed to ascertain the durability of cusp repair techniques used in reimplantation procedures. METHODS Between 2000 and 2015, 249 patients (mean age, 49 ± 17 years) with aortic insufficiency underwent the reimplantation procedure. The pathology was acute aortic dissection in 24 and non-dissection in 225 patients. Preoperative aortic regurgitation (AR) was absent in 9, 1+ in 19, 2+ in 20, 3+ in 71 and 4+ in 120 patients. The mean aortic root and ascending aortic diameters were 47 ± 9 mm and 38 ± 7 mm, respectively. The following techniques of cusp repair were used: none (83), central plication (130), free margin reinforcement (57) and patch repair (19). Annual echocardiography was performed. Freedom from moderate aortic insufficiency and aortic valve reoperation were calculated by the Kaplan-Meier method. Factors influencing the freedom from moderate or severe AR were calculated by proportional hazard analysis. RESULTS Mean follow-up period was 56 ± 44 months. Freedom from moderate or severe AR was 82%±3% and 77% ± 4% at 5 and 8 years, respectively, whereas freedom from aortic valve reoperation was 93%±8% and 87% ± 3% at 5 and 8 years, respectively. Recurrent AR and infection were causes of reoperation in 13 and 3 patients, respectively. Preoperative cusp prolapse, technique of free margin reinforcement used and patch repair were significant factors for recurrent AR by proportional hazard analysis. Central plication was not a significant factor for recurrent AR. CONCLUSIONS Preoperative cusp prolapse was a risk factor, whereas central plication was not a risk factor for recurrent AR. Free margin reinforcement had a positive effect, whereas patch repair had a negative effect on aortic valve durability.
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Affiliation(s)
- Hiroshi Tanaka
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Hiroaki Takahashi
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Takeshi Inoue
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Takashi Matsueda
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Tatsuya Oda
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Noriyuki Abe
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Yoshikatsu Nomura
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Yasuko Gotake
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
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16
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Berdajs D, Mosbahi S, Eckstein F, Reuthebuch O, Grapow M, Ferrari E, von Segesser LK. Impact of aortic root annuloplasty on 3D aortic root geometry. J Surg Res 2018; 225:45-53. [PMID: 29605034 DOI: 10.1016/j.jss.2017.12.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 12/06/2017] [Accepted: 12/13/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND The aim was to evaluate the impact of aortic root (AoR) annuloplasty on 3D AoR deformation. METHODS In experimental setup, Yacoub procedure and Yacoub with annuloplasty were performed. Results were compared to native AoR. In each AoR modality, six microsonometric (2 mm, 200 Hz) crystals were implanted at the sinotubular junction (STJ) and at the AoR base (AoB). 3D deformation of the AoR was determined by AoR tilt (α) and rotation (β) angle changes. RESULTS Tilt angle in Yacoub AoR with annuloplasty and in Yacoub AoR was maximal at ejection, 26.71 ± 0.18° and 24.91 ± 0.13°, respectively, and minimal at diastole, 25.34 ± 0.15° and 21.90 ± 0.15°, respectively. Rotation angle in Yacoub AoR with and without annuloplasty was maximal at ejection, 27.04 ± 0.25° and 23.53 ± 0.54°, respectively, and minimal at diastole, 24.84 ± 0.14° and 21.62 ± 0.16°, respectively. In native AoR, tilt angle and rotation were minimal at ejection, 14.34 ± 0.81° and 18.1 ± 3.20°, respectively, and maximal at diastole, 18.78 ± 0.84° and 21.23 ± 021°, respectively. AoB and STJ had maximal expansion at ejection; 2.59 ± 2.40% and 6.05 ± 0.66 for Yacoub and 3.75 ± 0.66% and 3.08 ± 0.24% for Yacoub with annuloplasty. In native AoR, the expansion at ejection for AoB was 7.13 ± 2.68% and for STJ was 16.42 ± 0.63%. CONCLUSIONS AoB annuloplasty reduces AoB deformation and has an impact on STJ dynamics. In both the Yacoub AoR modalities, during ejection, the AoR takes on more of a cone-like geometry, whereas in native AoR, it is of a cylinder-like shape.
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Affiliation(s)
- Denis Berdajs
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland; Department of Surgery and Anesthesiology, Cardiovascular Research, University Hospital Lausanne, Lausanne, Switzerland.
| | - Selim Mosbahi
- Department of Surgery and Anesthesiology, Cardiovascular Research, University Hospital Lausanne, Lausanne, Switzerland
| | - Friedrich Eckstein
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Oliver Reuthebuch
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Martin Grapow
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Enrico Ferrari
- Cardiac Surgery, Cardiocentro Ticino Foundation, Lugano, Switzerland
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17
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Klotz S, Stock S, Sievers HH, Diwoky M, Petersen M, Stierle U, Richardt D. Survival and reoperation pattern after 20 years of experience with aortic valve–sparing root replacement in patients with tricuspid and bicuspid valves. J Thorac Cardiovasc Surg 2018; 155:1403-1411.e1. [DOI: 10.1016/j.jtcvs.2017.12.039] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 11/15/2017] [Accepted: 12/05/2017] [Indexed: 11/26/2022]
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18
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Wojnarski CM, Roselli EE. Tighten your belt or lose your pants? Not if it is tailored to the patient-annuloplasty during remodeling. J Thorac Cardiovasc Surg 2017; 155:895-896. [PMID: 29249492 DOI: 10.1016/j.jtcvs.2017.11.030] [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: 10/31/2017] [Accepted: 11/11/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Charles M Wojnarski
- Department of Thoracic and Cardiovascular Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
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19
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Abstract
Aortic valve sparing root surgery (AVSRS) is a safe and durable alternative for patients with dilated roots or pure aortic regurgitation (AR), which avoids the risks of anticoagulation or valvular degeneration with prosthetic valves. Notwithstanding the theoretical challenges of greater tissue fragility in Marfan syndrome (MFS), AVSRS has been demonstrated to have equal outcomes in this condition as it does in those without MFS. The benefits of retaining the native aortic valve in this generally younger age group extend beyond those of avoiding the inconvenience and complications of prolonged exposure to anticoagulants and include ease of management for future aortic, cardiac and non-cardiac procedures which are the norm for these patients. The essential principles of AVSRS in MFS do not differ from those for the rest of the population. Successful repair and durable valve function depend on a sound understanding of the close interaction between the structure and function of this exquisitely designed piece of engineering. We are fortunate to have numerous tools in our surgical armamentarium to preserve these valves. It is the purpose of this paper to demystify the complex structure-function interactions of the aortic valve, thereby gaining an intuition for AVSRS. We will also elaborate on specific technical details of established techniques that we have found successful in preserving the normal function of these valves in the long term.
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Affiliation(s)
- George Matalanis
- Department of Cardiac Surgery, The Austin Hospital, Heidelberg, Australia
| | - Nisal K Perera
- Department of Cardiac Surgery, The Austin Hospital, Heidelberg, Australia
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20
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Berdajs D, Mosbahi S, Strano F, Forro Z, Burki M, von Segesser LK. Impact of synthetic elements on aortic root haemodynamics: computed fluid dynamics of aortic root reconstruction and valve reimplantation. Eur J Cardiothorac Surg 2017; 51:432-441. [PMID: 28013289 DOI: 10.1093/ejcts/ezw347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 09/19/2016] [Indexed: 11/14/2022] Open
Abstract
Objectives The aim was to evaluate the impact of the aortic valve reimplantation (David) and of the aortic root (AoR) remodelling (Yacoub) on the AoR haemodynamics. Methods In an experimental setup where the clinical scenario of Yacoub, ( n = 5, domestic pig) and of David ( n = 5, domestic pig) procedure was performed in each AoR, six high-fidelity (200 Hz) sonomicrometric crystals were implanted. Crystals were positioned at three commissures with their projection at the root base. In post-measurement processing 3D deformation of both AoR was determined and used for computed fluid dynamic modelling in order to evaluate pressure, velocity and shear stress profiles. Results In David AoR: high pressure (> 150 mmHg) and low to moderate shear stress (0-30 Pa) were found from the period of isovolemic contraction to the closure of the aortic valve. At mid diastole pressure augmentation (> 120 mmHg) a low shear stress (0-10 Pa) was registered at the leaflets, three commissures, and intervalvular triangles. In Yacoub AoR: high pressure (110-130 mmHg) with moderate low shear stress (0-30 Pa) was only registered at isovolemic contraction. Conclusions The results show that haemodynamic conditions following a David procedure have a less favourable pattern as compared to a Yacoub AoR. In David AoR, high pressure and low shear stress are present during 2/3 of the cardiac cycle, whereas in Yacoub root, these conditions are present only for a short period of isovolemic contraction.
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Affiliation(s)
- Denis Berdajs
- Department of Surgery and Anesthesiology, Cardiovascular Research, University Hospital Lausanne, Lausanne, Switzerland.,Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Selim Mosbahi
- Department of Surgery and Anesthesiology, Cardiovascular Research, University Hospital Lausanne, Lausanne, Switzerland
| | - Francesco Strano
- Department of Surgery and Anesthesiology, Cardiovascular Research, University Hospital Lausanne, Lausanne, Switzerland
| | - Zalan Forro
- Swiss Federal Institution of Technology Zürich, Zürich, Switzerland
| | - Marco Burki
- Department of Surgery and Anesthesiology, Cardiovascular Research, University Hospital Lausanne, Lausanne, Switzerland
| | - Ludwig K von Segesser
- Department of Surgery and Anesthesiology, Cardiovascular Research, University Hospital Lausanne, Lausanne, Switzerland
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Martín CE, García Montero C, Serrano SF, González A, Mingo S, Moñivas V, Centeno J, Forteza A. The influence of Marfans and bicuspid valves on outcomes following aortic valve reimplantation. J Card Surg 2017; 32:604-612. [PMID: 28929526 DOI: 10.1111/jocs.13206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND We analyzed our early and midterm results with aortic valve reimplantation surgery to determine the influence of Marfan syndrome and bicuspid valves on outcomes with this technique. METHODS Between March 2004 and December 2015, 267 patients underwent aortic valve reimplantation operations. The mean diameter of the sinuses of Valsalva was 50 ± 3 mm and moderate/severe aortic regurgitation was present in 34.4% of these patients. A bicuspid aortic valve was present in 21% and 40% had Marfan syndrome. RESULTS Overall 30-day mortality was 0.37% (1/267). Mean follow-up was 59.7 ± 38.7 months. Overall survival at 1, 3, and 5 years was 98 ± 8%, 98 ± 1%, and 94 ± 2%, respectively. Freedom from reoperation and aortic regurgitation >II was 99 ± 5%, 98 ± 8%, 96.7 ± 8%, and 99 ± 6%, 98 ± 1%, 98 ± 1%, respectively at 1, 3, and 5 years follow-up, with no differences between Marfan and bicuspid aortic valve groups. (p = 0.94 and p = 0.96, respectively). No endocarditis or thromboembolic complications were documented, and 93.6% of the patients did not receive any anticoagulation therapy. CONCLUSIONS The reimplantation technique for aortic root aneurysms is associated with excellent clinical and functional outcomes at short and mid-term follow-up.
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Affiliation(s)
- Carlos E Martín
- Department of Cardiac Surgery, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Carlos García Montero
- Department of Cardiac Surgery, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Santiago-Fiz Serrano
- Department of Cardiac Surgery, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Ana González
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Susana Mingo
- Department of Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Vanessa Moñivas
- Department of Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Jorge Centeno
- Department of Cardiac Surgery, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Alberto Forteza
- Department of Cardiac Surgery, Hospital Universitario Puerta de Hierro, Madrid, Spain
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22
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Valve-sparing aortic root surgery. CON: remodeling. Gen Thorac Cardiovasc Surg 2017; 67:82-92. [DOI: 10.1007/s11748-017-0833-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 09/06/2017] [Indexed: 01/05/2023]
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Risk Factors for Late Aortic Valve Dysfunction After the David V Valve-Sparing Root Replacement. Ann Thorac Surg 2017; 104:1479-1487. [PMID: 28669506 DOI: 10.1016/j.athoracsur.2017.04.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 03/28/2017] [Accepted: 04/04/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Valve-sparing root replacement (VSRR) is an established therapy for aortic root pathology. However, late aortic valve dysfunction requiring reoperation remains a primary concern of this procedure. This study examines risk factors for late aortic insufficiency (AI) and aortic stenosis (AS) after David V VSRR. METHODS A retrospective review from 2005 to 2015 at a US academic center identified 282 patients who underwent VSRR. Cox proportional hazards regression analysis was used to identify risk factors for late AI and AS after VSRR. RESULTS The mean age was 46.4 years. Sixty-four patients (22.7%) had bicuspid valves, and 41 patients (14.5%) had Marfan syndrome. The incidence of reoperations was 27 (9.6%), and 42 cases (14.9%) presented with acute type A dissection. Operative mortality was 8 (2.8%). Seven-year survival was 90.9%. Seven-year cumulative incidence of reoperation, greater than 2+ AI and greater than moderate AS were 3.1%, 2.2%, and 0.8%, respectively. Multivariable analysis showed aortic root size 55 mm or larger (hazard ratio 3.44, 95% confidence interval: 1.27 to 9.29, p = 0.01) to be a risk factor for late AI whereas bicuspid valve (hazard ratio 16.07, 95% confidence interval: 3.12 to 82.68, p = 0.001) and cusp repair were found to be risk factors (hazard ratio 5.91, 95% confidence interval: 1.17 to 29.86, p = 0.03) for late AS. CONCLUSIONS Valve-sparing root replacement can be performed with low operative risk and good overall long-term survival even in complex clinical settings. Durable valve function can be expected; however, aortic root size 55 cm or more, bicuspid valve anatomy, and cusp repair represent independent risk factors for late aortic valve dysfunction after these procedures.
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Gaudino M, Di Franco A, Weltert L, Benedetto U, Lau C, Gambardella I, De Paulis R, Girardi LN. The role of neo-sinus reconstruction in aortic valve-sparing surgery. J Card Surg 2017; 32:328-333. [DOI: 10.1111/jocs.13143] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Mario Gaudino
- Department of Cardio-Thoracic Surgery; Weill-Cornell Medical Center; New York City New York
| | - Antonino Di Franco
- Department of Cardio-Thoracic Surgery; Weill-Cornell Medical Center; New York City New York
| | - Luca Weltert
- Department of Cardiac Surgery; European Hospital; Rome Italy
| | - Umberto Benedetto
- Bristol Heart Institute; University of Bristol; Bristol United Kingdom
| | - Christopher Lau
- Department of Cardio-Thoracic Surgery; Weill-Cornell Medical Center; New York City New York
| | | | | | - Leonard N. Girardi
- Department of Cardio-Thoracic Surgery; Weill-Cornell Medical Center; New York City New York
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Remodeling root repair with an external aortic ring annuloplasty. J Thorac Cardiovasc Surg 2017; 153:1033-1042. [DOI: 10.1016/j.jtcvs.2016.12.031] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 11/25/2016] [Accepted: 12/09/2016] [Indexed: 12/20/2022]
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Keeling WB, Leshnower BG, Binongo J, Lasanajak Y, McPherson L, Chen EP. Severity of Preoperative Aortic Regurgitation Does Not Impact Valve Durability of Aortic Valve Repair Following the David V Valve Sparing Aortic Root Replacement. Ann Thorac Surg 2017; 103:756-763. [DOI: 10.1016/j.athoracsur.2016.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 06/04/2016] [Accepted: 07/05/2016] [Indexed: 10/21/2022]
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Cho SH, Kim DH, Kwak YT. Valve-Sparing Root Replacement: Aortic Root Remodeling with External Subvalvular Ring Annuloplasty. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:489-492. [PMID: 27965932 PMCID: PMC5147480 DOI: 10.5090/kjtcs.2016.49.6.489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 07/05/2016] [Accepted: 07/06/2016] [Indexed: 11/16/2022]
Abstract
The original valve-sparing procedures for aortic root aneurysms were remodeling and reimplantation of the aortic root. The remodeling technique provides more physiologic movement of the cusps within 3 reconstructed neo-sinuses, thus preserving root expansibility through the interleaflet triangles. However, the durability of remodeling has been a matter of concern due to the high rate of aortic insufficiency when annular dilation is not addressed. Therefore, a modified approach was developed, combining a physiologic remodeling of the root with a subvalvular annuloplasty. This case report highlights the first case of successful aortic root remodeling with external subvalvular ring annuloplasty in Korea.
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Affiliation(s)
- Sang-Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine
| | - Dae Hyun Kim
- Department of Thoracic and Cardiovascular Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine
| | - Young Tae Kwak
- Department of Thoracic and Cardiovascular Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine
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Holubec T, Higashigaito K, Belobradek Z, Dergel M, Harrer J, Alkadhi H, Zacek P, Vojacek J. An Expansible Aortic Ring in Aortic Root Remodeling: Exact Position, Pulsatility, Effectiveness, and Stability in Three-Dimensional CT Study. Ann Thorac Surg 2016; 103:83-90. [PMID: 27457826 DOI: 10.1016/j.athoracsur.2016.05.098] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 04/21/2016] [Accepted: 05/23/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to assess effectiveness, stability, position, and expansibility of an expansible aortic annuloplasty ring with computed tomography (CT). METHODS Ten men (median age 51 years) scheduled for aortic root remodeling with implantation of external annuloplasty ring underwent contrast-enhanced CT of the aortic root preoperatively, postoperatively, and at a median of 21 months after operation. A reconstructed transverse double oblique view of the aortic base (AB) and of the new defined annuloplasty ring base (ARB; plane of the lower edge of the ring) in systole and diastole were obtained. The diameters, perimeter, and area were measured. In addition, the distances between AB and ARB in the nadir of each sinus were measured. RESULTS We found 12% reduction of the postoperative AB and 19% of ARB perimeter in both systole (p = 0.004, p < 0.001, respectively) and diastole (p = 0.001, p < 0.001, respectively) compared with preoperative. There was 22% reduction of the postoperative AB area in systole and 24% in diastole (p = 0.002, p = 0.001, respectively) and 33% reduction of the ARB area in systole and 32% in diastole (p < 0.001 for both) compared with the preoperative period. Nearly all measured variables in the follow-up period showed a slight increase compared with the postoperative period; however, they did not reach statistical significance. The postoperative systolic-diastolic differences in the three measured variables at the level of AB and ARB were statistically significant and were maintained throughout the follow-up period. The base of the ring was implanted 2 ± 2 mm at the right, 0 ± 1 mm at the left above the AB, and 2 (-3 to 2) mm at the noncoronary nadir below the AB. CONCLUSIONS This study demonstrates imaging evidence of the effectiveness, stability, and pulsatility of the annuloplasty ring in aortic root remodeling in follow-up and describes the exact position of the ring at the base of the aortic root.
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Affiliation(s)
- Tomas Holubec
- Division of Cardiovascular Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Cardiac Surgery, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
| | - Kai Higashigaito
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Zdenek Belobradek
- Department of Radiology, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Martin Dergel
- Department of Cardiac Surgery, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jan Harrer
- Department of Cardiac Surgery, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Hatem Alkadhi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Pavel Zacek
- Department of Cardiac Surgery, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jan Vojacek
- Department of Cardiac Surgery, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
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Lansac E, Di Centa I, Sleilaty G, Lejeune S, Khelil N, Berrebi A, Diakov C, Mankoubi L, Malergue MC, Noghin M, Zannis K, Salvi S, Dervanian P, Debauchez M. Long-term results of external aortic ring annuloplasty for aortic valve repair. Eur J Cardiothorac Surg 2016; 50:350-60. [DOI: 10.1093/ejcts/ezw070] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 01/25/2016] [Indexed: 01/18/2023] Open
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Dhurandhar V, Parikh R, Saxena A, Vallely MP, Wilson MK, Black DA, Tran L, Reid C, Bannon PG. Early and Late Outcomes Following Valve Sparing Aortic Root Reconstruction: The ANZSCTS Database. Heart Lung Circ 2016; 25:505-11. [DOI: 10.1016/j.hlc.2015.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 09/20/2015] [Accepted: 10/27/2015] [Indexed: 10/22/2022]
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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. Residual and Progressive Aortic Regurgitation After Valve-Sparing Root Replacement: A Propensity-Matched Multi-Institutional Analysis in 764 Patients. Ann Thorac Surg 2015; 101:1500-6. [PMID: 26704413 DOI: 10.1016/j.athoracsur.2015.10.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/23/2015] [Accepted: 10/01/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Residual/progressive aortic regurgitation (rAR, pAR) after valve-sparing aortic root replacement (V-SARR) can lead to reoperations. We sought to characterize risk factors of mild rAR and pAR after V-SARR in a multicenter cohort. The effect of additional cusp repair on valve function was analyzed using propensity matching. METHODS A total of 1,015 patients after V-SARR were identified with (n = 288, 28%) or without additional cusp/commissure repair (n = 727, 72%) at four cardiac units in Germany. A total of 764 patients fulfilling transthoracic echocardiography follow-up-criteria comprised the study cohort. Logistic regression was used for risk factor analysis with endpoints rAR, new onset AR, and pAR. t tests and analyses of variance were used for between-group differences. The effects of additional cusp repair on valve function were studied comparing propensity-matched quintiles. RESULTS The incidence of rAR was 29%, with influencing factors aneurysm size (p = 0.07) and preoperative aortic valve function (p = 0.08). It was found more often among nonsyndromic patients (34% vs. 14%; OR, 0.4; p < 0.001). Progression of rAR was detectable in 30% after a mean of 4.3 years. The progression rate of rAR ∼ 0.3 grades per patient-year within the first 5 years. When quintiles identified by propensity score were compared, additional cusp repair was linked to new onset AR (p = 0.016) while it was not linked to rAR (p = 0.14) or pAR (p = 0.5). CONCLUSIONS The incidences of rAR and pAR are considerable after V-SARR. Patients should be operated on before large aneurysms are present. New onset AR after an initially good functional result is more likely after an additional cusp repair, while rAR and pAR are not influenced by cusp repair.
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Affiliation(s)
- Fabian A Kari
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.
| | | | | | | | - Hans-Hinrich Sievers
- Department of Heart and Thoracic Vascular Surgery, University Hospital Lübeck, Lübeck, Germany
| | - Doreen Richardt
- Department of Heart and Thoracic Vascular Surgery, University Hospital Lübeck, Lübeck, Germany
| | | | | | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
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Overview of current surgical strategies for aortic disease in patients with Marfan syndrome. Surg Today 2015; 46:1006-18. [DOI: 10.1007/s00595-015-1278-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 11/02/2015] [Indexed: 01/16/2023]
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33
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Técnicas de preservación de válvula aórtica. CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2014.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Khelil N, Sleilaty G, Palladino M, Fouda M, Escande R, Debauchez M, Di Centa I, Lansac E. Surgical Anatomy of the Aortic Annulus: Landmarks for External Annuloplasty in Aortic Valve Repair. Ann Thorac Surg 2015; 99:1220-6. [DOI: 10.1016/j.athoracsur.2014.12.034] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 12/02/2014] [Accepted: 12/05/2014] [Indexed: 10/23/2022]
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35
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Early and Medium Term Results of the Sleeve Valve-Sparing Procedure for Aortic Root Ectasia. Ann Thorac Surg 2015; 99:1228-33. [DOI: 10.1016/j.athoracsur.2014.10.044] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 10/15/2014] [Accepted: 10/21/2014] [Indexed: 11/18/2022]
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36
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de Kerchove L, Mastrobuoni S, Boodhwani M, Astarci P, Rubay J, Poncelet A, Vanoverschelde JL, Noirhomme P, El Khoury G. The role of annular dimension and annuloplasty in tricuspid aortic valve repair. Eur J Cardiothorac Surg 2015; 49:428-37; discussion 437-8. [DOI: 10.1093/ejcts/ezv050] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 01/12/2015] [Indexed: 01/05/2023] Open
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de Kerchove L, Jashari R, Boodhwani M, Duy KT, Lengelé B, Gianello P, Nezhad ZM, Astarci P, Noirhomme P, El Khoury G. Surgical anatomy of the aortic root: Implication for valve-sparing reimplantation and aortic valve annuloplasty. J Thorac Cardiovasc Surg 2015; 149:425-33. [DOI: 10.1016/j.jtcvs.2014.09.042] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 09/05/2014] [Accepted: 09/15/2014] [Indexed: 11/29/2022]
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Midterm follow-up of the reimplantation technique in patients with relatively normal annulus: Is David I still a clinically valid option? J Thorac Cardiovasc Surg 2014; 148:1334-40. [DOI: 10.1016/j.jtcvs.2013.11.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 11/18/2013] [Accepted: 11/29/2013] [Indexed: 11/15/2022]
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Abstract
BACKGROUND The treatment of patients with aneurysms of the ascending aorta and aortic arch often represents a challenge due to their complexity. The clinical picture is characterized by further progression of the disease and severe complications, such as acute aortic dissection or even aortic rupture are not uncommon. OBJECTIVES This article gives a review of definitions, etiology and indications for operative treatment of patients with aneurysms of the ascending aorta and aortic arch. RESULTS AND DISCUSSION An aortic aneurysm of the ascending aorta is defined as a dilatation of all wall layers of the aorta of more than 50 % in comparison to the normal diameter. This is dependent on age, sex, body surface area and the underlying diseases. In most cases the cause is the presence of atherosclerosis. Connective tissue diseases, bicuspid or monocuspid aortic valves and aortitis represent additional risk factors. Surgical treatment of the ascending aorta, aortic root and aortic arch is carried out in patients without connective tissue diseases and a diameter of ≥ 55 mm and for patients with Marfan syndrome and bicuspid aortic valves with a diameter of ≥ 50 mm. Earlier indications for surgery are present with an aortic diameter of ≥ 45 mm in patients with the following risk factors: familial disposition for aortic dissection (often unrecognized as sudden cardiac death), annual growth rate of the aortic diameter of > 2 mm, comorbid severe aortic valve or mitral valve insufficiency and female patients with a desire to have children. The standard surgical procedures include aortic root replacement, aortic valve reconstruction with aortic root or ascending aorta replacement and partial or total aortic arch replacement depending on the extent of the aneurysm. The so-called hybrid procedures for aortic arch surgery include frozen elephant trunk (ET) techniques and debranching procedures. Good perioperative and postoperative results can be achieved by early diagnostics and an assessment of the indications depending on the individual etiology. Individual and valve-preserving treatment strategies have a favorable influence on the operative outcome.
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Affiliation(s)
- S Leontyev
- Klinik für Herzchirurgie, Herzzentrum, Universität Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland,
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40
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Standardized approach to valve repair using an expansible aortic ring versus mechanical Bentall: early outcomes of the CAVIAAR multicentric prospective cohort study. J Thorac Cardiovasc Surg 2014; 149:S37-45. [PMID: 25240525 DOI: 10.1016/j.jtcvs.2014.07.105] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 07/22/2014] [Accepted: 07/25/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The study objective was to compare the 30-day outcomes of a standardized aortic valve repair technique (REPAIR group) associating root remodeling with an expansible aortic ring annuloplasty versus mechanical composite valve and graft (CVG group) replacement in treating aortic root aneurysms. METHODS A total of 261 consecutive patients with aortic root aneurysm were enrolled in this multicentric prospective cohort (131 in the CVG group, 130 in the REPAIR group) in 20 centers. The main end point is a composite criterion including mortality; reoperation; thromboembolic, hemorrhagic, or infectious events; and heart failure. Secondary end points were major adverse valve-related events. Crude and propensity score adjusted estimates are provided. RESULTS The mean age was 56.1 years, and the valve was bicuspid in 115 patients (44.7%). The median (interquartile range) preoperative aortic insufficiency grade was 2.0 (1.0-3.0) in the REPAIR group and 3.0 (2.0-3.0) in the CVG group (P = .0002). Thirty-day mortality was 3.8% (n = 5) in both groups (P = 1.00). Despite a learning curve and longer crossclamp times for valve repair (147.7 vs 99.8 minutes, P < .0001), the 2 groups did not differ significantly for the main criterion (odds ratio, 1.31; 95% confidence interval, 0.72-2.40; P = .38) or 30-day mortality (odds ratio, 0.99; 95% confidence interval, 0.28-3053; P = .99), with a trend toward more frequent major adverse valve-related events in the CVG group (odds ratio, 2.52; 95% confidence interval, 0.86-7.40; P = .09). At discharge, 121 patients (96.8%) in the REPAIR group had grade 0 or 1 aortic insufficiency. CONCLUSIONS A new standardized approach to valve repair, combining an expansible aortic annuloplasty ring with the remodeling technique, presented similar 30-day results to mechanical CVG with a trend toward reducing major adverse valve-related events. Analysis of late outcomes is in process for 3- and 10-year follow-ups.
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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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Forteza Gil A. Incidencia y progresión de la insuficiencia aórtica ligera tras el reimplante de la válvula aórtica según la técnica de David. CIRUGIA CARDIOVASCULAR 2014. [DOI: 10.1016/j.circv.2014.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Inoue T, Hashimoto K, Sakamoto Y, Yoshitake M, Matsumura Y, Kinami H, Takagi T. Left ventricular pseudoaneurysm after reimplantation procedure. Gen Thorac Cardiovasc Surg 2014; 64:224-6. [PMID: 24917204 DOI: 10.1007/s11748-014-0432-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 05/23/2014] [Indexed: 10/25/2022]
Abstract
Postoperative left ventricular pseudoaneurysm is a rare, but potentially lethal, complication because of the high risk of rupture and high mortality of repair. We report a 64-year-old man with Marfan syndrome who underwent the reimplantation valve-sparing aortic root replacement complicated by a postoperative left ventricular pseudoaneurysm that required urgent repair. Careful handling of the aortic root is required to avoid a left ventricular pseudoaneurysm, particularly in patients with connective tissue disorder.
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Affiliation(s)
- Takahiro Inoue
- Department of Cardiac Surgery, The Jikei University, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Kazuhiro Hashimoto
- Department of Cardiac Surgery, The Jikei University, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yoshimasa Sakamoto
- Department of Cardiac Surgery, The Jikei University, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Michio Yoshitake
- Department of Cardiac Surgery, The Jikei University, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yoko Matsumura
- Department of Cardiac Surgery, The Jikei University, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hiroo Kinami
- Department of Cardiac Surgery, The Jikei University, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Tomomitsu Takagi
- Department of Cardiac Surgery, The Jikei University, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
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Mohammadi S, Kalavrouziotis D, Voisine P, Dumont E, Doyle D, Perron J, Dagenais F. Bioprosthetic Valve Durability After Stentless Aortic Valve Replacement: The Effect of Implantation Technique. Ann Thorac Surg 2014; 97:2011-8. [DOI: 10.1016/j.athoracsur.2014.02.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 02/03/2014] [Accepted: 02/17/2014] [Indexed: 10/25/2022]
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45
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Wuliya M, Sleilaty G, Di Centa I, Khelil N, Berrebi A, Czitrom D, Mankoubi L, Noghin M, Malergue MC, Chatellier G, Debauchez M, Lansac E. An expansible aortic ring to preserve aortic root dynamics after aortic valve repair†. Eur J Cardiothorac Surg 2014; 47:482-90; discussion 490. [DOI: 10.1093/ejcts/ezu174] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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46
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Tan CNH, Fraser AG. Perioperative transesophageal echocardiography for aortic dissection. Can J Anaesth 2014; 61:362-78. [PMID: 24477464 DOI: 10.1007/s12630-014-0113-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 01/14/2014] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Aortic dissection is an infrequent but serious condition that often requires immediate operative intervention. We explore recent developments in the classification of aortic dissection and perioperative transesophageal echocardiography that assist with quantifying the severity of disease and facilitate its management. PRINCIPAL FINDINGS We describe the pivotal role of echocardiography in relation to key surgical considerations such as cannulation, aortic root surgery, perfusion in the aortic arch vessels, stenting in hybrid arch repair, and timing of preventative surgery. CONCLUSION Developments in the classification of aortic dissection have improved our perspective and understanding of the key presenting features that affect mortality. Improvements in patient outcome may be achieved in part by appropriately timed echocardiography-guided surgery.
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Affiliation(s)
- Christine N H Tan
- Department of Anaesthesia, Critical Care and Pain Management, B3, University Hospital of Wales, Cardiff, CF 14 4XW, UK,
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47
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Leshnower BG, Guyton RA, McPherson L, Kilgo PD, Chen EP. Improved Left Ventricular Function and Remodeling After the David V for Significant Aortic Insufficiency. Ann Thorac Surg 2013; 96:2090-4. [DOI: 10.1016/j.athoracsur.2013.07.056] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 06/20/2013] [Accepted: 07/02/2013] [Indexed: 11/30/2022]
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48
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Stephens EH, Liang DH, Kvitting JPE, Kari FA, Fischbein MP, Mitchell RS, Miller DC. Incidence and progression of mild aortic regurgitation after Tirone David reimplantation valve-sparing aortic root replacement. J Thorac Cardiovasc Surg 2013; 147:169-77, 178.e1-178.e3. [PMID: 24176278 DOI: 10.1016/j.jtcvs.2013.09.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 08/24/2013] [Accepted: 09/04/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The study objective was to determine whether recurrent or residual mild aortic regurgitation, which occurs after valve-sparing aortic root replacement, progresses over time. METHODS Between 2003 and 2008, 154 patients underwent Tirone David-V valve-sparing aortic root replacement; 96 patients (62%) had both 1-year (median, 12 ± 4 months) and mid-term (62 ± 22 months) transthoracic echocardiograms available for analysis. Age of patients averaged 38 ± 13 years, 71% were male, 31% had a bicuspid aortic valve, 41% had Marfan syndrome, and 51% underwent aortic valve repair, predominantly cusp free margin shortening. RESULTS Forty-one patients (43%) had mild aortic regurgitation on 1-year echocardiogram. In 85% of patients (n = 35), mild aortic regurgitation remained stable on the most recent echocardiogram (median, 57 ± 20 months); progression to moderate aortic regurgitation occurred in 5 patients (12%) at a median of 28 ± 18 months and remained stable thereafter; severe aortic regurgitation developed in 1 patient, eventually requiring reoperation. Five patients (5%) had moderate aortic regurgitation at 1 year, which did not progress subsequently. Two patients (2%) had more than moderate aortic regurgitation at 1 year, and both ultimately required reoperation. CONCLUSIONS Although mild aortic regurgitation occurs frequently after valve-sparing aortic root replacement, it is unlikely to progress over the next 5 years and should not be interpreted as failure of the valve-preservation concept. Further, we suggest that mild aortic regurgitation should not be considered nonstructural valve dysfunction, as the 2008 valve reporting guidelines would indicate. We need 10- to 15-year follow-up to learn the long-term clinical consequences of mild aortic regurgitation early after valve-sparing aortic root replacement.
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Affiliation(s)
- Elizabeth H Stephens
- Department of Cardiovascular and Thoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - David H Liang
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, Calif
| | | | - Fabian A Kari
- Department of Cardiovascular and Thoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Michael P Fischbein
- Department of Cardiovascular and Thoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - R Scott Mitchell
- Department of Cardiovascular and Thoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - D Craig Miller
- Department of Cardiovascular and Thoracic Surgery, Stanford University School of Medicine, Stanford, Calif.
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Lansac E, Di Centa I, Vojacek J, Nijs J, Hlubocky J, Mecozzi G, Debauchez M. Valve sparing root replacement: the remodeling technique with external ring annuloplasty. Ann Cardiothorac Surg 2013; 2:117-23. [PMID: 23977568 DOI: 10.3978/j.issn.2225-319x.2013.01.15] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 01/25/2013] [Indexed: 11/14/2022]
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Tian D, Rahnavardi M, Yan TD. Aortic valve sparing operations in aortic root aneurysms: remodeling or reimplantation? Ann Cardiothorac Surg 2013; 2:44-52. [PMID: 23977558 DOI: 10.3978/j.issn.2225-319x.2013.01.14] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 01/24/2013] [Indexed: 11/14/2022]
Affiliation(s)
- David Tian
- The Systematic Review Unit, The Collaborative Research (CORE) Group, Sydney, Australia
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