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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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2
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Köse Y, Özyurt Köse S, Koçoğulları CU. Dilated sinuses of Valsalva subsequent to type A dissection surgery: Is reoperation inevitable? TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2023; 31:171-175. [PMID: 37484642 PMCID: PMC10357858 DOI: 10.5606/tgkdc.dergisi.2023.24330] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 03/05/2023] [Indexed: 07/25/2023]
Abstract
Background This study aims to investigate the dilation of sinus valsalva in patients who underwent aortic repair due to type A aortic dissection and to evaluate its progression. Methods Between January 2004 and December 2019, a total of 68 patients (50 males, 18 females; mean age: 54.2±10.1 years; range, 30 to 82 years) who underwent root-preserving surgery and followed for at least one year in the outpatient setting were retrospectively analyzed. The patients were divided into two groups according to dilatation during follow-up. Group 1 (n=32) included patients with dilatation and Group 2 (n=36) included patients without dilatation. The sinus of Valsalva diameters were measured using pre- and postoperative computed tomography angiography. Results The mean follow-up was 4.9±3.1 (range, 1 to 4) years. Sinus of Valsalva dilatation was observed in 47% of the patients during follow-up. Preoperative sinus of Valsalva diameter was a risk factor for aneurysmatic dilatation. A diameter of ≥4.05 cm was calculated as a cut-off value for developing dilatation requiring reoperation. Conclusion Follow-up using postoperative echocardiography or computed tomography angiography is of utmost importance for the assessment of development of sinus of Valsalva dilatation which requires reoperation in patients without intervention to the aortic root.
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Affiliation(s)
- Yiğit Köse
- Department of Cardiovascular Surgery, Health Sciences University, Dr. Siyami Ersek Chest Heart and Vascular Surgery Training and Research Hospital, Istanbul, Türkiye
| | - Selen Özyurt Köse
- Department of Neurology, Marmara University Pendik Training and Research Hospital, Istanbul, Türkiye
| | - Cevdet Uğur Koçoğulları
- Department of Cardiovascular Surgery, Health Sciences University, Dr. Siyami Ersek Chest Heart and Vascular Surgery Training and Research Hospital, Istanbul, Türkiye
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3
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Valve-Sparing Aortic Root Replacement Technique: Valsalva Graft versus Two Straight Tubular Grafts. Cardiol Res Pract 2023; 2023:4076881. [PMID: 36776960 PMCID: PMC9918367 DOI: 10.1155/2023/4076881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 12/13/2022] [Accepted: 01/04/2023] [Indexed: 02/05/2023] Open
Abstract
Background There are many variations in valve-sparing aortic root replacement techniques. Our aim is to determine the impact of the graft on mid-term outcomes: Valsalva graft vs. two straight tubular grafts. Methods From 2004 to 2020, 332 patients underwent valve-sparing aortic root replacement with either a Valsalva graft (Valsalva group: n = 270) or two straight tubular grafts (two-graft group: n = 62). Data were obtained through chart review and the National Death Index. Primary outcomes were mid-term survival and freedom from reoperation. Results The preoperative characteristics of the groups were similar, but the two-graft group had more type A dissections (32% vs. 19%) and emergent operations (26% vs. 15%) and was younger (45 vs. 50 years). Intraoperatively, the groups were similar, but the two-graft group had longer cross-clamp (245 vs. 215 minutes) and cardiopulmonary bypass times (284 vs. 255 minutes). Postoperative complications including reoperation for bleeding, stroke, pacemaker implantation, and renal failure were slightly more frequent in the Valsalva group, but the differences were not significant. Operative mortality was similar between the Valsalva and two-graft groups (0.7% vs. 0%). Five-year survival in the two-graft group was 100% compared to 96% in the Valsalva group (p=0.56). Five-year freedom from reoperation in the two-graft group was 100% compared to 93% in the Valsalva group (p=0.29). Conclusions The Valsalva and two-graft techniques both have excellent short- and mid-term outcomes. The two-graft technique might have slightly better survival and freedom from reoperation, but a larger sample size and longer follow-up are needed to determine if these advantages are significant.
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4
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Manganiello S, Soquet J, Mugnier A, Rousse N, Juthier F, Banfi C, Loobuyck V, Coisne A, Richardson M, Marechaux S, Moussa MD, Robin E, Pinçon C, Prat A, Vincentelli A. David Procedure: A 21-Year Experience with 300 Patients. Ann Thorac Surg 2022; 115:1403-1410. [DOI: 10.1016/j.athoracsur.2022.04.058] [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: 07/18/2021] [Revised: 04/02/2022] [Accepted: 04/23/2022] [Indexed: 11/01/2022]
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Malaisrie SC, Kislitsina ON, Wilsbacher L, Mendelson M, Puthumana JJ, Vassallo P, Kruse J, Andrei AC, McCarthy PM. Valve-sparing versus valve-replacing aortic root replacement in patients with aortic root aneurysm. J Card Surg 2022; 37:1947-1956. [PMID: 35384050 DOI: 10.1111/jocs.16473] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Valve-sparing aortic root replacement (VSARR) is an alternative to valve-replacing aortic root replacement (VRARR) with valved-conduits based on recent guidelines for clinical practice. This study investigated outcomes of these two procedures in patients with nonstenotic valves. METHODS Between January 7, 2007 and June 30, 2019, 475 patients with aortic root aneurysm without aortic stenosis underwent VSARR (151) or VRARR (324) techniques. Propensity score-matching (PSM) was used to alleviate confounding. Endpoints were 30-day mortality, 8-year survival and reoperation, aortic regurgitation, and valve gradients. RESULTS PSM created 69 pairs of patients with a mean age 52 ± 13 years (10.1% Marfan syndrome, 34.8% bicuspid aortic valve). There was no statistically significant difference in major perioperative morbidity or 30-day mortality (0% VSARR vs. 1.4% VRARR; p = 0.316). Overall survival was significantly higher (p = 0.025) in the VSARR group versus the VRARR group (8-year estimates 100% vs. 88.9%, respectively), while freedom from valve reoperation was similar (p = 0.97, 8-year estimates 90.9% vs. 96.7%, respectively). Freedom from > moderate-severe AR was not significantly different (p = 0.08, 8-year estimates 90.0% VSARR group vs. 100% VRARR), but mean valve gradients at last follow-up were better in the VSARR group (5.9 vs. 13.2 mmHg, p < 0.001). CONCLUSIONS VSARR is a safe operation in patients with aortic root aneurysm and nonstenotic aortic valves in the hands of experienced surgeons. Freedom from reoperation is similar and the mode of aortic valve failure differs between the two groups.
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Affiliation(s)
- S Chris Malaisrie
- Department of Surgery, Division of Cardiac Surgery, Northwestern University, Chicago, Illinois, USA
| | - Olga N Kislitsina
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine and Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
| | - Lisa Wilsbacher
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine and Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
| | - Marla Mendelson
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine and Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jyothy J Puthumana
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine and Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
| | - Patricia Vassallo
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine and Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jane Kruse
- Department of Surgery, Division of Cardiac Surgery, Northwestern University, Chicago, Illinois, USA
| | - Adin-Cristian Andrei
- Department of Preventive Medicine, Division of Biostatistics, Northwestern University, Chicago, Illinois, USA
| | - Patrick M McCarthy
- Department of Surgery, Division of Cardiac Surgery, Northwestern University, Chicago, Illinois, USA
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6
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Parameswaran S, Ziganshin BA, Zafar M, Elefteriades JA. Progress in surgical interventions for aortic root aneurysms and dissections. Expert Rev Cardiovasc Ther 2022; 20:65-79. [PMID: 35037567 DOI: 10.1080/14779072.2022.2029702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION : The aortic root is a uniquely sensitive region as it anatomically encompasses the aortic valve leaflets and gives origin to the coronary arteries. These associated structures, in addition to the aortic tube, itself, add immensely to the complexity of replacing this segment when it is aneurysmal or dissected. Given this complexity, many contemporary choices for treatment of aortic root aneurysms have evolved over the past few decades. AREAS COVERED The aim of this study was to provide an updated review of the literature regarding various surgical options for management of aortic root aneurysmal disease. A systematic search in Pubmed database was performed for articles related to various aortic root surgeries and outcomes published between 1998 to 2020. EXPERT OPINION : For multiple technical options in aortic root replacement surgery, decades of surgical investigation and development have shown favorable results, which provide a formidable armamentarium to be used at the discretion of the surgeon to suit various patient anatomic patterns and risk profile-while still durably controlling the aortic pathology and protecting from recurrence, valve dysfunction, progressive dilatation, and aortic dissection.
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Affiliation(s)
- Shamini Parameswaran
- Aortic Institute at Yale New-Haven Hospital, Yale University School of Medicine, New Haven, CT.,Department of Surgery, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX
| | - Bulat A Ziganshin
- Aortic Institute at Yale New-Haven Hospital, Yale University School of Medicine, New Haven, CT.,Department of Cardiovascular and Endovascular Surgery, Kazan State Medical University, Kazan, Russia
| | - Mohammad Zafar
- Aortic Institute at Yale New-Haven Hospital, Yale University School of Medicine, New Haven, CT
| | - John A Elefteriades
- Aortic Institute at Yale New-Haven Hospital, Yale University School of Medicine, New Haven, CT
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6564472. [DOI: 10.1093/ejcts/ezac149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 02/07/2022] [Accepted: 02/21/2022] [Indexed: 11/13/2022] Open
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8
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 61:1318-1325. [DOI: 10.1093/ejcts/ezac050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/11/2022] [Accepted: 01/27/2022] [Indexed: 11/13/2022] Open
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VAN DER MERWE J, CASSELMAN F. Minimally invasive surgical and transcatheter interventions for aortic valve incompetence: current concepts and future perspectives. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:3-11. [DOI: 10.23736/s0021-9509.20.11516-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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10
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Lau C, Wingo M, Rahouma M, Ivascu N, Iannacone E, Kamel M, Gaudino MF, Girardi LN. Valve-sparing root replacement in patients with bicuspid aortopathy: An analysis of cusp repair strategy and valve durability. J Thorac Cardiovasc Surg 2021; 161:469-478. [DOI: 10.1016/j.jtcvs.2019.10.048] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 09/20/2019] [Accepted: 10/07/2019] [Indexed: 12/15/2022]
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Beckmann E, Leone A, Martens A, Mariani C, Krueger H, Cebotari S, Di Bartolomeo R, Haverich A, Shrestha ML, Pacini D. Comparison of Two Strategies for Aortic Valve-Sparing Root Replacement. Ann Thorac Surg 2020; 109:505-511. [DOI: 10.1016/j.athoracsur.2019.07.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 04/03/2019] [Accepted: 06/03/2019] [Indexed: 11/28/2022]
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12
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Sirajuddin S, Wang CK, Al-Abri Q, Ridwan K, Hatzakorzian R, Lachapelle K, De Varennes B, Shum-Tim D. Early results of a modified biological valved conduit for the Bentall procedure. J Card Surg 2019; 34:412-418. [PMID: 30995341 DOI: 10.1111/jocs.14046] [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: 01/15/2019] [Revised: 02/26/2019] [Accepted: 03/19/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Few bioprosthetic valved conduits for aortic root surgery are commercially available. Long-term Warfarin therapy (mechanical), potential root calcification (xeno- or homograft valves), and the need for additional ascending aorta grafts are concerns associated with currently used valved conduits. A simplified, self-assembled bioroot conduit comprising currently available materials that facilitates future intervention and exhibits advantages of a bioprosthesis was used. METHODS From November 2015 to January 2017, 17 consecutive patients underwent urgent or elective aortic root surgery. A bioroot conduit, constructed using 28 or 30 mm of sinus of Valsalva Gelweave tube graft and a 3 to 5 mm smaller bioprosthetic Trifecta valve sewn into the sinus of Valsalva base, was preconstructed in the operating room before sternotomy. The size of the valved conduit was based on the distal ascending aorta or proximal arch and not aortic annular dimension. The bioroot was sutured to the native aortic annulus at the level of the bottom skirt of the Valsalva graft without contacting the sewing cuff of the bioprosthetic valve. RESULTS All patients survived the operation and were discharged home without long-term anticoagulation therapy. The mean age was 65 ± 12 years, and 13 patients were male. The cardiopulmonary bypass duration was 169 ± 84 minutes, and the cross-clamp (XC) duration was 110 ± 32 minutes. The operation was elective in 12 patients, urgent/emergent in five, and redo in three. CONCLUSION A simplified self-assembled bioroot Bentall conduit is appropriate for aortic root reconstruction. Use of a patient-tailored valved conduit will not prolong the cardiac ischemic time and will facilitate future valve replacement.
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Affiliation(s)
- Sarah Sirajuddin
- Department of Surgery, Division of Cardiac Surgery, The McGill University Health Center, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Casey K Wang
- Department of Surgery, Division of Cardiac Surgery, The McGill University Health Center, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Qasim Al-Abri
- Department of Surgery, Division of Cardiac Surgery, The McGill University Health Center, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Khalid Ridwan
- Department of Surgery, Division of Cardiac Surgery, The McGill University Health Center, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Roupen Hatzakorzian
- Department of Anesthesia and Critical Care, The McGill University Health Center, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Kevin Lachapelle
- Department of Surgery, Division of Cardiac Surgery, The McGill University Health Center, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Benoit De Varennes
- Department of Surgery, Division of Cardiac Surgery, The McGill University Health Center, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Dominique Shum-Tim
- Department of Surgery, Division of Cardiac Surgery, The McGill University Health Center, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
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Cevasco M, McGurk S, Yammine M, Sharma L, Ejiofor J, Norman A, Singh MN, Shekar P. Early and Midterm Outcomes of Valve-Sparing Aortic Root Replacement-Reimplantation Technique. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2019; 6:113-117. [PMID: 30934106 PMCID: PMC6443388 DOI: 10.1055/s-0039-1683383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background
Valve-sparing aortic root replacement (VSARR) is an increasingly popular alternative to traditional aortic root replacement for aortic root aneurysm disease with a normal aortic valve. We evaluated the early and midterm outcomes of VSARR—reimplantation technique (VSARR-RT) done at a single institution over a decade.
Materials and Methods
We performed a retrospective study of all patients who underwent VSARR-RT between January 2004 and July 2014.
Results
A total of 85 patients underwent VSARR-RT. Median time to latest echocardiographic follow-up was 4 years (range: 15–72 months). Total observation time was 491 patient years. Mean age was 44.6 ± 14.3 years, and 13 (15%) were women. Thirty-nine (46%) patients had a connective tissue disorder and 6 (7%) had a bicuspid aortic valve. Thirty-three (39%) patients underwent concomitant procedures, including coronary artery bypass grafting (
n
= 9, 11%), mitral valve repair (
n
= 8, 9%), and aortic hemi-arch replacement (
n
= 7, 8%). There were no operative deaths or in-house mortality and no postoperative strokes. Kaplan-Meier analysis demonstrated survival of 99% (95% confidence interval [CI]: 97–100%) at 2 years and 98% (95% CI: 97–100%) at 8 years. Freedom from reoperation was 95.8% (95% CI: 91.2–100%) at 8 years. Freedom from endocarditis was 100% at 8 years. At the last echocardiographic follow-up, 95% of patients were free of severe aortic regurgitation (AR) and 82% free of moderate AR. Of the four patients who had severe AR, three underwent reoperations and received prosthetic valves and one is being clinically monitored.
Conclusion
This study reports early and midterm outcomes after VSARR-RT at our institution, including those patients who underwent a VSARR-RT procedure combined with other procedures. Further follow-up remains necessary to determine long-term outcomes.
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Affiliation(s)
- Marisa Cevasco
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Maroun Yammine
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lokesh Sharma
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Julius Ejiofor
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Anthony Norman
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael N Singh
- Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Prem Shekar
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Valvular Disease in Marfan Syndrome: Surgical Considerations and Management. Curr Cardiol Rep 2019; 21:23. [PMID: 30828749 DOI: 10.1007/s11886-019-1110-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE OF REVIEW Detail the current strategies for the management of valve dysfunction in Marfan syndrome (MFS), understand the limitations of surgical interventions, and delineate the likely direction of future innovations. RECENT FINDINGS Significant advances in both medical and surgical management of MFS have been made over the last 50 years. This has resulted in improved overall outcomes. As MFS patients age, new clinical challenges that were once rare have emerged and can require complex care strategies. Medical management has seen advances and focuses on anti-impulse and molecular-based pharmacotherapy, along with close monitoring with serial imaging to minimize acute aortic dissection risk by selecting appropriate timing of prophylactic surgical intervention with increasing aortic dimensions. Ongoing trials are evaluating other potential drug therapies with the ultimate goal of targeted treatment. Over the last 50 years, significant advances have been made in the understanding and management of MFS. A move to prophylactic surgery for aortopathy and valve disease has progressed from a valve replacement to a valve-sparing strategy in many cases. However, the durability of these repairs is variable and the possibility of reintervention looms.
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Aortic root remodeling in bicuspid and tricuspid aortic valves-long-term results. Indian J Thorac Cardiovasc Surg 2019; 36:81-87. [PMID: 33061188 DOI: 10.1007/s12055-019-00798-y] [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: 12/04/2018] [Revised: 01/14/2019] [Accepted: 01/16/2019] [Indexed: 10/27/2022] Open
Abstract
Background Root remodeling is one form of valve-preserving root replacement to treat patients with aortic regurgitation (AR) and root aneurysm. We have consistently used it for patients with and without connective tissue disease and different aortic valve morphologies. The objective of this retrospective study was to review 23 years of experience with root remodeling. Methods and patients Between 10/95 and 9/2018, 1004 of 1038 root remodeling procedures were performed in patients with tricuspid (n = 589) or bicuspid (n = 414) anatomy of the aortic valve in our institution. Aortic aneurysm was present in 932 cases, 73 procedures were performed for acute aortic dissection type A. The severity of aortic regurgitation ranged from grade I to grade IV (mean 2.5 ± 0.8). Results All patients underwent root remodeling, concomitant operations were performed in 433, and cusp repair in 883 instances. Hospital mortality was 2%. Overall freedom from reoperation was 92% at 10 years and 89% at 15 years. It was 94% for tricuspid valves at 10 and 15 years, and 88% for bicuspid aortic valves at 10 years and 80% at 15 years (p = 0.003). Conclusion In conclusion, root remodeling is a viable option in valve-preserving root replacement. If combined with careful assessment and, if necessary, correction of aortic valve form reproducible restoration of aortic valve function can be achieved.
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Shehada SE, Benedik J, Serrano M, Lurbaski J, Demircioglu E, Wendt D, Jakob H, Mourad F. Modified sizing technique with newly designed tools to facilitate the valve sparing aortic root replacement "David" procedure with mid-term results. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 60:259-267. [PMID: 30465417 DOI: 10.23736/s0021-9509.18.10690-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Valve sparing root replacement differs in specific points. The main target remains to achieve a perfect intraoperative result and long-term stability. We aimed in this study to present our modified sizing technique for valve-sparing "David" procedure and its mid-term results. METHODS We present a retrospective single-center study. A newly designed sizing ring in addition to triple-armed forceps (Trifeet®) was used to measure the proper size of the Valsalva® prosthesis for patients undergoing David-procedure. Primary endpoints are intraoperative aortic regurgitation (AR) and early postoperative outcomes. Secondary endpoints included freedom from aortic regurgitation or reoperation and overall mortality. RESULTS A total of 63 consecutive patients who underwent David procedure between 09/2012 and 12/2016 were evaluated. Mean age was 52±15 years and 76.2% were male. Moderate to severe aortic regurgitation was reported in 60 (95.2%) patients. Four (6.3%) patients presented with type-A aortic dissection, 20 (31.7%) patients had bicuspid and 3 (4.8%) had a unicuspid aortic valve, 2 (3.2%) patients had a prior aortic valve repair. Intraoperative echocardiography revealed no 34 (54%), trace 26 (41.2%) or moderate 3 (4.8%) AR. Stroke, myocardial infarction, and 30-day mortality occurred in 1 patient (1.6%). During follow-up 5 (7.9%) patients needed reoperation due to recurrent AR within a mean of 35±18 months. One could be re-repaired, and the other four underwent aortic valve replacement. A second patient died in the late follow-up. CONCLUSIONS Our modified sizing technique simplifies the "David-procedure" and allows to achieve a good intraoperative and mid-term results. However, these results have to be confirmed in a larger cohort with a long-term follow-up.
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Affiliation(s)
- Sharaf-Eldin Shehada
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany -
| | - Jaroslav Benedik
- Department of Cardiovascular Surgery, Helios Clinic Krefeld, Krefeld, Germany
| | - Maria Serrano
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany
| | - Juri Lurbaski
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany
| | - Ender Demircioglu
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany
| | - Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany
| | - Fanar Mourad
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany
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Beckerman Z, Leshnower BG, McPherson L, Binongo JN, Lasanajak Y, Chen EP. The evidence in a Bentall procedure with Valsalva graft: is this standard of care? J Vis Surg 2018; 4:98. [PMID: 29963387 DOI: 10.21037/jovs.2018.04.05] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 03/27/2018] [Indexed: 11/06/2022]
Abstract
Background Biologic valved-conduits avoids the need for anticoagulation and can exploit the excellent hemodynamic performance of stentless valves. Incorporation of the sinuses of Valsalva into the neoaortic root can improve the function and longevity of stentless valves. We report our experience in performing the Bentall procedure with a self-prefabricated composite valved-conduit and review the published experience with the Valsalva graft. Methods From Feb 2005 through Sep 2017, 428 patients underwent aortic root replacement utilizing a composite graft constructed from a 27-29-mm Freestyle MS valve (Medtronic) sutured into a 28-30-mm Gelweave Valsalva prosthesis (Sulzer Vascutek, Renfrewshire, Scotland). Data were retrospectively analyzed. Results Mean age was 58±13 years, with a male predominance (337, 79%). Additional surgical procedures included a mitral valve repair/replacement in 10 patients (2%), coronary artery bypass graft (CABG) in 114 patients (27%), and aortic arch (hemi or total) replacement in 252 patients (59%). Average cardiopulmonary bypass, cross-clamp, and circulatory arrest times were 210±57, 180±44, and 29±15 min, respectively. Thirty-day mortality was 7% (31 patients). Mean echocardiography follow-up was 27.2±29.0 months (range, 1-138 months). Pressure gradients (mean, peak) across the aortic valve on latest echocardiography were 5.59, 10.57 mmHg respectively. Freedom from >2+ aortic insufficiency (AI) at 6 and 9 years was 96%, and 87% respectively. Freedom from aortic valve replacement (AVR) at 6 and 9 years was 99%, and 95% respectively. To date, 4 (1%) patients required an additional aortic valve intervention secondary to structural valve degeneration. Conclusions Use of the Valsalva graft combined with the Freestyle valve for Bentall procedures is associated with favorable results. Clinical outcomes are excellent and in longitudinal follow-up, valve-related complications are minimal.
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Affiliation(s)
- Ziv Beckerman
- Division of Cardiothoracic Surgery, Department of Surgery, Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA, USA
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA, USA
| | - LaRonica McPherson
- Division of Cardiothoracic Surgery, Department of Surgery, Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA, USA
| | - Jose N Binongo
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA, USA
| | - Yi Lasanajak
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA, USA
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Department of Surgery, Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA, USA
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De Paulis R, Scaffa R, Salica A, Weltert L, Chirichilli I. Biological solutions to aortic root replacement: valve-sparing versus bioprosthetic conduit. J Vis Surg 2018; 4:94. [PMID: 29963383 DOI: 10.21037/jovs.2018.04.12] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/11/2018] [Indexed: 11/06/2022]
Abstract
Composite valve graft implantation described by Bentall and De Bono is a well-documented technique of aortic root replacement used for a large spectrum of pathologic conditions involving the aortic valve and the ascending aorta. While mechanical valves were initially used, biological prostheses were later introduced in order to avoid long-term anticoagulation and its related complications. The increasing age of patients who undergo aortic root surgery, and data supporting the use of a biological aortic valve in the younger population, have significantly increased the need for a composite biological valved conduit. However, parallel to the increased use of biological valve in the context of a Bentall operation, aortic valve-sparing (AVS) operation have also been performed in a growing number of patients. Sarsam and David described the remodeling and the reimplantation procedures more than 25 years ago with the aim of sparing otherwise normal aortic valves in the presence of a root aneurysm. Important achievements in this discipline have occurred over the past decade including development and refinement of valve preserving aortic root replacement techniques, development of a classification system for aortic insufficiency, surgical approaches to cusp disease with different cusp anatomy. Both procedures can now provide excellent root reconstruction and adequate clinical results in terms of late valve durability. The AVS technique offers several advantages over the Bentall procedure, such as no need for oral anticoagulation and lifestyle adjustments. AVS operations have become established alternatives to Bentall procedures for patients with aortic root pathology. However, data comparing the safety and durability of these approaches are lacking.
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Affiliation(s)
| | - Raffaele Scaffa
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Andrea Salica
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Luca Weltert
- Department of Cardiac Surgery, European Hospital, Rome, Italy
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Liberski A, Ayad N, Wojciechowska D, Kot R, Vo DM, Aibibu D, Hoffmann G, Cherif C, Grobelny-Mayer K, Snycerski M, Goldmann H. Weaving for heart valve tissue engineering. Biotechnol Adv 2017; 35:633-656. [DOI: 10.1016/j.biotechadv.2017.07.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 07/30/2017] [Accepted: 07/31/2017] [Indexed: 10/19/2022]
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Martino AD, Re FD, Blasi S, Celiento M, Ravenni G, Pratali S, Milano AD, Bortolotti U. Surgical Treatment of Annuloaortic Ectasia - Replace or Repair? AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2017; 5:139-147. [PMID: 29657952 DOI: 10.12945/j.aorta.2017.17.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 07/15/2017] [Indexed: 11/18/2022]
Abstract
Background Patients with annuloaortic ectasia may be surgically treated with modified Bentall or David I valve-sparing procedures. Here, we compared the long-term results of these procedures. Methods A total of 181 patients with annuloaortic ectasia underwent modified Bentall (102 patients, Group 1) or David I (79 patients, Group 2) procedures from 1994 to 2015. Mean age was 62 ± 11 years in Group 1 and 64 ± 16 years in Group 2. Group 1 patients were in poorer health, with a lower ejection fraction and higher functional class. Results Early mortality was 3% in Group 1 and 2.5% in Group 2. Patients undergoing a modified Bentall procedure had a higher incidence of thromboembolism and hemorrhage, whereas those undergoing a David I procedure had a higher incidence of endocarditis. Actuarial survival was 70 ± 6% at 15 years in Group 1 and 84 ± 7% at 10 years in Group 2. Actuarial freedom from reoperation was 97 ± 2% at 15 years in Group 1 and 84 ± 7% at 10 years in Group 2. In Group 2, freedom from procedure-related reoperations was 98 ± 2% at 10 years. At last follow-up, no cases of moderate or severe aortic regurgitation were observed. Conclusions The modified Bentall and David I procedures showed excellent early and late results. The modified Bentall procedure with a mechanical conduit was associated with thromboembolic and hemorrhagic complications, whereas the David I procedure was associated with unexplained occurrences of endocarditis. Thus, the David I procedure appears to be safe, reproducible, and capable of achieving stable aortic valve repair and is therefore our currently preferred solution for patients with annuloaortic ectasia. However, the much shorter follow-up for David I patients limits the strength of our comparison between the two techniques.
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Affiliation(s)
- Andrea De Martino
- Section of Cardiac Surgery, Cardiac Thoracic and Vascular Department, University Hospital, Pisa, Italy
| | - Federico Del Re
- Section of Cardiac Surgery, Cardiac Thoracic and Vascular Department, University Hospital, Pisa, Italy
| | - Stefania Blasi
- Section of Cardiac Surgery, Cardiac Thoracic and Vascular Department, University Hospital, Pisa, Italy
| | - Michele Celiento
- Section of Cardiac Surgery, Cardiac Thoracic and Vascular Department, University Hospital, Pisa, Italy
| | - Giacomo Ravenni
- Section of Cardiac Surgery, Cardiac Thoracic and Vascular Department, University Hospital, Pisa, Italy
| | - Stefano Pratali
- Section of Cardiac Surgery, Cardiac Thoracic and Vascular Department, University Hospital, Pisa, Italy
| | - Aldo D Milano
- Division of Cardiac Surgery, University of Verona, Verona, Italy
| | - Uberto Bortolotti
- Section of Cardiac Surgery, Cardiac Thoracic and Vascular Department, University Hospital, Pisa, Italy
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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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Mok SCM, Ma WG, Mansour A, Charilaou P, Chou AS, Peterss S, Tranquilli M, Ziganshin BA, Elefteriades JA. Twenty-five year outcomes following composite graft aortic root replacement. J Card Surg 2016; 32:99-109. [PMID: 27966257 DOI: 10.1111/jocs.12875] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Operative choices for aortic root disease include traditional root replacement with a composite valved graft as well as various valve-sparing and root repair procedures. OBJECTIVES To report our experience with traditional composite graft aortic root replacement by a single surgeon over a 25-year period in 449 patients, focusing on long-term survival and freedom from late reoperation and adverse events. METHODS The coronary button technique was used in all patients. Mean age was 56.1 ± 14.0 years (range 14-87) with 83% males (373/449). Valve prosthesis was mechanical in 343 (76%) and bioprosthetic in 106 (24%). A modified Cabrol procedure (Dacron coronary graft) was employed in 10% (45/449) and concomitant coronary artery bypass graft in 10.9% (49/449). There were 15.8% (71/449) urgent/emergent and 8.2% (37/449) redo procedures. Survival follow-up was 100%. Mean follow-up was 7.0 ± 5.1 years (range 0.1-24.8). RESULTS Operative mortality occurred in 14 patients (3.1%) and was 2.2% (9/418) in non-dissection and 1.9% (7/361) in elective first-time operations. Stroke and re-exploration for bleeding occurred in nine (2.0%) and 20 (4.5%) patients, respectively. Major late events included bleeding in 2.5% (11/435) and thromboembolism in 1.1% (5/435). At 5, 10, and 20 years, freedom from major events and reoperations on the root were 97.8, 95.4, and 94.39%, and 99.0, 99.0, and 97.9%, respectively. Survival in patients aged <60 years was 92.0, 90.1, and 79.8% at five, 10, and 20 years versus 88.4, 67.9, and 42.6% in patients aged ≥60 years (p = 0.001). Compared with age- and gender-matched controls, survival was not significantly different (p = 0.20). CONCLUSIONS Composite graft aortic root replacement is associated with low operative risk, excellent long-term survival, and low incidence of reoperation and late events.
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Affiliation(s)
- Salvior C M Mok
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Wei-Guo Ma
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut.,Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Ahmed Mansour
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Paris Charilaou
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Alan S Chou
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Sven Peterss
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Maryann Tranquilli
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut.,Department of Surgical Diseases #2, Kazan State Medical University, Kazan, Russia
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
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Settepani F, Cappai A, Basciu A, Barbone A, Moz M, Citterio E, Ornaghi D, Tarelli G. Impact of Cusp Repair on Reoperation Risk After the David Procedure. Ann Thorac Surg 2016; 102:1503-1511. [DOI: 10.1016/j.athoracsur.2016.04.061] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/31/2016] [Accepted: 04/18/2016] [Indexed: 11/28/2022]
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da Costa FDA, Colatusso DDFF, da Costa ACBA, Balbi Filho EM, Cavicchioli VN, Lopes SAV, Ferreira ADDA, Collatusso C. Initial Surgical Experience with Aortic Valve Repair: Clinical and Echocardiographic Results. Braz J Cardiovasc Surg 2016; 31:183-90. [PMID: 27556321 PMCID: PMC5062723 DOI: 10.5935/1678-9741.20160027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 03/08/2016] [Indexed: 11/20/2022] Open
Abstract
Introduction Due to late complications associated with the use of conventional prosthetic
heart valves, several centers have advocated aortic valve repair and/or
valve sparing aortic root replacement for patients with aortic valve
insufficiency, in order to enhance late survival and minimize adverse
postoperative events. Methods From March/2012 thru March 2015, 37 patients consecutively underwent
conservative operations of the aortic valve and/or aortic root. Mean age was
48±16 years and 81% were males. The aortic valve was bicuspid in
54% and tricuspid in the remaining. All were operated with the aid of
intraoperative transesophageal echocardiography. Surgical techniques
consisted of replacing the aortic root with a Dacron graft whenever it was
dilated or aneurysmatic, using either the remodeling or the reimplantation
technique, besides correcting leaflet prolapse when present. Patients were
sequentially evaluated with clinical and echocardiographic studies and mean
follow-up time was 16±5 months. Results Thirty-day mortality was 2.7%. In addition there were two late deaths, with
late survival being 85% (CI 95% - 68%-95%) at two years. Two patients were
reoperated due to primary structural valve failure. Freedom from reoperation
or from primary structural valve failure was 90% (CI 95% - 66%-97%) and 91%
(CI 95% - 69%-97%) at 2 years, respectively. During clinical follow-up up to
3 years, there were no cases of thromboembolism, hemorrhage or
endocarditis. Conclusions Although this represents an initial series, these data demonstrates that
aortic valve repair and/or valve sparing aortic root surgery can be
performed with satisfactory immediate and short-term results.
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Ius F, Koigeldiyev N, Roumieh M, Ismail I, Tudorache I, Shrestha M, Fleissner F, Haverich A, Cebotari S. Impact of sinuses of Valsalva on prosthesis durability in patients undergoing ascending aorta and aortic valve replacement with Carpentier-Edwards bioprosthesis: a propensity score-based study. Eur J Cardiothorac Surg 2015; 49:1676-84. [PMID: 26656448 DOI: 10.1093/ejcts/ezv425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 10/13/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The effect of sinuses of Valsalva on aortic bioprosthesis durability has not been investigated so far. The aim of this study was to compare durability of the Carpentier-Edwards aortic bioprosthesis in patients undergoing aortic valve and ascending aorta replacement as a composite bioconduit (Group A, case group) versus patients undergoing separate replacement of the aortic valve and ascending aorta, with preservation of the aortic root (Group B, control group), between January 2000 and January 2014. METHODS Records of Group A (n = 133) and Group B (n = 162) patients were retrospectively reviewed. End-points were evaluated among groups in three ways: before and after propensity score 1:1 matching (Group A, n = 94; Group B, n = 94 patients) and after patient stratification through quintiles of propensity scores. RESULTS There was no difference among groups regarding mean and maximal trans-prosthetic pressure gradients at discharge (P = 0.07 and 0.45, respectively). Maximal trans-prosthetic gradients were lower in Group A patients at last control (P = 0.03). Structural valve deterioration (SVD) was due to prosthesis regurgitation (Group A, n = 5; Group B, n = 1), stenosis (Group A, n = 2; Group B, n = 5) or combined (Group A, n = 4; Group B, n = 2). After a mean follow-up of 68 ± 42 months, there was no difference among groups, at 5 and 12 years, regarding mortality, freedom from SVD, from redo aortic valve replacement for SVD and cardiac redo of any type, before and after matching and after stratification according to quintiles of propensity scores. CONCLUSIONS Within the 12-year follow-up, the absence of the sinuses of Valsalva seems to have no influence on durability of Carpentier Edwards aortic bioprosthesis. Longer follow-up may be warranted.
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Affiliation(s)
- Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Nurbol Koigeldiyev
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Mazen Roumieh
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Issam Ismail
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Malakh Shrestha
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Felix Fleissner
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Serghei Cebotari
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Regeer MV, Versteegh MI, Marsan NA, Bax JJ, Delgado V. The role of multimodality imaging in the selection of patients for aortic valve repair. Expert Rev Cardiovasc Ther 2015; 14:75-86. [DOI: 10.1586/14779072.2016.1109448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Reported Outcome After Valve-Sparing Aortic Root Replacement for Aortic Root Aneurysm: A Systematic Review and Meta-Analysis. Ann Thorac Surg 2015; 100:1126-31. [DOI: 10.1016/j.athoracsur.2015.05.093] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 04/20/2015] [Accepted: 05/14/2015] [Indexed: 11/17/2022]
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De Paulis R, Chirichilli I, Scaffa R, Weltert L, Maselli D, Salica A, Guerrieri Wolf L, Bellisario A, Chiariello L. Long-term results of the valve reimplantation technique using a graft with sinuses. J Thorac Cardiovasc Surg 2015; 151:112-9. [PMID: 26349596 DOI: 10.1016/j.jtcvs.2015.08.026] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 07/27/2015] [Accepted: 08/08/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Aortic valve reimplantation is the most commonly used technique to spare the aortic valve. Long-term results data are scarce and available only with the use of standard straight graft. We examined the long-term results of reimplantation of the aortic valve using a graft incorporating sinuses of Valsalva. METHODS From May 2000 to December 2014, 124 patients had an aortic valve reimplanted into a graft with sinuses of Valsalva. The mean age was 53 ± 13 years and the majority were men (87%). Marfan syndrome was present in 21 patients (17%) and 12% had a bicuspid valve. Patients were prospectively followed by means of transthoracic echocardiography. The mean follow-up was 63 ± 52 months. RESULTS Overall survival at 5, 10, and 13 years was 94.4% ± 2.2%, 90.5% ± 4.4%, and 81.4% ± 7.3%, respectively. Six patients required reoperation within a time frame of 6 to 96 months. None of the patients died at reoperation. Freedom from reoperation was 95.4% ± 2.3% at 5 years and 90.1% ± 4.3% at 10 and 13 years. All patients who needed reoperation had surgery during the first 5 years. Three patients had residual aortic insufficiency >2. Considering also all patients who underwent reoperation because of aortic insufficiency, freedom from moderate to severe residual aortic insufficiency was 94.1% ± 2.6% at 5 years, and 87.1% ± 4.7% at 10 and 13 years. CONCLUSIONS The majority of patients who had their valve reimplanted in a graft with sinuses continue to perform well after 10 years.
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Affiliation(s)
| | | | | | - Luca Weltert
- Cardiac Surgery Department, European Hospital, Rome, Italy
| | | | - Andrea Salica
- Cardiac Surgery Department, European Hospital, Rome, Italy
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Shinkawa T, Tang X, Gossett JM, Mustafa T, Hategekimana F, Watanabe F, Miyazaki T, Yamagishi M, Imamura M. Valved Polytetrafluoroethylene Conduits for Right Ventricular Outflow Tract Reconstruction. Ann Thorac Surg 2015; 100:129-37; discussion 137. [DOI: 10.1016/j.athoracsur.2015.02.114] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 02/23/2015] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
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Ando M, Yamauchi H, Morota T, Taketani T, Shimada S, Nawata K, Umeki A, Ono M. Long-term outcome after the original and simple modified technique of valve-sparing aortic root reimplantation in Marfan-based population, David V University of Tokyo modification. J Cardiol 2015; 67:86-91. [PMID: 25920727 DOI: 10.1016/j.jjcc.2015.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 02/10/2015] [Accepted: 03/16/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND In valve-sparing aortic root replacement (VSARR), how to reproduce Valsalva sinus has been an issue. In the original David V procedure, they put plication stitches at sinotubular junction level, although the reefing effect is limited and distal graft remains larger than native. Other modified techniques are two-grafts technique and ready-made Valsalva graft. However, the former needs graft-graft anastomosis and may not be cost-effective, while in the latter, the shape of sinus is fixed and minor adjustment is difficult. David V University of Tokyo modification (David V-UT) is our original solution to that, creating pseudosinus with one straight graft by longitudinal size-reduction running sutures above each pseudosinus. The purpose of the present study is to investigate long-term outcome of David V-UT. METHODS We analyzed 59 David V-UT patients from February 2004 to February 2013 and long-term outcomes were investigated by Kaplan-Meier methods. Risk factors for adverse events "death or recurrent aortic insufficiency (AI) with or without aortic valve reoperation" were analyzed by using Cox proportional hazard models. RESULTS Mean age was 33.1±14.5 years, and 38 patients (64%) were male. Marfan syndrome (MFS) accounts for 47 patients (80%). Only one patient was with bicuspid aortic valve. No in-hospital mortality was observed. Mean follow-up was 4.9±2.4 years. Estimated survival was 94.0±3.4% at 5 years. Freedoms from aortic valve reoperation and recurrent AI greater than mild were 95.7±3.0% and 88.9±4.7% at 5 years, respectively. In Cox proportional hazard analysis, preoperative AI greater than mild and Z score of annular diameter were significant risks for adverse events (p=0.027 and 0.045, hazard ratio 6.084 and 1.432, 95% C.I. 1.225-30.21 and 1.008-2.035, respectively). CONCLUSIONS Even in Marfan-characterized population, David V-UT provided satisfactory long-term outcome, comparable to other VSARR modifications. It is simple but can freely reproduce trilobed sinus with one straight graft.
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Affiliation(s)
- Masahiko Ando
- The University of Tokyo, Department of Cardiac Surgery, Tokyo, Japan.
| | - Haruo Yamauchi
- The University of Tokyo, Department of Cardiac Surgery, Tokyo, Japan
| | - Tetsuro Morota
- Nippon Medical School Hospital, Department of Cardiovascular Surgery, Tokyo, Japan
| | - Tsuyoshi Taketani
- Mitsui Memorial Hospital, Department of Cardiovascular Surgery, Tokyo, Japan
| | - Shogo Shimada
- The University of Tokyo, Department of Cardiac Surgery, Tokyo, Japan
| | - Kan Nawata
- The University of Tokyo, Department of Cardiac Surgery, Tokyo, Japan
| | - Akihide Umeki
- The University of Tokyo, Department of Cardiac Surgery, Tokyo, Japan
| | - Minoru Ono
- The University of Tokyo, Department of Cardiac Surgery, Tokyo, Japan
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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
OBJECTIVE Root remodeling was proposed as valve-preserving root replacement to treat patients with aortic regurgitation and root aneurysm. The objective of this retrospective study was to review 18 years of experience with root remodeling and to identify predictors of valve durability. METHODS Between October 1995 and December 2013, root remodeling was performed in 747 patients. The aortic valve anatomy was tricuspid in 431 patients, bicuspid in 290 patients, and unicuspid in 26 patients. Aortic aneurysm was present in 688 patients, and 59 procedures were performed for acute aortic dissection type A. The severity of aortic regurgitation ranged from grade 0 to IV (grade 0, 1%; grade 1, 8%; grade 2, 26%; grade 3, 62%; grade 4, 3%; median, 3). All patients underwent root remodeling, concomitant operations were performed in 352 patients, and cusp repair was used in 690 procedures. RESULTS Hospital mortality was 2%. Overall freedom from reoperation was 92% at 10 years and 91% at 15 years. Overall freedom from reoperation was 95% for tricuspid valves at 10 and 15 years, 89% for bicuspid aortic valves at 10 years (P = .006), and 83% for bicuspid aortic valves at 15 years. By multivariate analysis, the strongest risk factors for failure were an aortoventricular junction 28 mm or greater (hazard ratio, 1.43) and the use of a pericardial patch as part of cusp repair (hazard ratio, 6.24). CONCLUSIONS Root remodeling continues to be a viable option in valve-preserving root replacement. If combined with careful assessment and, if necessary, correction of aortic valve geometry, reproducible restoration of aortic valve function can be achieved with good long term durability.
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Toeg H, Chan V, Rao RV, Chan KL, Ruel M, Mesana T, Boodhwani M. Contemporary midterm echocardiographic outcomes of Bentall procedure and aortic valve sparing root replacement. Ann Thorac Surg 2014; 98:590-6. [PMID: 24968770 DOI: 10.1016/j.athoracsur.2014.04.121] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 04/21/2014] [Accepted: 04/23/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Valve sparing root replacement (VSRR) and aortic valve repair (AVr) is an attractive treatment option compared with composite valve and root replacement (Bentall procedure) for patients with aortic root dilatation with or without aortic valve disease. While aortic valve preservation reduces the risk of valve-related complications, little is known about echocardiographic differences at follow-up between these 2 strategies. METHODS Consecutive nonemergent patients undergoing VSRR and AVr (n=68) were compared with contemporary historical controls undergoing the Bentall procedure for aortic root pathology with or without mixed aortic valve disease (insufficiency or stenosis) (n=96). The VSRR was performed preferentially using the reimplantation technique. Bentall procedure utilized a mechanical valve in 65% of patients, a biologic prosthesis in 22%, and a homograft in 13%. Clinical and echocardiographic data were obtained at baseline and at follow-up (median=30 months). RESULTS The 2 cohorts were similar with respect to all preoperative characteristics with the exception of disease etiology. The Bentall group had a higher proportion of degenerative valve and root disease (47.8% vs 27.9%) and a lower proportion of bicuspid aortic valve disease (22.8% vs 51.5%) as compared with the VSRR group (p=0.007). Postoperative echocardiographic outcomes were comparable between groups with the exception of higher peak (23.37±11.80 vs 18.0±12.04; p=0.02) and mean (13.07±7.53 vs 9.56±6.49; p=0.01) transvalvular aortic gradients in the Bentall group. Persistence of left ventricular dysfunction (8.4% vs 6.1%; p=0.61), presence of greater than moderate aortic valve (AV) insufficiency (3% vs 4.6%; p=0.32), and left ventricular mass (213.24±72.36 vs 207.38±63.07, p=0.61) were comparable between the Bentall and VSRR group, respectively. Finally, survival (p=0.21) and freedom from valve-related events (p=0.74) were similar between groups. CONCLUSIONS Valve sparing root replacement with AV repair provides similar mid-term echocardiographic and clinical outcomes compared with the Bentall.
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Affiliation(s)
- Hadi Toeg
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Vincent Chan
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Rajeev V Rao
- Division of Cardiology (Echocardiography), University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Kwan-Leung Chan
- Division of Cardiology (Echocardiography), University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Thierry Mesana
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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Coselli JS, Hughes MS, Green SY, Price MD, Zarda S, de la Cruz KI, Preventza O, LeMaire SA. Valve-sparing aortic root replacement: early and midterm outcomes in 83 patients. Ann Thorac Surg 2014; 97:1267-73; discussion 1273-4. [PMID: 24424011 DOI: 10.1016/j.athoracsur.2013.10.076] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 10/07/2013] [Accepted: 10/18/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Valve-sparing aortic root replacement (VSARR) is an alternative to traditional composite valve graft (CVG) root replacement. We examined early and midterm outcomes after VSARR. METHODS A combined retrospective/prospective study was performed in 83 patients who underwent VSARR (16%) among 515 patients who underwent aortic root replacement during a nearly 12-year period. Thirty-six patients (43%) had a connective tissue disorder, 3 patients (4%) had acute aortic dissection, and 40 (48%) patients had at least moderate aortic regurgitation (AR). Twenty-eight patients (34%) had left ventricular hypertrophy or dilatation. The reimplantation VSARR technique was used in 82 patients (99%), and the Florida sleeve technique was used in 1 patient. Thirty-two patients (39%) underwent concomitant aortic arch replacement. For early survivors, the median duration of follow-up was 3.5 years (range, 5 days-12.2 years). RESULTS One patient had severe AR after VSARR that necessitated intraoperative conversion to a mechanical CVG. The 1 operative death and 1 stroke occurred in a patient with acute dissection. Actuarial survival was 96.4%±2.0% at 2 years and 86.9%±5.6% at 8 years. Six patients (7%) had late valve-related complications: 1 died of endocarditis, 4 underwent reoperation for severe AR and received replacement valves, and 1 had severe AR and is being monitored. Freedom from repair failure (reoperation, endocarditis, or severe AR) was 94.8%±2.6% at 2 years and 87.3%±5.7% at 8 years. CONCLUSIONS Valve-sparing aortic root replacement can have excellent early and respectable midterm outcomes, even when combined with arch repair. Further follow-up remains necessary to evaluate the long-term durability of VSARR.
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Affiliation(s)
- Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Michael S Hughes
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Matt D Price
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Samantha Zarda
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Kim I de la Cruz
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas.
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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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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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Saczkowski R, Malas T, de Kerchove L, El Khoury G, Boodhwani M. Systematic review of aortic valve preservation and repair. Ann Cardiothorac Surg 2013; 2:3-9. [PMID: 23977553 DOI: 10.3978/j.issn.2225-319x.2013.01.07] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 01/16/2013] [Indexed: 11/14/2022]
Abstract
BACKGROUND Aortic valve repair has emerged as a feasible alternative to replacement in the surgical treatment of selected patients with aortic valve (AV) pathology. In order to provide a synopsis of the current literature, we preformed a systematic review with a focus on valve-related events following AV repair. METHODS Structured keyword searches of Embase and PubMed were performed in January 2012. A study was eligible for inclusion if it reported early mortality, late mortality, or valve-related morbidity in the adult population. RESULTS Initial search results identified 3,507 unique studies. After applying inclusion and exclusion criteria, 111 studies remained for full-text review. Of these, 17 studies involving 2,891 patients were included for quantitative assessment. No randomized trials were identified. Tricuspid and bicuspid AV pathologies were present in 65% (range, 21-100%) and 13.5% (range, 5-100%) of the population, respectively. Cusp repair techniques were applied in a median of 46% (range, 5-100%) of patients. The median requirement for early reoperation for post-operative bleeding and early reintervention for primary AV repair failure was 3% (range, 0-10%) and 2% (range, 0-16%), respectively. Pooled early mortality was 2.6% (95% CI: 1.4-4.4%, I(2) =0%). Late mortality and valve-related events were linearized [(number of events/number of patient-years) ×100] (%/pt-yr) for each study. Late operated valve endocarditis was reported at median event rate of 0.23%/pt-yr (range, 0-0.78%/pt-yr), while a composite outcome of neurological events and thromboembolism occurred at a median rate of 0.52%/pt-yr (0-0.95%/pt-yr). Late AV re-intervention requiring AV replacement or re-repair occurred at a rate of 2.4%/pt-yr (range, 0-4.2%/pt-yr). The median 5-year freedom from AV re-intervention and late recurrent aortic insufficiency >2+ estimated from survival curves was 92% (range, 87-98%) and 88% (range, 87-100%), respectively. Pooled late mortality produced summary estimate of 1.3%/pt-yr (95% CI: 0.9-2.1%, I(2) =0%). CONCLUSIONS The present systematic review confirmed the low operative risk of patients who underwent aortic valve preservation and repair. There is a need for long-term follow-up studies with meticulous reporting of outcomes following AV repair, as well as comparative studies with aortic valve replacement.
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Affiliation(s)
- Richard Saczkowski
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Canada
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Aicher D, Schäfers HJ. Aortic valve repair--current status, indications, and outcomes. Semin Thorac Cardiovasc Surg 2013. [PMID: 23200074 DOI: 10.1053/j.semtcvs.2012.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Aortic valve repair is a new development with old roots. In the past 20 years, marked progress has been made in understanding the normal anatomy of the aortic valve and the interrelation between cusps and root. Aortic dilatation is the single most frequent pathogenetic factor in aortic regurgitation, accompanied by cusp pathology, that is, prolapse or congenital anomaly in most industrialized countries. Frequently, aortic and cusp pathology coexist. Different operative techniques have been established for correction of aortic and cusp pathology. Experience has shown that the combined application of repair procedures will lead to good results if normal valve and cusp configuration is achieved. Some congenital anomalies may require design alteration of the aortic valve. Low-operative mortality rates have been reported consistently. When adequate repair durability is achieved, the incidence of valve-related complications is lower than what has been reported for valve replacement. Aortic valve repair is currently in transition from surgical improvisation to a reproducible operation and an option for many patients with aortic regurgitation. Current research focuses on some special aspects, such as stabilization of the basal ring, ideal material and technique for cusp replacement, and more objective information on ideal valve configuration.
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Affiliation(s)
- Diana Aicher
- Department of Thoracic and Cardiovascular Surgery, University of Saarland Medical Center, Homburg/Saar, Germany
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Malvindi PG, van Putte BP, Sonker U, Heijmen RH, Schepens MA, Morshuis WJ. Reoperation After Acute Type A Aortic Dissection Repair: A Series of 104 Patients. Ann Thorac Surg 2013; 95:922-7. [DOI: 10.1016/j.athoracsur.2012.11.029] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 11/09/2012] [Accepted: 11/13/2012] [Indexed: 11/30/2022]
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Kallenbach K, Kojic D, Oezsoez M, Bruckner T, Sandrio S, Arif R, Beller CJ, Weymann A, Karck M. Treatment of ascending aortic aneurysms using different surgical techniques: a single-centre experience with 548 patients. Eur J Cardiothorac Surg 2013; 44:337-45. [DOI: 10.1093/ejcts/ezs661] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Lange R, Badiu CC, Vogt M, Voss B, Hörer J, Prodan Z, Schreiber C, Mazzitelli D. Valve-sparing root replacement in children with aortic root aneurysm: mid-term results†. Eur J Cardiothorac Surg 2012. [DOI: 10.1093/ejcts/ezs598] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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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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Malvindi PG, Raffa GM, Basciu A, Citterio E, Cappai A, Ornaghi D, Tarelli G, Settepani F. Bicuspidy does not affect reoperation risk following aortic valve reimplantation. Interact Cardiovasc Thorac Surg 2012; 14:717-20. [PMID: 22389000 DOI: 10.1093/icvts/ivs059] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Aortic valve reimplantation has been shown to be a safe procedure. However, evidences of durability in bicuspid aortic valves (BAVs) are limited in the literature. Between 2002 and 2011, 132 patients (mean age 61 ± 12 years) underwent aortic valve reimplantation. In 24 patients (18%), aortic valve was bicuspid. Mean follow-up was 50 ± 26 months (range 1-102 months) and was 99% complete. In-hospital mortality was 0.8% (1 patient). Survival at 1 and 5 years was 99 and 94%, respectively. Overall freedom from aortic valve reoperation at 1 and 5 years was 96 and 90%, respectively, without significant difference between patients with bicuspid and tricuspid aortic valve. Freedom from aortic valve regurgitation >2+/4+, excluding patients reoperated, was at 1 and 5 years of 100 and 99%, respectively. Patients with valve cusp repair showed a higher rate of aortic valve reoperation; however, only postoperative aortic regurgitation >2+/4+ was significant risk factor for redo procedure at multivariate analysis. Aortic valve reimplantation in BAV without cusp repair provides excellent mid-term results. Further observations and longer follow-up are necessary to determine if BAV sparing, even in the presence of cusps alterations, could allow satisfying durability.
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Leshnower BG, Guyton RA, Myung RJ, Puskas JD, Kilgo PD, McPherson L, Chen EP. Expanding the indications for the David V aortic root replacement: early results. J Thorac Cardiovasc Surg 2012; 143:879-84. [PMID: 22329981 DOI: 10.1016/j.jtcvs.2012.01.048] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 12/25/2011] [Accepted: 01/16/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To examine the early results of the David V valve-sparing aortic root replacement procedure in expanded, higher risk clinical scenarios with appropriately selected patients. METHODS From 2005 to 2011, 150 David V valve-sparing aortic root replacements were performed within Emory Healthcare. A total of 78 patients (expanded group) had undergone the David V in expanded, difficult clinical settings such as emergent type A dissection (n = 29), grade 3+ or greater aortic insufficiency (AI) (n = 53), or reoperative cardiac surgery (n = 14). These patients were evaluated and compared with a group of 72 patients (traditional group) with less than grade 3+ AI who underwent a David V in a traditional, elective setting. The mean follow-up was 19 months (range, 1-72), and the follow-up data were 88% complete. RESULTS There were 3 operative deaths (2.2%), all occurring in the expanded group. The overall patient survival at 6 years was 95%. Three patients required aortic valve replacement: two for severe AI and one for fungal endocarditis. Both groups had concomitant cusp repairs performed in conjunction with the David V (traditional, n = 10; and expanded, n = 16; P = .27). At follow-up, freedom from moderate AI was 93%, and the freedom from aortic valve replacement was 98%. No significant difference was observed in the freedom from moderate AI between the expanded and traditional groups (91% vs 95%, respectively; P = .16). CONCLUSIONS In selected patients possessing appropriate aortic cusp anatomy, the David V can be safely and effectively performed for the expanded indications of aortic dissection, severe AI, and reoperative cardiac surgery with low operative risk. Valve function has remained excellent in the short term, providing evidence of durability and a low rate of valve-related complications.
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Affiliation(s)
- Bradley G Leshnower
- Clinical Research Unit, Division of Cardiothoracic Surgery, Joseph B Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Abstract
The aortic root has a unique 3-dimensional configuration and the distinctive function of supporting the aortic valve and blood vessels. The sinuses of Valsalva are crucial to create appropriate eddy currents that are important in initiating and coordinating aortic valve closure and promoting coronary artery blood flow. Most aneurysms in the aortic root are associated with degenerative changes in the elastic media rather than atherosclerosis. Valve-sparing root repair has become widely accepted, although the Bentall procedure remains the gold standard. Because reimplantation using the Valsalva graft allows root geometry to be retained and theoretically and practically prevents recurrent aortic valve regurgitation, it is considered the most reliable and preferred technique among various valve-sparing aortic root repair procedures.
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Affiliation(s)
- Hideyuki Shimizu
- Division of Cardiovascular Surgery, School of Medicine, Keio University, Shinjuku-ku, Tokyo, Japan.
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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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Midterm Outcome of Valve-Sparing Aortic Root Replacement in Inherited Connective Tissue Disorders. Ann Thorac Surg 2011; 92:1646-9; discussion 1649-50. [DOI: 10.1016/j.athoracsur.2011.06.090] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 06/21/2011] [Accepted: 06/22/2011] [Indexed: 10/15/2022]
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