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Argaw S, Azizgolshani N, Blitzer D, Takayama H, George I, Pirelli L. Treatment options for isolated aortic valve insufficiency: a review. Front Cardiovasc Med 2024; 11:1381102. [PMID: 38665234 PMCID: PMC11043486 DOI: 10.3389/fcvm.2024.1381102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Aortic insufficiency (AI) is a valvular disease with increasing prevalence in older patients. The modern era provides numerous options for the management of AI which is explored here. Traditional interventions included aortic valve replacement with either mechanical or bioprosthetic aortic valves. While the former is known for its durability, it has grown out of favor due to the potential complications of anticoagulation. The preference for bioprosthetic valves is thus on the rise, especially with the advancements of transcatheter technology and the use of valve-in-valve therapy. Surgical options are also no longer limited to replacement but include complex techniques such as those required for aortic valve repair, Ozaki neocuspidization, Ross procedure and valve-sparring aortic root repair. Transcatheter options for the management of AI are not commercially available currently; however, preliminary data from ad-hoc trials, showed promising results and potential use of transcatheter technology in a variety of patients with pure AI.
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Affiliation(s)
| | | | | | | | | | - Luigi Pirelli
- Division of Cardiovascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, United States
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2
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Stephens EH, Dearani JA, Pochettino A, Vricella LA, Sundt TM, David TE, Bavaria JE, Cameron DE. Valve-Sparing Aortic Root Replacement State-of-the-Art Review, Part I: Anatomy and Physiology. Ann Thorac Surg 2024:S0003-4975(24)00115-2. [PMID: 38360340 DOI: 10.1016/j.athoracsur.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/03/2023] [Accepted: 12/09/2023] [Indexed: 02/17/2024]
Abstract
Aortic valve disease is common, and valve-preserving operations are preferred whenever possible. Valve-sparing aortic root replacement has become an important tool for managing aortic root pathology in children and adults. The learning curve for this operation is challenging, but with increasing experience and technical modifications, early and late outcomes continue to improve. Durable long-term results vary based on the underlying anatomy, pathology, and patient selection, as well as surgeon expertise. The first installment of this Valve-Sparing Aortic Root Replacement State-of-the-Art Review article addresses patient anatomy and physiology as it relates to candidacy for VSRR.
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Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | | | - Luca A Vricella
- Division of Pediatric Cardiovascular Surgery, Department of Surgery, Advocate Children's Heart Institute, Chicago, Illinois
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Tirone E David
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Duke E Cameron
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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3
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Stephens EH, Dearani JA, Pochettino A, Vricella LA, Sundt TM, David TE, Bavaria JE, Cameron DE. Valve-Sparing Aortic Root Replacement State-of-the-Art Review, Part II: Surgical Techniques. Ann Thorac Surg 2024:S0003-4975(24)00116-4. [PMID: 38360342 DOI: 10.1016/j.athoracsur.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 12/03/2023] [Accepted: 12/19/2023] [Indexed: 02/17/2024]
Abstract
Aortic valve disease is common, and valve-preserving operations are preferred whenever possible. Valve-sparing aortic root replacement (VSRR) has become an important tool for managing aortic root pathology in children and adults. The learning curve for this operation is challenging, but with increasing experience and technical modifications, early and late outcomes continue to improve. Durable long term results vary based on underlying anatomy, pathology, and patient selection, as well as surgeon expertise. Part II of this VSRR State-of-the-Art Review article provides technical pearls related to VSRR.
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Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | | | - Luca A Vricella
- Division of Pediatric Cardiovascular Surgery, Department of Surgery, Advocate Children's Heart Institute, Chicago, Illinois
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Tirone E David
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Duke E Cameron
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Dolmaci OB, Hilhorst TL, Malekzadeh A, Mertens BJ, Klautz RJ, Poelmann RE, Grewal N. The Prevalence of Coronary Artery Disease in Bicuspid Aortic Valve Patients: An Overview of the Literature. AORTA (STAMFORD, CONN.) 2023; 11:191-197. [PMID: 38698623 PMCID: PMC11219131 DOI: 10.1055/s-0044-1785190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/07/2024] [Indexed: 05/05/2024]
Abstract
The prevalence of coronary artery disease (CAD) in bicuspid aortic valve (BAV) patients is a debatable topic. Several studies have indicated that BAV patients have a lower prevalence of CAD compared with patients with a tricuspid aortic valve (TAV), but the effects of age and gender have not always been considered. This systematic review provides an overview of articles which report on CAD in BAV and TAV patients. Searches were executed in April 2021 and January 2022 according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analyses) guidelines in three online databases: Medline, Embase, and Scopus. Screening and data extraction was done by two investigators separately. Primary and secondary outcomes were compared between BAV and TAV patients; a fixed effects model was used for correcting on confounders. Literature search yielded 1,529 articles with 44 being eligible for inclusion. BAV patients were younger (56.4 ± 8.3 years) than TAV patients (64 ± 10.3 years, p < 0.001). All CAD risk factors and CAD were more prevalent in TAV patients. No significant difference remained after correcting for age and gender as confounders. BAV patients have a lower prevalence of CAD and CAD risk factors compared with TAV patients. However, when the age differences between both groups are considered in the analyses, a similar prevalence of both CAD and CAD risk factors is found.
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Affiliation(s)
- Onur B. Dolmaci
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Tijmen L. Hilhorst
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Arjan Malekzadeh
- Medical Library, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, Netherlands
| | - Bart J.A. Mertens
- Department of Statistics, Leiden University Medical Center, Leiden, Netherlands
| | - Robert J.M. Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Robert E. Poelmann
- Institute of Biology, Leiden University, Sylvius Laboratory, Leiden, Netherlands
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nimrat Grewal
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands
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5
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Zuo Y, Tan R, Qin C. Outcomes of valve-sparing aortic root replacement in patients with bicuspid aortic valve and tricuspid aortic valve: a systematic review and meta-analysis. J Cardiothorac Surg 2023; 18:206. [PMID: 37400892 DOI: 10.1186/s13019-023-02329-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 06/29/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Valve-sparing aortic root replacement (VSARR) is a safe and effective surgical procedure to treat aortic root aneurysm. This meta-analysis aimed to investigate how this procedure might differ in patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV). DESIGN Meta-analysis with meta-regression and systematic review. SETTING Systematic search in the following databases: PubMed, Cochrane Central Register of Controlled Trials, and Embase. INTERVENTIONS All observational studies of VSARR in patients with BAV or TAV were included in our study. Studies were included without any restrictions on language or publication date. A trial sequential analysis and a post-hoc meta-regression was performed on the main outcomes. RESULT Eleven articles met the inclusion criteria. A total of 1138 patients in BAV group, and 2125 patients in TAV group. No significant differences in gender and age were observed between BAV and TAV patients. BAV and TAV patients showed no differences in in-hospital mortality rate [0.00% vs. 1.93%; RR (95% CI) 0.33 (0.09, 1.26), I2 = 0%, P = 0.11] and the rate of in-hospital reoperation [5.64% vs. 5.99%; RR (95% CI) 1.01(0.59, 1.73), I2 = 33%, P = 0.98]. The overall long-term mortality rate of BAV patients was better than that of TAV patients [1.63% vs. 8.15%; RR (95% CI) 0.34 (0.13, 0.86), I2 = 0%, P = 0.02]. During the follow-up observation period, patients in TAV group showed small but no statistic advantage in 3-year, 5-year, and over 10-year incidences of reintervention. Regarding the secondary endpoints, the two groups showed similar aortic cross-clamping time and total cardiopulmonary bypass time. CONCLUSION The VSARR techniques yielded similar clinical outcomes in both BAV and TAV patients. Although patients with BAV might have a higher incidence of reinterventions after initial VSARR, it is still a safe and effective approach to treat aortic root dilation with or without aortic valve insufficiency. TAV patients showed small but no statistic advantage in long-term (over 10 years) reintervention rate, which means, patients with BAV may face a higher risk of reintervention in the clinic.
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Affiliation(s)
- Yiding Zuo
- Department of Anesthesia, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ruixi Tan
- Department of Anesthesia, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Chaoyi Qin
- Department of Cardiovascular Surgery and Cardiovascular Surgery Research Laboratory, West China Hospital, Sichuan University, 37th Guoxue Road, Chengdu, 610041, China.
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El Sherif N, Dearani JA, Connolly HM, Bagameri G, Pochettino A, Stulak JM, Stephens EH. Complexity and Outcome of Reoperations After the Ross Procedure in the Current Era. Ann Thorac Surg 2023; 115:633-639. [PMID: 35644264 DOI: 10.1016/j.athoracsur.2022.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 04/04/2022] [Accepted: 05/09/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Ross procedure has several advantages, but the need for reintervention is inevitable. The aim of this study was to examine the complexity and outcomes of reoperation after the Ross procedure. METHODS Retrospective chart review was performed of patients with a prior Ross procedure who underwent reoperation at our institution from September 1991 to January 2021. Demographic, echocardiographic, surgical, and perioperative data were collected. Descriptive statistical and regression analyses were performed. RESULTS A total of 105 patients underwent a reoperation at Mayo Clinic after the initial Ross procedure performed at our institution (n = 16; 16.2%) or elsewhere (n = 83; 83.8%). Mean age at the Ross procedure was 27 ± 17 years, and mean age at reoperation at our institution was 37 ± 19 years. Indications for surgical procedure varied, but 64% had autograft regurgitation as 1 of their indications for reoperation. Autograft interventions were performed in 78 patients (74.2%). Pulmonary valve or conduit replacement was performed in 56 patients (53.3%). Double root replacement was performed in 11 patients (10.5%). Aortic reconstruction was performed in 37 patients (38.4%). There were 5 early deaths (5%). During a median follow-up of 6.25 years (3 months-24 years), late deaths occurred in 14 patients (13.1%). Patients with ejection fraction <30% on preoperative echocardiography had shorter duration between the Ross procedure and subsequent reoperation (P = .03). CONCLUSIONS Reoperations after the Ross procedure are performed for a wide range of indications, with most due to autograft dysfunction. The number of early deaths is not low. Reoperation after the Ross procedure should be advised before left ventricular systolic dysfunction.
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Affiliation(s)
- Nibras El Sherif
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Heidi M Connolly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Gabor Bagameri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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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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8
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Impact of Aortic Valve Effective Height following Valve-Sparing Root Replacement on Postoperative Insufficiency and Reoperation. J Thorac Cardiovasc Surg 2022; 164:1672-1680.e3. [DOI: 10.1016/j.jtcvs.2022.02.065] [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: 05/14/2021] [Revised: 02/10/2022] [Accepted: 02/22/2022] [Indexed: 11/18/2022]
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Early results after aortic annuloplasty with a complete external Dacron band. Gen Thorac Cardiovasc Surg 2021; 70:329-336. [PMID: 34542798 PMCID: PMC8930909 DOI: 10.1007/s11748-021-01695-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 09/04/2021] [Indexed: 10/29/2022]
Abstract
OBJECTIVE This study evaluates the early results of our initial experience with aortic annuloplasty using a complete external Dacron band in the setting of type Ic or type II aortic regurgitation (AR). METHODS From May 2017 to August 2019, 16 patients (88% bicuspid aortic valves, no patients with connective tissue disorders) underwent aortic annuloplasty with an external complete Dacron band. Clinical and echocardiographic follow-up was 100% complete. Clinical and echocardiographic follow-up averaged 24.4 ± 9.3 and 15.1 ± 8.3 months, respectively. RESULTS Mean cardiopulmonary and cross-clamp times were 105 ± 15 (72-127) and 86 ± 15 (51-113) min, respectively. Early and late mortality was 0%, with no incidents of endocarditis or cerebrovascular events during the follow-up. Two patients were re-operated during the follow-up, one due recurrent aortic regurgitation (12 months after the first operation) yielding a freedom from reoperation due to AR at 1 year and 3 years of 100% ± 0% and 93.3% ± 5.7%, respectively. Based on the latest echocardiogram, five patients had either none or trivial AR, six had mild AR, and three had mild-to-moderate AR. CONCLUSIONS The early clinical and echocardiographic results after using a complete external Dacron band are promising; however, more data and longer follow-up are needed to determine its role in annular management during aortic valve repair.
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Varotto L, Spigolon L, Dotto A, Siviero V, Scodro M, Cabianca E, Magagna P, Caprioglio F. Case Report: Severe Aortic Valve Regurgitation and Pseudoaneurysm in Aortic Valve-Sparing Operation: The Usefulness of Multimodality Imaging in a Complex Clinical Scenario. Front Cardiovasc Med 2021; 8:719405. [PMID: 34513958 PMCID: PMC8423922 DOI: 10.3389/fcvm.2021.719405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Failure of the native aortic valve and degenerative anatomy of ascending aorta in patients with previous Tirone-David operation may represent a clinical challenge, because sometimes the risk of reoperation is prohibitive. Case: We described the case of a patient suffering from severe aortic valve regurgitation and pseudoaneurysm of the aortic arch, 6 years after cardiac surgery operation. The aim of this clinical case was to assess if the complex anatomy of aortic pseudoaneurysm and aortic root geometry can be accurately reproduced from contrast-enhanced computed tomography scan into a three-dimensional (3D) printed model. Based on this procedural method, with the aid of transesophageal 3D ultrasound, we efficaciously treated the patient percutaneously with a combination of transcatheter occluder device plus microcoil embolization and transfemoral aortic valve implantation. The patient was free from complications and the need to redo cardiac surgery. Conclusion: To the best of our knowledge, this is the first description of two simultaneous complications and their staged treatment in a patient with previous aortic valve-sparing operation. This is a useful report in a single 3D model applying such specific technology to these two simultaneous clinical settings.
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Affiliation(s)
| | - Luca Spigolon
- Department of Radiology, San Bortolo Hospital, Vicenza, Italy
| | - Alberto Dotto
- Department of Cardiology, San Bortolo Hospital, Vicenza, Italy
| | | | - Marta Scodro
- Department of Cardiology, San Bortolo Hospital, Vicenza, Italy
| | - Ester Cabianca
- Department of Cardiology, San Bortolo Hospital, Vicenza, Italy
| | - Paolo Magagna
- Department of Cardiac Surgery, San Bortolo Hospital, Vicenza, Italy
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11
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Coselli JS, Volguina IV, LeMaire SA, Connolly HM, Sundt TM, Milewicz DM, Dietz HC, Amarasekara HS, Green SY, Zhang Q, Schaff HV, Miller DC. Midterm outcomes of aortic root surgery in patients with Marfan syndrome: A prospective, multicenter, comparative study. J Thorac Cardiovasc Surg 2021; 165:1790-1799.e12. [PMID: 34629178 DOI: 10.1016/j.jtcvs.2021.08.064] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 08/10/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The objective of this study was to compare midterm outcomes of aortic valve-replacing root replacement (AVR) and aortic valve-sparing root replacement (AVS) operations in patients with Marfan syndrome. METHODS Patients who met strict Ghent diagnostic criteria for Marfan syndrome and who underwent either AVR or AVS between March 1, 2005 and December 31, 2010 were enrolled in a 3-year follow-up prospective, multicenter, international registry study; the study was subsequently amended to include 20-year follow-up. Enrollees were followed clinically and echocardiographically. RESULTS Of the 316 patients enrolled, 77 underwent AVR and 239 underwent AVS; 214 gave reconsent for 20-year follow-up. The median clinical follow-up time for surviving patients was 64 months (interquartile range, 42-66 months). Survival rates for the AVR and AVS groups were similar at 88.2% ± 4.4% and 95.0% ± 1.5%, respectively (P = .1). Propensity score-adjusted competing risk modeling showed associations between AVS and higher cumulative incidences of major adverse valve-related events, valve-related morbidity, combined structural valve deterioration and nonstructural valve dysfunction, and aortic regurgitation ≥2+ (all P < .01). No differences were found for reintervention (P = .7), bleeding (P = .2), embolism (P = .3), or valve-related mortality (P = .8). CONCLUSIONS Five years postoperatively, major adverse valve-related events and valve-related morbidity were more frequent after AVS than after AVR procedures, primarily because of more frequent aortic valve dysfunction. No between-group differences were found in rates of survival, valve-related mortality, reintervention on the aortic valve, or bleeding. We plan to follow this homogenous cohort for 20 years after aortic root replacement.
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Affiliation(s)
- Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
| | - Irina V Volguina
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex.
| | - Heidi M Connolly
- Division of Structural Heart Disease, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Dianna M Milewicz
- Division of Medical Genetics, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Tex
| | - Harry C Dietz
- Department of Genetic Medicine and Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Hiruni S Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Qianzi Zhang
- Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | | | - D Craig Miller
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
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12
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Vervoort D, El-Hamamsy I, Chu MWA, Peterson MD, Ouzounian M. The Ross procedure and valve-sparing root replacement procedures in the adult patient: do guidelines follow the evidence? Ann Cardiothorac Surg 2021; 10:433-443. [PMID: 34422555 DOI: 10.21037/acs-2021-rp-24] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 04/15/2021] [Indexed: 12/16/2022]
Abstract
Prosthetic aortic valve replacements have long been the mainstay of valvular surgery due to their favorable outcomes and low operative complexity. Yet, mechanical valves require lifelong anticoagulation, whereas bioprosthetic valves increase the risk for earlier and more frequent reoperation. Alternative reconstructive techniques have been proposed to address these challenges. These include valve-sparing root replacement procedures if the native aortic valve can be salvaged, and the Ross procedure, which nearly eliminates prosthetic valve-related thromboembolism, anticoagulation-related hemorrhage and endocarditis. Both procedures are technically more complex and thus subject to surgeons' volume and expertise compared to conventional aortic valve replacements. However, they are associated with more favorable outcomes compared to aortic valve replacements if performed by experienced surgeons, especially in younger patients. Nevertheless, despite the growing high-quality literature supporting both procedures, existing multi-society guidelines fail to acknowledge the strength of evidence in support of valve-sparing root replacement procedures and the Ross procedure. In this review, we summarize the existing long-term evidence for the use of each procedure, describe the current guidelines for the treatment of aortic valve pathology, and propose the reevaluation of guidelines based on the available clinical evidence.
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Affiliation(s)
- Dominique Vervoort
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, USA
| | - Michael W A Chu
- Division of Cardiac Surgery, Western University, London, Canada
| | - Mark D Peterson
- Division of Cardiovascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, University of Toronto, Toronto, Ontario, Canada
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13
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Tamer S, Mastrobuoni S, Lemaire G, Jahanyar J, Navarra E, Poncelet A, Astarci P, El Khoury G, de Kerchove L. Two decades of valve-sparing root reimplantation in tricuspid aortic valve: impact of aortic regurgitation and cusp repair. Eur J Cardiothorac Surg 2021; 59:1069-1076. [PMID: 33332548 DOI: 10.1093/ejcts/ezaa427] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/05/2020] [Accepted: 10/26/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES Our goal was to analyse the influence of preoperative aortic regurgitation (AR) on the necessity of cusp repair during valve-sparing reimplantation (VSR). We focused on patients with tricuspid aortic valves (TAV) and evaluated the impact of AR and cusp repair on long-term outcomes. METHODS From March 1998 to December 2018, a total of 512 consecutive patients underwent VSR at our institution; of these, 303 had a TAV. The mean age was 53 ± 15 years, and the median follow-up was 6.12 years. The rate and type of cusp repair were analysed based on preoperative AR. Time-to-event analysis was performed, as well as risk of death, reoperation and AR recurrence. RESULTS Cusp repair was necessary in 168 (55.4%) patients; the rate rose significantly as AR grade increased (P < 0.001). In-hospital mortality was 1% (n = 3). At 5 and 10 years, overall survival was 92 ± 2% and 75 ± 5%, respectively. Freedom from valve reoperation was 95 ± 2% and 90 ± 3%. Freedom from AR >2+ and AR >1+ at 10 years was 88 ± 4% and 70.4 ± 4.6%, respectively. Independent predictors of death included age, New York Heart Association functional class and type-A aortic dissection. Predictors of AR greater than mild included previous cardiac surgery and severe preoperative AR. CONCLUSION In patients with TAV receiving VSR, the necessity of cusp repair increased with the degree of preoperative AR. Preoperative AR and cusp repair do not impact long-term survival and aortic valve reoperation, but severe preoperative AR and multiple cusp repair increase the risk of recurrent moderate-to-severe AR. Overall, cusp repair seems to attenuate the negative impact of preoperative AR for at least 1 decade in a majority of patients.
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Affiliation(s)
- Saadallah Tamer
- Cardiovascular and Thoracic Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Stefano Mastrobuoni
- Cardiovascular and Thoracic Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Guillaume Lemaire
- Anesthesiology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jama Jahanyar
- Cardiovascular and Thoracic Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Emiliano Navarra
- Cardiovascular and Thoracic Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Alain Poncelet
- Cardiovascular and Thoracic Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Parla Astarci
- Cardiovascular and Thoracic Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Gebrine El Khoury
- Cardiovascular and Thoracic Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Laurent de Kerchove
- Cardiovascular and Thoracic Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Yiğit G, Özen A, Çetinkaya F, Ünal EU, İşcan HZ, Birincioğlu CL, Sarıtaş A. Early and Late-Term Follow-Up Results of Patients Diagnosed with Aortic Aneurysm or Aortic Dissection with Aortic Regurgitation Undergoing Aortic Valve Repair or Valve-Sparing Aortic Surgery. Braz J Cardiovasc Surg 2021; 36:192-200. [PMID: 33113319 PMCID: PMC8163274 DOI: 10.21470/1678-9741-2020-0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Valve-reimplantation and remodelling techniques used in aortic reconstruction provide successful early, mid, and long-term results. We present our early and late-term experience with 110 patients with aortic regurgitation (AR) who underwent aortic valve repair (AVr) or valve-sparing aortic root surgeries (VSARS) due to aortic dissection or aortic aneurysm. METHODS Nine hundred eighty-two patients who underwent aneurysm or dissection surgery and aortic valve surgery between April 1997 and January 2017 were analysed using the patient database. A total of 110 patients with AR who underwent AVr or VSARS due to aortic dissection or aortic aneurysm were included in the study. RESULTS In the postoperative period, a decrease was observed in AR compared to the preoperative period (P<0.001); there was an increase in postoperative ejection fraction (EF) compared to the preoperative values (P<0.005) and a significant decrease in postoperative left ventricle diameters compared to the preoperative values (P<0.001). Kaplan-Meier analysis revealed one, two, four, and five-year freedom from moderate-severe AR as 95%, 91%, 87%, and 70%, respectively. Freedom from reoperation in one, two, and five years were 97.9%, 93.6%, and 81%, respectively. Eight patients (7.4%) underwent AVr during follow-up. Out of the remaining 100 patients, 13 (12%) had minimum AR, 52 (48%) had 1st-2nd degree AR, and 35 (32%) had 2nd-3rd degree AR during follow-up. CONCLUSION For the purpose of maintaining the native valve tissue, preserving the EF and the left ventricular end-diastolic diameter, valve-sparing surgeries should be preferred for appropriate patients.
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Affiliation(s)
- Görkem Yiğit
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Anıl Özen
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Ferit Çetinkaya
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Ertekin Utku Ünal
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Hakki Zafer İşcan
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | | | - Ahmet Sarıtaş
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
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Nguyen SN, Yamabe T, Zhao Y, Kurlansky PA, George I, Smith CR, Takayama H. Bicuspid-Associated Aortic Root Aneurysm: Mid to Long-Term Outcomes of David V Versus the Bio-Bentall Procedure. Semin Thorac Cardiovasc Surg 2021; 33:933-943. [PMID: 33609674 DOI: 10.1053/j.semtcvs.2021.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 02/12/2021] [Indexed: 11/11/2022]
Abstract
David V valve-sparing root replacement (VSRR) and bio-Bentall (BB) are increasingly performed for aortic root aneurysms associated with a bicuspid aortic valve (BAV). However, durability remains a concern in both procedures. We compared the 10-year outcomes of VSRR vs BB for BAV-associated root aneurysms. A retrospective review identified 134 patients with a BAV-associated root aneurysm who underwent VSRR (n = 65) or BB (n = 69) from 2005 to 2019. Patients with aortic stenosis, endocarditis, previous aortic valve replacement, and emergent cases were excluded. Propensity-score matching was performed, resulting in 2 risk-adjusted groups (n = 40 per group). Median follow-up was 6.21 (1.43-8.28) years. The VSRR cohort was younger (46.0 years vs 56.0 years, P < 0.001) and had a lower incidence of at least moderate aortic insufficiency (AI) (78.5% vs 92.8%, P = 0.02). The incidence of Marfan syndrome, aortic root diameter, and ascending aortic diameter were similar. In-hospital mortality was 1.5% (n = 1) and 1.4% (n = 1) for VSRR and BB, respectively. There was no difference between VSRR and BB in 10-year survival (98.3% [95% confidence interval (CI): 88.6-99.8%] vs 96.2% [95% CI: 85.5-99.0%], P = 0.567) and aortic valve reintervention at 10 years (16.1% [95% CI: 6.3-29.8%] vs 12.9% [95% CI: 3.7-28.0%], P = 0.309). The most common reason for valve reintervention in both groups was AI. Survival and valve reintervention at 10 years were similar in the matched cohort. David V VSRR yields similar mid to long-term outcomes to BB for select patients with a BAV-associated aortic root aneurysm in regards to survival and reintervention rates. Further studies comparing longer term outcomes between root replacement techniques and native valve durability are needed.
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Affiliation(s)
- Stephanie N Nguyen
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York Presbyterian-Columbia University Medical Center, New York, New York
| | - Tsuyoshi Yamabe
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York Presbyterian-Columbia University Medical Center, New York, New York; Department of Cardiac Surgery, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Yanling Zhao
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York Presbyterian-Columbia University Medical Center, New York, New York
| | - Paul A Kurlansky
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York Presbyterian-Columbia University Medical Center, New York, New York
| | - Isaac George
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York Presbyterian-Columbia University Medical Center, New York, New York
| | - Craig R Smith
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York Presbyterian-Columbia University Medical Center, New York, New York
| | - Hiroo Takayama
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York Presbyterian-Columbia University Medical Center, New York, New York.
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16
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Huuskonen A, Valo J, Kaarne M, Ropponen J, Ihlberg L, Juvonen T, Raivio P. Outcome of valve sparing root replacement for diverse indications. SCAND CARDIOVASC J 2021; 55:173-179. [PMID: 33501855 DOI: 10.1080/14017431.2020.1869298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES We report the mid-term outcomes of valve-sparing aortic root replacement (VSRR) in a cohort including patients with bicuspid aortic valve (BAV), connective tissue disorder (CTD), aortic dissection (AD), and congenital heart disease (CHD). Design. From 2005 to 2017, 174 patients underwent VSRR with the reimplantation technique. The mean age was 46 ± 14 years. The mean follow-up time was 4.8 ± 2.8 years. The indication for operation was aortic aneurysm for 127 (73%), aortic insufficiency (AI) for 38 (22%), and AD for 9 patients (5%). Preoperatively, 53 patients (31%) had ≥ moderate AI. BAV, CTD (Marfan or Loyes-Dietz), previous Ross procedure, or CHD was present in 57 (33%), 28 (16%), 7 (4%) and 12 patients (7%), respectively. Concomitant aortic valve repair was performed for 103 patients (59%). Results. Thirty-day mortality was zero. Four patients underwent aortic valve replacement (AVR) during follow-up. Kaplan-Meier estimates for survival, freedom from AVR, and freedom from ≥ moderate AI or reoperation were 96, 98, and 97% at 5 years. There was no difference in survival, freedom from AVR, or freedom from ≥ moderate AI or reoperation in patients with and without BAV, CTD, leaflet repair, or preoperative ≥ moderate AI. In Cox regression analysis, BAV, CTD, aortic valve repair, preoperative ≥ moderate AI, or aortic dimension were not risk factors for reoperation or valve dysfunction. Conclusions. Mid-term outcomes of VSRR for patients with diverse indications in terms of survival, reoperation rate, and valve dysfunction rate were excellent in a center with a limited annual volume of VSSR.
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Affiliation(s)
- Antti Huuskonen
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Johanna Valo
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Markku Kaarne
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Jussi Ropponen
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Leo Ihlberg
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Tatu Juvonen
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Peter Raivio
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
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17
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Tamer S, Mastrobuoni S, Momeni M, Aphram G, Navarra E, Poncelet A, Noirhomme P, Astarci P, El Khoury G, de Kerchove L. Long-term experience with valve-sparing root reimplantation surgery in tricuspid aortic valve. Indian J Thorac Cardiovasc Surg 2020; 36:71-80. [PMID: 33061187 DOI: 10.1007/s12055-019-00842-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/26/2019] [Accepted: 05/30/2019] [Indexed: 01/16/2023] Open
Abstract
Objective To analyze our long-term experience with valve-sparing reimplantation technique in treating aortic root aneurysm, aortic regurgitation, and aortic dissection in patients with tricuspid aortic valve. Methods Between March 1998 and October 2018, 303 consecutive patients underwent valve-sparing reimplantation in our institution. The mean age of this cohort was 52.9 ± 15 years. Time to event analysis was performed with the Kaplan-Meier method. Risk of death, reoperation, and aortic regurgitation (AR) recurrence were analyzed using the cox-regression method. Results In-hospital mortality was 1% (n = 3) of which two were admitted for acute aortic dissection. Median follow-up was 5.81 years ([IQR]: 2.8-10 years). Thirty-nine patients (14.4%) died during follow-up. At 5 and 10 years, overall survival was 92 ± 2%and 75 ± 4.9%, respectively. Seventeen patients required late aortic valve reoperation. Freedom from valve reoperation was 95 ± 2% and 90 ± 3%. Freedom from AR > 2+ and AR > 1+ at 10 years was 91 ± 4% and 71.5 ± 4.6%, respectively. Significant multivariate predictors of death included age, New York Heart Association dyspnea class (NYHA), type A acute dissection (TAAD), and preoperative left ventricular end-diastolic diameter (LVEDD). Significant multivariate predictors of AR recurrence included indication for surgery, previous cardiac surgery, and presence of preoperative AR. Freedom from events like major bleeding, thromboembolic events, and infective endocarditis at 10 years were 97%, 98%, and 96%, respectively. Conclusions Aortic valve-sparing with the reimplantation technique has been performed for over two decades in our institution, and the results in patients with tricuspid aortic valve (TAV) are excellent in terms of survival and freedom from valve-related adverse outcomes including valve reoperation. These results continue supporting the use of valve sparing root replacement using the reimplantation technique (VSRR) in patients with aortic aneurysm, irrespective of whether they have preoperative AR or not. VSRR is safe, durable, and reproducible, but further follow-up, well into the second decade is still necessary.
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Affiliation(s)
- Saadallah Tamer
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Stefano Mastrobuoni
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Mona Momeni
- Division of Anesthesiologyy, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Gaby Aphram
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Emiliano Navarra
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Alain Poncelet
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Philippe Noirhomme
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Parla Astarci
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Gebrine El Khoury
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Laurent de Kerchove
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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18
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Aalaei-Andabili SH, Beaver TM, Martin TD, Hess PJ, Arnaoutakis GJ. Outcomes of Florida Sleeve Procedure in Patients with Bicuspid Versus Tricuspid Aortic Valve. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2020; 15:361-368. [PMID: 32729751 DOI: 10.1177/1556984520938470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Outcomes of the Florida Sleeve (FS) procedure in patients with bicuspid aortic valve (BAV) have not been reported before. We compared outcomes of the FS procedure between patients with BAV and those with tricuspid aortic valve (TAV). METHODS From May 1, 2002 to January 1, 2016, 177 patients including 18 BAV and 159 TAV underwent the FS procedure. Baseline characteristics, perioperative outcomes, and echocardiographic measurements were compared between the 2 groups. Kaplan-Meier and life-table analyses were used to evaluate survival and freedom from reintervention rates. RESULTS Mean ± standard deviation age and aortic root diameter were comparable in BAV and TAV groups, 47.83 ± 11.19 versus 49.59 ± 15.79 years (P = 0.55) and 56.57 ± 6.18 versus 55.17 ± 8.84 mm (P = 0.46), respectively. The 30-day mortality and stroke rates were zero in the BAV group and 1.88% (n = 3) in the TAV group (P = 1.00). One patient (5.55%) in the BAV group and 8 (5.03%) patients in the TAV group needed permanent pacemaker implantation (P = 0.62). Freedom from reoperation was 93% in the BAV group and 99% in the TAV group at 8 years (P = 0.041). Patient survival rate was 100% in the BAV group and 91% in the TAV group at 8 years (P = 0.42). Freedom from aortic insufficiency greater than mild was 93% in the BAV group and 96.5% in the TAV group at 5 years (P = 0.61). CONCLUSIONS This is the first study reporting outcomes of the FS procedure in patients with BAV. This technique is feasible, and the results appear to be durable when compared to patients with TAV.
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Affiliation(s)
- Seyed Hossein Aalaei-Andabili
- 3463 Department of Medicine, University of Florida, Gainesville, FL, USA.,Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Tomas D Martin
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Philip J Hess
- 22535 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Indiana University, Bloomington, IN, USA
| | - George J Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
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19
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Martín C, Evangelista A, Serrano-Fiz S, Villar S, Ospina V, Martínez D, De Villarreal J, Sanchez V, Moñivas V, Mingo S, Forteza A. Aortic Complications in Marfan Syndrome: Should We Anticipate Preventive Aortic Root Surgery? Ann Thorac Surg 2020; 109:1850-1857. [DOI: 10.1016/j.athoracsur.2019.08.096] [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: 03/28/2019] [Revised: 07/27/2019] [Accepted: 08/26/2019] [Indexed: 01/09/2023]
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20
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David TE. Commentary: Are the results of reimplantation of the aortic valve the same for bicuspid and tricuspid valves? J Thorac Cardiovasc Surg 2020; 163:64-65. [DOI: 10.1016/j.jtcvs.2020.03.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 12/29/2022]
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21
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Borger MA, Fedak PWM, Stephens EH, Gleason TG, Girdauskas E, Ikonomidis JS, Khoynezhad A, Siu SC, Verma S, Hope MD, Cameron DE, Hammer DF, Coselli JS, Moon MR, Sundt TM, Barker AJ, Markl M, Della Corte A, Michelena HI, Elefteriades JA. The American Association for Thoracic Surgery consensus guidelines on bicuspid aortic valve-related aortopathy: Full online-only version. J Thorac Cardiovasc Surg 2019; 156:e41-e74. [PMID: 30011777 DOI: 10.1016/j.jtcvs.2018.02.115] [Citation(s) in RCA: 162] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 01/17/2018] [Accepted: 02/12/2018] [Indexed: 12/11/2022]
Abstract
Bicuspid aortic valve disease is the most common congenital cardiac disorder, being present in 1% to 2% of the general population. Associated aortopathy is a common finding in patients with bicuspid aortic valve disease, with thoracic aortic dilation noted in approximately 40% of patients in referral centers. Several previous consensus statements and guidelines have addressed the management of bicuspid aortic valve-associated aortopathy, but none focused entirely on this disease process. The current guidelines cover all major aspects of bicuspid aortic valve aortopathy, including natural history, phenotypic expression, histology and molecular pathomechanisms, imaging, indications for surgery, surveillance, and follow-up, and recommendations for future research. It is intended to provide clinicians with a current and comprehensive review of bicuspid aortic valve aortopathy and to guide the daily management of these complex patients.
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Affiliation(s)
- Michael A Borger
- Leipzig Heart Center, Cardiac Surgery, University of Leipzig, Leipzig, Germany.
| | - Paul W M Fedak
- Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Thomas G Gleason
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - John S Ikonomidis
- Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, NC
| | - Ali Khoynezhad
- Memorial Care Heart and Vascular Institute, Memorial Care Long Beach Medical Center, Long Beach, Calif
| | - Samuel C Siu
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Subodh Verma
- Department of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michael D Hope
- San Francisco (UCSF) Department of Radiology & Biomedical Imaging, University of California, San Francisco, Calif
| | - Duke E Cameron
- Department of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass
| | - Donald F Hammer
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Texas Heart Institute, Baylor College of Medicine, Houston, Tex
| | - Marc R Moon
- Section of Cardiac Surgery, Washington University School of Medicine, St Louis, Mo
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass
| | - Alex J Barker
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Michael Markl
- Departments of Radiology and Biomedical Engineering, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | | | | | - John A Elefteriades
- Department of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Conn
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22
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The Influence of Connective Tissue Disease in Breast Reconstruction: A National Database Analysis. Ann Plast Surg 2019; 80:S182-S188. [PMID: 29596085 DOI: 10.1097/sap.0000000000001387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Patients with connective tissue diseases (CTD), or collagen vascular diseases, are at risk of potentially higher morbidity after surgical procedures. We aimed to investigate the complication profile in CTD versus non-CTD patients who underwent breast reconstruction on a national scale. METHODS A retrospective analysis of the Healthcare Cost and Utilization Project NIS Database between 2010 and 2014 was conducted for patients 18 years or older admitted for immediate autologous or implant breast reconstruction. Connective tissue disease was defined as systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, scleroderma, Raynaud phenomenon, psoriatic arthritis, or sarcoidosis. Independent t test/Wilcoxon-Mann-Whitney was used to compare continuous variables and Pearson χ/Fischer exact test was used for categorical variables. Outcomes of interest were assessed using multivariable linear regressions for continuous variables and multivariable logistic regressions for categorical variables. RESULTS There were 19,496 immediate autologous breast reconstruction patients, with 357 CTD and 19,139 non-CTD patients (2010-2014). The CTD patients had higher postoperative complication rates for infection (2.8% vs 0.8%, P < 0.001), wound dehiscence (1.4% vs 0.4%, P = 0.019), and bleeding (hemorrhage and hematoma) (6.7% vs 3.5%, P < 0.001). After multivariable analysis, CTD remained an independent risk factor for bleeding (odds ratio [OR], 1.568; 95% confidence interval [CI], 1.019-2.412). There were a total of 23,048 immediate implant breast reconstruction patients, with 431 CTD and 22,617 non-CTD patients (2010-2014). The CTD patients had a higher postoperative complication rate for wound dehiscence/complication (2.3% vs 0.6%, P < 0.001). They also experienced a longer length of stay (2.31 days vs 2.07 days, P < 0.001). After multivariable analysis, CTD remained an independent risk factor for wound dehiscence (OR, 4.084; 95% CI, 2.101-7.939) and increased length of stay by 0.050 days (95% CI, -0.081 to 0.181). CONCLUSIONS Connective tissue disease patients who underwent autologous breast reconstruction had significantly higher infection, wound dehiscence, and bleeding rates, and those who underwent implant breast reconstruction had significantly higher wound dehiscence rates. Connective tissue diseases appear to be an independent risk factor for bleeding and wound dehiscence in autologous and implant breast reconstruction, respectively. This information may help clinicians be aware of this increased risk when determining patients for reconstruction.
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23
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Aalaei-Andabili SH, Martin TD, Hess PJ, Karimi A, Bavry AA, Arnaoutakis GJ, Beaver TM. The Florida Sleeve Procedure Is Durable and Improves Aortic Valve Function. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2019; 7:49-55. [PMID: 31529428 PMCID: PMC6748854 DOI: 10.1055/s-0039-1687854] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background
The Florida (FL) Sleeve procedure was introduced as a simplified approach for valve-sparing correction of functional Type I aortic insufficiency (AI) associated with aortic root aneurysms. In this study, short- and long-term outcomes after the FL Sleeve procedure were investigated.
Methods
From May 2002 to January 2016, 177 patients underwent the FL Sleeve procedure. Left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter, left ventricular ejection fraction, and degree of AI (none = 0, minimal = 1, mild = 2, moderate = 3, severe = 4) were evaluated by echocardiography.
Results
Mean ± standard deviation of age was 49.41 ± 15.37 years. Survival rate was 98% at 1 year, 97% at 5 years, and 93% at 8 years. Freedom from reoperation was 99% at 1 year and 98% at 2 to 8 years. Three patients (1.69%) died during hospitalization. Three patients (1.69%) developed periprocedural stroke. Postoperative follow-up echocardiography was available in 140 patients at 30 days, and 31 patients at 5 years. AI grade significantly improved from baseline at 30 days (2.18 ± 1.26 vs. 1.1 ± 0.93,
p
< 0.001) and at 5 years (2.0 ± 1.23 vs. 1.45 ± 0.88,
p
= 0.04). Preoperative mean LVEDD significantly decreased from 52.20 ± 6.73 to 46.87 ± 8.40 (
p
< 0.001) at 30 days, and from 53.22 ± 7.07 to 46.61 ± 10.51 (
p
= 0.01) at 5 years.
Conclusions
The FL Sleeve procedure is a safe, effective, and durable treatment of aortic root aneurysm and Type I AI. Long-term survival and freedom from reoperation rates are encouraging.
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Affiliation(s)
- Seyed Hossein Aalaei-Andabili
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida.,Division of Cardiology, Department of Medicine, University of Florida, Gainesville, Florida
| | - Tomas D Martin
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Philip J Hess
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Indiana University, Indianapolis, Indiana
| | - Ashkan Karimi
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, Florida
| | - Anthony A Bavry
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, Florida.,North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - George J Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
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24
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Siki MA, Habertheuer A, Bavaria JE, Komlo C, Hunt M, Freas MA, Milewski RK, Desai ND, Szeto WY, Vallabhajosyula P. Two different geometric orientations for aortic neoroot creation in bicuspid aortic valve repair with root reimplantation. J Thorac Cardiovasc Surg 2019; 160:47-57. [PMID: 31982122 DOI: 10.1016/j.jtcvs.2019.06.119] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 05/31/2019] [Accepted: 06/15/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Bicuspid aortic valve (BAV) represents 2 cusps oriented along a spectrum of equal (180°/180°) or unequal (150°/210°) leaflet surface area distribution along the aortic annular plane. We have taken the approach of respecting the native geometric orientation of the repaired BAV leaflets when creating the aortic neoroot during valve-sparing root reimplantation (VSRR) procedures. We investigated midterm outcomes with this 2-prong approach for VSRR in BAV syndrome. METHODS Of 72 patients in a prospectively maintained BAV repair database, 68 met inclusion criteria: 36 patients had 180°/180° neoroot geometry, and 32 patients had 150°/210° orientation. A multivariate ordinal logistic mixed effects model was performed to study parameters associated with recurrent AI greater than 2+. RESULTS Preoperative parameters were similar between 180°/180° and 150°/210° groups, except for greater incidence of AI 4+ in the latter (50.0% [n = 16] vs 8.3% [n = 3]; P < .001). Postoperatively, stroke, renal failure, reoperation for bleeding, and pacemaker rates were 0 in the entire cohort. In-hospital/30-day mortality in the entire cohort was 1.5% (n = 1). Multivariate ordinal logistic mixed effects model showed that preoperative AI greater than 3+ (odds ratio, 0.4; P = .46) and geometric orientation of the aortic neoroot (odds ratio, 3.8; P = .25) were not significantly associated with recurrence of AI greater than 2+. CONCLUSIONS Respecting BAV geometry for VSRR neoroot creation yields excellent midterm outcomes and may minimize conjoint cusp leaflet stress that may occur in "forcing" a 150°/210° type I BAV into a 180°/180° neoroot.
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Affiliation(s)
- Mary A Siki
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Andreas Habertheuer
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Caroline Komlo
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Maxwell Hunt
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Melanie A Freas
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Rita K Milewski
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
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25
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Modeling conduit choice for valve-sparing aortic root replacement on biomechanics with a 3-dimensional–printed heart simulator. J Thorac Cardiovasc Surg 2019; 158:392-403. [DOI: 10.1016/j.jtcvs.2018.10.145] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/07/2018] [Accepted: 10/19/2018] [Indexed: 12/24/2022]
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26
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Ouzounian M, Feindel CM, Manlhiot C, David C, David TE. Valve-sparing root replacement in patients with bicuspid versus tricuspid aortic valves. J Thorac Cardiovasc Surg 2019; 158:1-9. [DOI: 10.1016/j.jtcvs.2018.10.151] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 08/28/2018] [Accepted: 10/04/2018] [Indexed: 12/12/2022]
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27
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Valdis M, Thain A, Jones PM, Chan I, Chu MWA. Multimodal imaging of aortic annulus and root geometry after valve sparing root reconstruction. Ann Cardiothorac Surg 2019; 8:362-371. [PMID: 31240180 DOI: 10.21037/acs.2019.05.09] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Controversy exists regarding the optimal annular stabilization technique following valve sparing aortic root reconstruction (VSRR) with no comprehensive imaging data to evaluate the natural history of aortic root graft geometry, aortic valve competency and patient prognosis post-reconstruction. Methods Between 2008-2017, 70 consecutive patients (mean age 56.4±16.4 years, 19.7% females) underwent VSRR. All patients were prospectively evaluated annually with clinical follow-up, echocardiography and CT imaging. Patients were assessed for survival, freedom from reoperation, degree of regurgitation, New York Heart Association (NYHA) status and graft complications and followed up to nine years post-operatively (mean 36±21 months). Results The largest increase of the aortic annulus diameter observed during the surveillance period was 2.64%±5.4% which occurred between the second and third years of follow-up and the aortic sinuses, sinotubular junction and ascending aorta all remained relatively stable based on annual CT imaging. Echocardiographic data showed far more variability in measurements at each annual post-operative visit with far less precision compared to the CT measurements taken at the same time. Due to the large variability and greater standard deviations, no significant difference was detected between the more precise CT measurements and those from the echocardiogram images. The overall survival rate was 94.3% (66 patients) at one year. Freedom from reoperation was 98.6% (69 patients). Throughout the entire duration of follow-up, aortic insufficiency was identified as 0 in 46 (65.7%), 1+ in 19 (27.1%), 2+ in 4 (5.7%), 3+ in 0 (0%) and 4+ in 1 (1.4%). Mean NYHA status was 1.1±0.3 at most recent follow-up for all patients. CT evidence showed 97.0% (64 patients) freedom from graft complication including: endocarditis, thrombosis, embolism, aneurysm, pseudoaneurysm, dehiscence, dissection and kinking. Conclusions The annual imaging data presented here demonstrates stability of the Dacron aortic annuloplasty reconstruction over time, without the need for internal or external annular stabilization. CT imaging proved to be far more reliable than echocardiographic images, however given the stability, annual CT imaging is of little benefit. This is the first prospective study to compare echocardiographic, CT and clinical data following VSRR.
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Affiliation(s)
- Matthew Valdis
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Andrew Thain
- Division of Cardiology, Department of Medicine, Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Philip M Jones
- Department of Anesthesia & Perioperative Medicine, Western University, London Health Sciences Centre, London, Ontario, Canada.,Department of Epidemiology & Biostatistics, Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Ian Chan
- Department of Radiology, Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, Ontario, Canada
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28
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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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29
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Toward standardization of valve-sparing root replacement and annuloplasty. Gen Thorac Cardiovasc Surg 2018; 66:685-691. [DOI: 10.1007/s11748-018-1015-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 09/11/2018] [Indexed: 12/14/2022]
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30
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Tanaka H, Takahashi H, Inoue T, Matsueda T, Oda T, Abe N, Nomura Y, Gotake Y, Okita Y. Which technique of cusp repair is durable in reimplantation procedure? Eur J Cardiothorac Surg 2018; 52:112-117. [PMID: 28498897 DOI: 10.1093/ejcts/ezx034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 01/18/2017] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES We aimed to ascertain the durability of cusp repair techniques used in reimplantation procedures. METHODS Between 2000 and 2015, 249 patients (mean age, 49 ± 17 years) with aortic insufficiency underwent the reimplantation procedure. The pathology was acute aortic dissection in 24 and non-dissection in 225 patients. Preoperative aortic regurgitation (AR) was absent in 9, 1+ in 19, 2+ in 20, 3+ in 71 and 4+ in 120 patients. The mean aortic root and ascending aortic diameters were 47 ± 9 mm and 38 ± 7 mm, respectively. The following techniques of cusp repair were used: none (83), central plication (130), free margin reinforcement (57) and patch repair (19). Annual echocardiography was performed. Freedom from moderate aortic insufficiency and aortic valve reoperation were calculated by the Kaplan-Meier method. Factors influencing the freedom from moderate or severe AR were calculated by proportional hazard analysis. RESULTS Mean follow-up period was 56 ± 44 months. Freedom from moderate or severe AR was 82%±3% and 77% ± 4% at 5 and 8 years, respectively, whereas freedom from aortic valve reoperation was 93%±8% and 87% ± 3% at 5 and 8 years, respectively. Recurrent AR and infection were causes of reoperation in 13 and 3 patients, respectively. Preoperative cusp prolapse, technique of free margin reinforcement used and patch repair were significant factors for recurrent AR by proportional hazard analysis. Central plication was not a significant factor for recurrent AR. CONCLUSIONS Preoperative cusp prolapse was a risk factor, whereas central plication was not a risk factor for recurrent AR. Free margin reinforcement had a positive effect, whereas patch repair had a negative effect on aortic valve durability.
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Affiliation(s)
- Hiroshi Tanaka
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Hiroaki Takahashi
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Takeshi Inoue
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Takashi Matsueda
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Tatsuya Oda
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Noriyuki Abe
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Yoshikatsu Nomura
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Yasuko Gotake
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Japan
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31
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Klotz S, Stock S, Sievers HH, Diwoky M, Petersen M, Stierle U, Richardt D. Survival and reoperation pattern after 20 years of experience with aortic valve–sparing root replacement in patients with tricuspid and bicuspid valves. J Thorac Cardiovasc Surg 2018; 155:1403-1411.e1. [DOI: 10.1016/j.jtcvs.2017.12.039] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 11/15/2017] [Accepted: 12/05/2017] [Indexed: 11/26/2022]
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32
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Tanaka H, Ikeno Y, Abe N, Takahashi H, Inoue T, Okita Y. Outcomes of valve-sparing root replacement in acute Type A aortic dissection. Eur J Cardiothorac Surg 2018; 53:1021-1026. [DOI: 10.1093/ejcts/ezx463] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 11/28/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Hiroshi Tanaka
- Department of Cardiovascular Surgery, Kobe University, Kobe, Japan
| | - Yuki Ikeno
- Department of Cardiovascular Surgery, Kobe University, Kobe, Japan
| | - Noriyuki Abe
- Department of Cardiovascular Surgery, Kobe University, Kobe, Japan
| | | | - Takeshi Inoue
- Department of Cardiovascular Surgery, Kobe University, Kobe, Japan
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Kobe University, Kobe, Japan
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33
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Bori Bata AK, D'Ostrevy N, Pereira B, Geoffroy E, Dauphin N, Eljezi V, Azarnoush K, Ulman L, Camilleri L. Valve-sparing aortic root replacement-midterm outcomes and quality of life. Cardiovasc Diagn Ther 2017; 7:572-580. [PMID: 29302462 DOI: 10.21037/cdt.2017.08.02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background This study evaluated the midterm outcomes, the valve related events and quality of life of patients treated by valve-sparing aortic root replacement (VSRR). Methods From January 2003 to December 2014, 88 consecutive patients diagnosed with an aortic root aneurysm or ascending aortic aneurysms underwent VSRR surgery. The mean age was 55±14 (range 19-77) years. A total of 84% of the patients were male; 89% were in New York Heart Association functional class I or II, 55% had aortic regurgitation (AR) grade III or IV. Twenty-four patients (27.3%) had bicuspid aortic valve. The mean left ventricular ejection fraction (LVEF) was 61%±9% (range 29-78%). Patients were yearly followed by family doctors and referent cardiologists. Doppler echocardiographic examinations were obtained annually in all patients. The midterm clinical, echocardiographic results and quality of life were analyzed. The mean follow-up was 5.3±3 (range 1-12) years. Results Hospital mortality was 1%. There were 10 late deaths (11%) including 5 cardiac cases. Two patients (2%) required an aortic valve or graft prosthesis reoperation. Aortic valve endocarditis occurred in two patients. Thromboembolic events were reported in three patients. None of the following morbidity has been observed: structural valve deterioration, nonstructural dysfunction, valve thrombosis, bleeding event. The 5- and 8-year survival were 92% and 88%, respectively. The 8-year survival free from cardiac death was 88%. The mean of EuroQoL visual analogue scale (EQ VAS) and EQ index were respectively 83±15 (range 30-100) and 0.94±0.12 (range 0.5-1). Conclusions Eight-year clinical improvement, function of the spared aortic valve and quality of life after valve sparing aortic root surgery appear excellent.
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Affiliation(s)
- Abdel-Kémal Bori Bata
- Heart Surgery Department, Clinical Research and Innovation Direction, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Nicolas D'Ostrevy
- Heart Surgery Department, Clinical Research and Innovation Direction, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistic's Unit, Clinical Research and Innovation Direction, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Etienne Geoffroy
- Heart Surgery Department, Clinical Research and Innovation Direction, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Nicolas Dauphin
- Heart Surgery Department, Clinical Research and Innovation Direction, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Vedat Eljezi
- Heart Surgery Department, Clinical Research and Innovation Direction, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Kasra Azarnoush
- Heart Surgery Department, Clinical Research and Innovation Direction, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Lucie Ulman
- Heart Surgery Department, Clinical Research and Innovation Direction, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Lionel Camilleri
- Heart Surgery Department, Clinical Research and Innovation Direction, Gabriel Montpied University Hospital, Clermont-Ferrand, France.,Clermont University, Université d'Auvergne, Clermont-Ferrand, France
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34
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Ouzounian M, Butany J, David TE. Reimplantation for Marfan syndrome: If it ain't broke…. J Thorac Cardiovasc Surg 2017; 155:52-53. [PMID: 28969850 DOI: 10.1016/j.jtcvs.2017.08.085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 08/26/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Maral Ouzounian
- Peter Munk Cardiac Centre, Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Jagdish Butany
- Department of Pathology, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
| | - Tirone E David
- Peter Munk Cardiac Centre, Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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35
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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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36
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Stephens EH, Fukuhara S, Neely RC, Takayama H. Aortic root replacement for bicuspid aortopathy following heart transplantation. J Card Surg 2017; 32:667-669. [PMID: 28960491 DOI: 10.1111/jocs.13215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Although donors with well-functioning bicuspid aortic valves (BAV) are not a contraindication for transplantation, BAV patients are at risk for long-term aortopathy and valve dysfunction. We report a case of a patient status-post heart transplant 13 years ago who presented to our institution with a BAV and severe aortic regurgitation associated with an aortic root aneurysm and underwent aortic root replacement.
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Affiliation(s)
- Elizabeth H Stephens
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Medical Center, New York, New York
| | - Shinichi Fukuhara
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Medical Center, New York, New York
| | - Robert C Neely
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Medical Center, New York, New York
| | - Hiroo Takayama
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Medical Center, New York, New York
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37
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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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Valve-sparing aortic root surgery. CON: remodeling. Gen Thorac Cardiovasc Surg 2017; 67:82-92. [DOI: 10.1007/s11748-017-0833-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 09/06/2017] [Indexed: 01/05/2023]
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Álvarez-Cabo R, Meana B, Díaz R, Hernández-Vaquero D, Mencía P, Martín M, de la Hera J, García-Campos A, Pascual C, Llosa JC, Morales C, Silva J. Reparación de prolapso de velo por rotura en válvula aórtica. CIRUGIA CARDIOVASCULAR 2017. [DOI: 10.1016/j.circv.2016.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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40
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Risk Factors for Late Aortic Valve Dysfunction After the David V Valve-Sparing Root Replacement. Ann Thorac Surg 2017; 104:1479-1487. [PMID: 28669506 DOI: 10.1016/j.athoracsur.2017.04.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 03/28/2017] [Accepted: 04/04/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Valve-sparing root replacement (VSRR) is an established therapy for aortic root pathology. However, late aortic valve dysfunction requiring reoperation remains a primary concern of this procedure. This study examines risk factors for late aortic insufficiency (AI) and aortic stenosis (AS) after David V VSRR. METHODS A retrospective review from 2005 to 2015 at a US academic center identified 282 patients who underwent VSRR. Cox proportional hazards regression analysis was used to identify risk factors for late AI and AS after VSRR. RESULTS The mean age was 46.4 years. Sixty-four patients (22.7%) had bicuspid valves, and 41 patients (14.5%) had Marfan syndrome. The incidence of reoperations was 27 (9.6%), and 42 cases (14.9%) presented with acute type A dissection. Operative mortality was 8 (2.8%). Seven-year survival was 90.9%. Seven-year cumulative incidence of reoperation, greater than 2+ AI and greater than moderate AS were 3.1%, 2.2%, and 0.8%, respectively. Multivariable analysis showed aortic root size 55 mm or larger (hazard ratio 3.44, 95% confidence interval: 1.27 to 9.29, p = 0.01) to be a risk factor for late AI whereas bicuspid valve (hazard ratio 16.07, 95% confidence interval: 3.12 to 82.68, p = 0.001) and cusp repair were found to be risk factors (hazard ratio 5.91, 95% confidence interval: 1.17 to 29.86, p = 0.03) for late AS. CONCLUSIONS Valve-sparing root replacement can be performed with low operative risk and good overall long-term survival even in complex clinical settings. Durable valve function can be expected; however, aortic root size 55 cm or more, bicuspid valve anatomy, and cusp repair represent independent risk factors for late aortic valve dysfunction after these procedures.
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Abstract
Prosthetic valve implantation is the most widely used therapeutic option for aortic regurgitation (AR), but complications associated with prosthetic valves, with an incidence of 3-5% patient/year, and the need for anticoagulation in mechanical valves, force us to consider aortic valve repair as an alternative to the prosthetic implant, especially in young people with many potential years of life for these complications. Aortic valve repair techniques are not excessively complicated, but there is no standardization, so they are not reproducible in all medical centers. There are multiple repair procedures, but to study them we can divide, arbitrarily, into two large groups, techniques for treatment of aortic root dilatation (reimplantation and remodeling); and repair techniques without treatment of the aortic root, that act on annulus and on aortic leaflets. The two sets of techniques are often used together, but it is easier to understand them if this arbitrary division is made. Our goal is to publish our experience and knowledge of repair techniques to facilitate their learning by other professionals. In this article, we will focus on the procedures on the aortic annulus and leaflets, because they can be applied in patients without aortic root dilatation, but they are also complementary to the reimplantation and remodeling techniques. We will present the procedures describing them individually, with an explanation in text accompanied by three videos in which the application of each technique is visualized in several cases. The standardization of sparing aortic valve techniques is difficult, because each patient requires its individualized application, yet we have tried to illustrate reproducible procedures so that professionals have more tools to deal with aortic valve-preserving surgery.
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Affiliation(s)
- Rubén Álvarez-Cabo
- Cardiac Surgery Department, Heart Area, Central University Hospital of Asturias (HUCA), Oviedo, Spain
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42
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Valve-Sparing Root Replacement Compared With Composite Valve Graft Procedures in Patients With Aortic Root Dilation. J Am Coll Cardiol 2016; 68:1838-1847. [DOI: 10.1016/j.jacc.2016.07.767] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 07/13/2016] [Accepted: 07/27/2016] [Indexed: 11/23/2022]
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43
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Bicuspid Aortic Insufficiency With Aortic Root Aneurysm: Root Reimplantation Versus Bentall Root Replacement. Ann Thorac Surg 2016; 102:1221-8. [DOI: 10.1016/j.athoracsur.2016.03.087] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 03/15/2016] [Accepted: 03/22/2016] [Indexed: 11/21/2022]
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Chiu P, Miller DC. Evolution of surgical therapy for Stanford acute type A aortic dissection. Ann Cardiothorac Surg 2016; 5:275-95. [PMID: 27563541 DOI: 10.21037/acs.2016.05.05] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Acute type A aortic dissection (AcA-AoD) is a surgical emergency associated with very high morbidity and mortality. Unfortunately, the early outcome of emergency surgical repair has not improved substantially over the last 20 years. Many of the same debates occur repeatedly regarding operative extent and optimal conduct of the operation. The question remains: are patients suffering from too large an operation or too small? The pendulum favoring routine aortic valve resuspension, when feasible, has swung towards frequent aortic root replacement. This already aggressive approach is now being challenged with the even more extensive valve-sparing aortic root replacement (V-SARR) in selected patients. Distally, open replacement of most of the transverse arch is best in most patients. The need for late aortic re-intervention has not been shown to be affected by more extensive distal operative procedures, but the contemporary enthusiasm for a distal frozen elephant trunk (FET) only seems to build. It must be remembered that the first and foremost goal of the operation is to have an operative survivor; additional measures to reduce late morbidity are secondary aspirations. With increasing experience, true contraindications to emergency surgical operation have dwindled, but patients with advanced age, multiple comorbidities, and major neurological deficits do not fare well. The endovascular revolution, moreover, has spawned innovative options for modern practice, including ascending stent graft and adaptations of the old flap fenestration technique. Despite the increasingly complex operations and ever expanding therapies, this life-threatening disease remains a stubborn challenge for all cardiovascular surgeons. Development of specialized thoracic aortic teams and regionalization of care for patients with AcA-AoD offers the most promise to improve overall results.
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Affiliation(s)
- Peter Chiu
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, CA, USA
| | - D Craig Miller
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, CA, USA
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David TE. Aortic Valve Sparing in Different Aortic Valve and Aortic Root Conditions. J Am Coll Cardiol 2016; 68:654-664. [DOI: 10.1016/j.jacc.2016.04.062] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 04/14/2016] [Accepted: 04/19/2016] [Indexed: 01/13/2023]
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Poggio P, Cavallotti L, Songia P, Di Minno A, Ambrosino P, Mammana L, Parolari A, Alamanni F, Tremoli E, Di Minno MND. Impact of Valve Morphology on the Prevalence of Coronary Artery Disease: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2016; 5:JAHA.116.003200. [PMID: 27194004 PMCID: PMC4889190 DOI: 10.1161/jaha.116.003200] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Literature studies suggested a lower prevalence of coronary artery disease (CAD) in bicuspid aortic valve (BAV) than in tricuspid aortic valve (TAV) patients. However, this finding has been challenged. We performed a meta‐analysis to assess whether aortic valve morphology has a different association with CAD, concomitant coronary artery bypass grafting (CABG), and postoperative mortality. Methods and Results Detailed search was conducted according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta‐Analyses) guideline to identify all patients with BAV or TAV and presence of CAD, concomitant myocardial surgical revascularization, and the postoperative mortality. Thirty‐one studies on 3017 BAV and 4586 TAV patients undergoing aortic valve surgery were included. BAV patients showed a lower prevalence of CAD (odds ratio [OR]: 0.33; 95% CI: 0.17, 0.65), concomitant CABG (OR, 0.45; 95% CI: 0.35, 0.59), and postoperative mortality (OR, 0.62; 95% CI: 0.40, 0.97) than TAV. However, BAV subjects were significantly younger than TAV (mean difference: −7.29; 95% CI: −11.17, −3.41) were more frequently males (OR, 1.61; 95% CI: 1.33, 1.94) and exhibited a lower prevalence of hypertension (OR, 0.58; 95% CI: 0.39, 0.87) and diabetes (OR, 0.71; 95% CI: 0.54, 0.93). Interestingly, a metaregression analysis showed that younger age and lower prevalence of diabetes were associated with lower prevalence of CAD (Z value: −3.03; P=0.002 and Z value: −3.10; P=0.002, respectively) and CABG (Z value: −2.69; P=0.007 and Z value: −3.36; P=0.001, respectively) documented in BAV patients. Conclusions Analysis of raw data suggested an association of aortic valve morphology with prevalence of CAD, concomitant CABG, and postoperative mortality. Interestingly, the differences in age and diabetes have a profound impact on prevalence of CAD between BAV and TAV. In conclusion, our meta‐analysis suggests that the presence of CAD is independent of aortic valve morphology.
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Affiliation(s)
| | - Laura Cavallotti
- Centro Cardiologico Monzino IRCCS, Milan, Italy Dipartimento di Medicina e Chirurgia, University of Milan, Italy
| | - Paola Songia
- Centro Cardiologico Monzino IRCCS, Milan, Italy Department of Pharmacological and Biomolecular Sciences, University of Milan, Italy
| | | | - Pasquale Ambrosino
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Liborio Mammana
- Centro Cardiologico Monzino IRCCS, Milan, Italy Dipartimento di Medicina e Chirurgia, University of Milan, Italy
| | - Alessandro Parolari
- Department of Biomedical Sciences for Health, University of Milan, Italy Unità Operativa di Cardiochirurgia e Ricerca Traslazionale, San Donato IRCCS, San Donato Milanese, Italy
| | - Francesco Alamanni
- Centro Cardiologico Monzino IRCCS, Milan, Italy Dipartimento di Medicina e Chirurgia, University of Milan, Italy
| | - Elena Tremoli
- Centro Cardiologico Monzino IRCCS, Milan, Italy Department of Pharmacological and Biomolecular Sciences, University of Milan, Italy
| | - Matteo Nicola Dario Di Minno
- Centro Cardiologico Monzino IRCCS, Milan, Italy Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
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Dhurandhar V, Parikh R, Saxena A, Vallely MP, Wilson MK, Black DA, Tran L, Reid C, Bannon PG. Early and Late Outcomes Following Valve Sparing Aortic Root Reconstruction: The ANZSCTS Database. Heart Lung Circ 2016; 25:505-11. [DOI: 10.1016/j.hlc.2015.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 09/20/2015] [Accepted: 10/27/2015] [Indexed: 10/22/2022]
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Long-term outcomes of aortic root operations for Marfan syndrome: A comparison of Bentall versus aortic valve-sparing procedures. J Thorac Cardiovasc Surg 2016; 151:330-6. [DOI: 10.1016/j.jtcvs.2015.10.068] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 09/23/2015] [Accepted: 10/06/2015] [Indexed: 10/22/2022]
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Kari FA, Doll KN, Hemmer W, Liebrich M, Sievers HH, Richardt D, Reichenspurner H, Detter C, Siepe M, Czerny M, Beyersdorf F. Survival and freedom from aortic valve-related reoperation after valve-sparing aortic root replacement in 1015 patients. Interact Cardiovasc Thorac Surg 2015; 22:431-8. [DOI: 10.1093/icvts/ivv354] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 11/16/2015] [Indexed: 11/14/2022] Open
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50
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Kari FA, Doll KN, Hemmer W, Liebrich M, Sievers HH, Richardt D, Reichenspurner H, Detter C, Siepe M, Czerny M, Beyersdorf F. Residual and Progressive Aortic Regurgitation After Valve-Sparing Root Replacement: A Propensity-Matched Multi-Institutional Analysis in 764 Patients. Ann Thorac Surg 2015; 101:1500-6. [PMID: 26704413 DOI: 10.1016/j.athoracsur.2015.10.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/23/2015] [Accepted: 10/01/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Residual/progressive aortic regurgitation (rAR, pAR) after valve-sparing aortic root replacement (V-SARR) can lead to reoperations. We sought to characterize risk factors of mild rAR and pAR after V-SARR in a multicenter cohort. The effect of additional cusp repair on valve function was analyzed using propensity matching. METHODS A total of 1,015 patients after V-SARR were identified with (n = 288, 28%) or without additional cusp/commissure repair (n = 727, 72%) at four cardiac units in Germany. A total of 764 patients fulfilling transthoracic echocardiography follow-up-criteria comprised the study cohort. Logistic regression was used for risk factor analysis with endpoints rAR, new onset AR, and pAR. t tests and analyses of variance were used for between-group differences. The effects of additional cusp repair on valve function were studied comparing propensity-matched quintiles. RESULTS The incidence of rAR was 29%, with influencing factors aneurysm size (p = 0.07) and preoperative aortic valve function (p = 0.08). It was found more often among nonsyndromic patients (34% vs. 14%; OR, 0.4; p < 0.001). Progression of rAR was detectable in 30% after a mean of 4.3 years. The progression rate of rAR ∼ 0.3 grades per patient-year within the first 5 years. When quintiles identified by propensity score were compared, additional cusp repair was linked to new onset AR (p = 0.016) while it was not linked to rAR (p = 0.14) or pAR (p = 0.5). CONCLUSIONS The incidences of rAR and pAR are considerable after V-SARR. Patients should be operated on before large aneurysms are present. New onset AR after an initially good functional result is more likely after an additional cusp repair, while rAR and pAR are not influenced by cusp repair.
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Affiliation(s)
- Fabian A Kari
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.
| | | | | | | | - Hans-Hinrich Sievers
- Department of Heart and Thoracic Vascular Surgery, University Hospital Lübeck, Lübeck, Germany
| | - Doreen Richardt
- Department of Heart and Thoracic Vascular Surgery, University Hospital Lübeck, Lübeck, Germany
| | | | | | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
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