Standardized approach to valve repair using an expansible aortic ring versus mechanical Bentall: early outcomes of the CAVIAAR multicentric prospective cohort study

Aortic Valve Repair Results in Better 1-Year Survival Than Replacement: Results From German Aortic Valve Registry

BACKGROUND

Aortic valve (AV) repair is an evolving surgical strategy in the treatment of nonelderly adults with aortic regurgitation. We aimed to determine the 1-year outcome after AV repair vs surgical AV replacement (sAVR) using real-world data from the German Aortic Valve Registry.

METHODS

A total of 8076 aortic regurgitation patients (mean age, 59.1 ± 15.0 years; 76% men; mean The Society of Thoracic Surgeons score, 1.3 ± 1.1), who underwent AV surgical procedures between 2011 and 2015, were identified from German Aortic Valve Registry. The AV was repaired in 2327 patients (29%), and the remaining 5749 patients (71%) underwent sAVR. A weighted propensity score model, including the variables of age, sex, and The Society of Thoracic Surgeons score, was used to correct for baseline differences between AV repair and sAVR cohorts. The primary end point was 1-year survival after AV repair vs sAVR. Secondary end points were freedom from cardiac events and AV reinterventions.

RESULTS

Survival at 1 year was 97.7% (95% CI, 97.0%-98.5%) in the AV repair cohort vs 96.4% (95% CI, 95.9%-96.9%) in the propensity score-weighted sAVR cohort (log-rank P < .001). Cox regression revealed a significant advantage of AV repair vs sAVR (hazard ratio, 0.68; 95% CI, 0.51-0.90; P < .0001) on 1-year survival, which was independent of age. Cardiac event-free survival at 1 year was 85.7% (95% CI, 483.8%-87.7%) in the AV repair group vs 81.7% (95% CI, 80.7%-82.9%) in the sAVR group (log-rank P < .001). AV reintervention was required in 38 AV repair patients (1.6%) compared with 1.6% in the sAVR cohort (P = .59).

CONCLUSIONS

AV repair surgery, whenever intraoperatively feasible, is associated with a significantly better 1-year survival and 1-year cardiac event-free survival compared with sAVR.

Novel Expansible Aortic Annuloplasty Ring Exhibits Similar Characteristics as the Dacron Ring-an In Vitro Evaluation

An increasing body of research indicates that annular stability plays a key role for a successful aortic valve repair. The aim of this study was to evaluate and compare a novel open aortic annuloplasty ring (the A-ring) with the Dacron ring. Both rings were compared with native aortic roots in vitro. Eighteen aortic roots were included in the study and randomized into three groups: the native, Dacron, and A-ring group. The roots were evaluated in an in vitro physiologic pulsatile model simulating the left side of the heart. Aortic annulus diameters were significantly reduced both in the Dacron ring group (p = 0.003) and the A-ring group (p = 0.020) when compared with the native group. Both the Dacron ring and A-ring effectively downsized the aortic annulus diameter. The A-ring also displayed an ability to maintain aortic root distensibility during the cardiac cycle equally to the Dacron ring.

Outcomes of aortic valve-sparing root replacement with cusp repair in connective tissue disease

BACKGROUND

Although, valve sparing is commonly performed in patients with Marfan syndrome, feasibility and results of cusp repair for aortic insufficiency have not been studied.

AIM

To report on the outcomes and durability of aortic cusp repair in valve sparing in patients with Marfan syndrome.

METHODS

All consecutive adult patients with Marfan syndrome who underwent remodelling and annuloplasty with aortic valve repair for aortic insufficiency between May 2005 and December 2020 were included. Patients with Marfan syndrome treated for aortic aneurysm, but without aortic insufficiency, were excluded. Data were collected prospectively and reviewed retrospectively from the Aorticvalve repair International Registry (AVIATOR).

RESULTS

During the study period, 71 patients with Marfan syndrome were referred to surgery. Fifty-five patients with connective tissue disease and aortic insufficiency with aorta aneurysm were treated: 46 underwent aortic valve repair and nine underwent aortic valve replacement (five mechanical aortic valve replacements and four biological aortic valve replacements). The mean age was 42.9±15.4 years, and the mean EuroScore II was 2.5±2.2. No patient died, and no patient had significant aortic insufficiency (grade≥II) at discharge. The 5-year survival rate estimate was 94.4%, which seems statistically similar to that of the age- and sex-matched general population. At 5 years, freedom from reoperation was 94.6%, and the incidence of infective endocarditis was 2.6%. No valve thrombosis, aortic dissection, major bleeding events, thromboembolic events (stroke) or myocardial infarctions were noted during follow-up.

CONCLUSION

Remodelling and aortic valve repair showed excellent durability at 5 years, even in connective tissue disorders.

Outcomes of aortic valve repair: early results from the German Aortic Valve Registry

OBJECTIVES

Aortic valve (AV) repair is an evolving surgical strategy in the treatment of young patients with aortic regurgitation (AR) and/or aortic root aneurysm. We aimed to determine the clinical outcome following AV repair/AV sparing root surgery using real-world data from the German Aortic Valve Registry (GARY).

METHODS

A total of 2327 patients with AR (mean age 55.2 ± 15.0 years, 76% men), who underwent AV repair/AV sparing root surgery between 2011 and 2015 (i.e., 5% of 42.868 AV surgery patients enrolled in the GARY registry during the same period) were included. Study cohort was subdivided according to the technique of AV repair: isolated AV repair without root surgery (Group I) (n = 914), AV sparing root surgery (i.e., reimplantation or remodelling) without cusp repair (Group II) (n = 1077), and AV sparing root surgery (i.e., reimplantation or remodelling) with simultaneous cusp repair (Group III) (n = 336). Primary end-point was 1-year survival after AV repair/AV sparing root surgery. Secondary end-points were freedom from cardiac adverse events and freedom from AV reinterventions at 1-year follow-up.

RESULTS

30-day mortality was 19 (0.8%) in the whole study cohort without significant differences in the three subgroups (4 (0.4%) patients in Group I vs 14 (1.3%) patients in the Group II vs 1 (0.3%) patient in the Group III (p = 0.054)). Postoperatively, 1445 (74%) patients had no residual AR, 474 (24%) patients had mild AR, and 40 (2%) patients had moderate/severe AR at the time of hospital discharge. One-year survival (95% CI) was 97.7% (97.1-98.3) in the whole study cohort and without significant difference among the three subgroups. One-year cardiac adverse event-free survival (95% CI) was 85.7% (84.2-87.1) and was similar in all three study groups in propensity-score weighted analysis. A total of 38 (1.6%) patients required AV reintervention during a 1-year follow-up, without significant difference among subgroups (p = 0.11).

CONCLUSIONS

AV repair/AV sparing root surgery is performed in 5% of patients requiring AV surgery in Germany. Our data demonstrate very satisfactory periprocedural and 1-year survival and cardiac event-free survival after AV repair surgery. Implementation of specific surgical techniques during the index procedure seems to result in comparable outcomes.

Aortic valve repair versus mechanical valve replacement for root aneurysm: The CAVIAAR Multicentric Study

AIMS

Despite growing evidence that aortic valve repair improves long-term patient outcomes and quality of life, aortic valves are mostly replaced. We evaluate the effect of aortic valve repair versus replacement in patients with dystrophic aortic root aneurysm up to 4 years.

METHODS

The multicentric CAVIAAR prospective cohort study enrolled 261 patients: 130 underwent standardized aortic valve repair (REPAIR) consisting of remodelling root repair with expansible aortic ring annuloplasty, and 131 received mechanical composite valve and graft replacement (REPLACE). Primary outcome was a composite criterion of mortality, reoperation, thromboembolic or major bleeding events, endocarditis or operating site infections, pacemaker implantation and heart failure, analyzed with propensity score-weighted Cox model analysis. Secondary outcomes included Major Adverse Valve Related Events (MAVRE) and components of primary outcome.

RESULTS

Mean age was 56.1 years, valve was bicuspid in 115 patients (44.7%). Up to 4 years, REPAIR did not significantly differ from REPLACE in terms of primary outcome (HR 0.66 [0.39; 1.12]), but showed significantly less valve-related deaths (HR 0.09 [0.02; 0.34]) and major bleeding events (HR 0.37 [0.16; 0.85]) without an increased risk of valve-related reoperation (HR 2.10 [0.64; 6.96]). When accounting for occurrence of multiple events in a single patient, REPAIR group had half the occurrence of MAVRE (RR 0.51 [0.31; 0.86]).

CONCLUSION

Although primary outcome did not significantly differ between REPAIR and REPLACE group, the trend is in favour of REPAIR by a significant reduction of valve-related deaths and major bleeding events. Long-term follow-up beyond 4 years is needed to confirm these findings.

[Aortic root remodeling and aortic valve annuloplasty in patients with aortic root aneurysm and no severe aortic valve disease]

OBJECTIVE

Analysis of the outcomes after aortic root remodeling with aortic valve annuloplasty in patients with aortic root aneurysm and no severe aortic valve disease.

MATERIAL AND METHODS

There were 19 patients with connective tissue dysplasia, aneurysm of aortic root and/or ascending aorta and aortic regurgitation between September 2020 and December 2021. All patients underwent aortic root remodeling with aortic valve annuloplasty.

RESULTS

Mean time of cardiopulmonary bypass was 148.7±23.5 min, aortic clamping - 117.3±19.5 min. According to postoperative transthoracic echocardiography, mild aortic regurgitation was observed in 6 patients, 13 patients had no regurgitation. There was no in-hospital mortality or significant cardiovascular complications. Freedom from moderate-to-severe aortic regurgitation after 14 months was 94.7%, overall survival - 100%.

CONCLUSION

Aortic root remodeling is characterized by favorable hemodynamic efficiency and low complication rate. Further accumulation of data with clinical analysis are planned for a more accurate assessment of effectiveness of surgical treatment, determination of predictors of successful reconstruction, development of indications, contraindications and a personalized algorithm for patient selection.

[In-hospital and mid-term results of aortic root remodeling and aortic valve annuloplasty in patients with aortic root aneurysm and no severe aortic valve disease]

OBJECTIVE

To analyze early and mid-term results of aortic root remodeling with aortic valve annuloplasty in patients with aortic root aneurysm and no severe aortic valve disease.

MATERIAL AND METHODS

There were 33 patients with connective tissue dysplasia, aneurysm of aortic root and/or ascending aorta and aortic regurgitation between September 2019 and December 2022. All patients underwent aortic root remodeling with aortic valve annuloplasty.

RESULTS

Mean time of cardiopulmonary bypass was 138.5±21.5 min, aortic clamping - 115.3±20.5 min. According to postoperative transthoracic echocardiography, mild aortic regurgitation was observed in 28 patients, 5 patients had moderate regurgitation. Postoperative follow-up period varied from 3 months to 2 years. There was no in-hospital mortality or significant cardiovascular complications. Two-year freedom from moderate-to-severe aortic regurgitation was 93.9%, overall survival - 100%.

CONCLUSION

Aortic root remodeling is characterized by favorable hemodynamic efficiency and low complication rate.

Systematic review and meta-analysis of aortic valve-sparing surgery versus replacement surgery in ascending aortic aneurysms and dissection in patients with Marfan syndrome and other genetic connective tissue disorders

Background

Aortic aneurysm and dissection are important causes of morbimortality in patients with Marfan syndrome (MFS) and other connective tissue diseases that affect the cardiovascular tissues. Timely intervention through different surgical techniques improves the prognosis. Both sparing and replacement-type interventions of the aortic valve are used, but selection depends on the condition of the patient at the time of diagnosis, the patient's emergency condition, surgeon preference and hospital resources. Previous meta-analyses have suggested an advantage with the use of sparing-type interventions, but this finding must be updated and extended to patients with other connective tissue disorders. The objetive of this study is to evaluate the outcomes of valve-sparing root replacement versus aortic root replacement procedures in patients with MFS and similar connective tissue diseases that present with aortic aneurysm or dissection.

Methods

A systematic review of cohort studies that evaluated sparing-type (preserving, remodeling, reimplantation, Yacoub, David or Florida Sleeve) or replacement-type (repair, Bentall, Button-Bentall, composite valve graft or Cabrol) procedures in patients with Marfan, Loeys-Dietz, Beals-Hecht or Ehlers-Danlos syndromes was done. Studies were retrieved from the SCOPUS, MEDLINE, CINAHL, EMBASE and LILACS electronic databases up to January 2020 without language restrictions. Only studies that directly compared sparing- versus replacement-type procedures were included in the meta-analysis.

Results

A total of 33 studies (n=1,807 subjects) reported sparing-type surgical interventions and 26 studies (n=2,218 subjects) reported replacement-type surgical interventions. Pooled rates of endocarditis, thromboembolism and aneurysm were higher in replacement-type surgical intervention studies. Sixteen studies were included in the meta-analysis. Sparing-type interventions were associated with a reduced risk of endocarditis (RR =0.13, 95% CI: 0.03-0.61); however, replacement-type interventions favored freedom from valve reoperation (RR =2.39, 95% CI: 1.24-4.60). All studies were at low risk of bias.

Conclusions

The choice of the best surgical technique is dependent on the type of disease (MFS or other connective tissue diseases) as well as the accompanying aortic and cardiovascular damage, since these key factors are heterogeneous. Although the results of this meta-analysis tend to show some advantages for one type of surgical intervention over the other and viceversa, the surgeon can only make the best decision during the surgical act.

Effect of Valve Height on the Opening and Closing Performance of the Aortic Valve Under Aortic Root Dilatation

Patients with aortic valve disease can suffer from valve insufficiency after valve repair surgery due to aortic root dilatation. The paper investigates the effect of valve height (Hv) on the aortic valve opening and closing in order to select the appropriate range of Hv for smoother blood flow through the aortic valve and valve closure completely in the case of continuous aortic root dilatation. A total of 20 parameterized three-dimensional models of the aortic root were constructed following clinical surgical guidance. Aortic annulus diameter (DAA) was separately set to 26, 27, 28, 29, and 30 mm to simulate aortic root dilatation. H_V value was separately set to 13.5, 14, 14.5, and 15 mm to simulate aortic valve alterations in surgery. Time-varying pressure loads were applied to the valve, vessel wall of the ascending aorta, and left ventricle. Then, finite element analysis software was employed to simulate the movement and mechanics of the aortic root. The feasible design range of the valve size was evaluated using maximum stress, geometric orifice area (GOA), and leaflet contact force. The results show that the valve was incompletely closed when H_V was 13.5 mm and D_AA was 29 or 30 mm. The GOA of the valve was small when H_V was 15 mm and D_AA was 26 or 27 mm. The corresponding values of the other models were within the normal range. Compared with the model with an H_V of 14 mm, the model with an H_V of 14.5 mm could effectively reduce maximum stress and had relatively larger GOA and less change in contact force. As a result, valve height affects the performance of aortic valve opening and closing. Smaller H_V is adapted to smaller D_AA and vice versa. When H_V is 14.5 mm, the valve is well adapted to the dilatation of the aortic root to enhance repair durability. Therefore, more attention should be paid to H_V in surgical planning.

Current trends in aortic valve-preserving surgery

The natural history of aortic regurgitation is not as benign as once believed, even in asymptomatic patients with preserved left ventricular function. Aortic valve surgery can prolong survival in these patients. However, both mechanical and biological aortic valve replacement have major disadvantages, especially in young patients. Aortic valve-preserving surgery has attracted a great deal of attention because it has a significant survival benefit over replacement. Nonetheless, aortic valve-preserving surgery has not been widely adopted due to the complexity of the technique and assessment (i.e., long learning curve). With recent technical and theoretical advances, aortic valve-preserving surgery has increasingly been performed with better outcomes, and therefore earlier surgical intervention in cases of aortic regurgitation has been considered. Recent advances in aortic valve-preserving surgery include repair-oriented classification of the etiology of aortic regurgitation, objective assessment of the cusp configuration (i.e., effective height and geometric height), use of aortic annuloplasty, introduction of two reproducible valve-sparing root replacement procedures (i.e., aortic valve reimplantation and aortic root remodeling techniques), standardization of aortic valve-preserving surgery, and assessment of cusp configuration with aortoscopy. A number of prospective multicenter studies are currently underway and will clarify the role of aortic valve-preserving surgery in the treatment of aortic regurgitation in the near future.

Aortic annulus and the importance of annuloplasty

Dystrophic aortic insufficiency accounts for the majority of Western cases of aortic insufficiency and can be divided into the three phenotypes of isolated aortic insufficiency, dilated aortic root, and dilated ascending aorta. Each of these phenotypes is associated with a dilated annulus and/or sinotubular junction. Recent international guidelines recommend reimplantation or remodeling with aortic annuloplasty for valve-sparing root replacement, as well as consideration of aortic valve repair in cases of aortic insufficiency. A dilated aortic annulus is a major risk factor for failure of aortic valve repair procedures, indicating the need to address the annulus at the time of aortic valve or root repair. Calibrated annuloplasty should be performed at sub- and supravalular levels in order to restore the ratio of the sinotubular junction and annulus and be adapted according to the phenotype of the root and ascending aorta. Standardization of aortic valve repair techniques with use of a calibrated annuloplasty will improve dissemination of techniques and rate of aortic valve repair. Current medical evidence shows that aortic valve repair is safe, produces better quality of life, and reduces valve-related mortality compared to prosthetic valve replacement.

Aortic root remodeling with external annuloplasty for acute type A aortic dissection: Midterm results

BACKGROUND

To evaluate the role of aortic root remodeling with external aortic annuloplasty (ARREAA) in acute type A aortic dissection (AAAD).

METHODS

From May 2011 to May 2020, 59 patients out of 240 with AAAD underwent ARREAA. Data were retrospectively collected and analyzed.

RESULTS

The mean age was 61.4 ± 8.6 years and 43 patients were males (73%). Hemiarch and total arch replacement were performed in 37 (62.7%) and 14 (23.7%) patients. An aortic valvuloplasty was performed in seven patients (11.8%). Five patients (8.5%) required coronary artery bypass graft. Re-exploration for bleeding was required in six patients (10.1%). The 30-day mortality rate was 18.6%. Preoperative hemodynamic instability (odds ratio [OR] = 8.57, 95% confidence interval [CI] = 1.57-46.71; p = 0.013), consciousness disorder (OR = 19.18, 95% CI = 3.02-121.72]; p = 0.002) or myocardial ischemia (OR = 6.28, 95% CI = 1.27-31.10; p = 0.013) were significantly associated with postoperative mortality. No patient was reoperated for aortic valve during the postoperative period. One patient suffered a stroke postoperatively with partial recovery. Kidney failure requiring temporary dialysis occurred in 12 patients (20.3%). At discharge, a transthoracic echocardiogram showed moderate aortic regurgitation (AR; grade 2) in two patients. During follow-up (mean = 58.4 ± 32.4 months), three patients died. The rate of mortality was 6.2%. Actuarial survival at 5 years was 76.3%. No patient required reoperation on the proximal aorta or aortic valve. At 4 years, freedom from any aortic valve or root reintervention and AR > 2 were both 100%.

CONCLUSION

In a center with expertise in valve-sparing procedures, ARREAA is a reasonable option in the surgical management of AAAD in selected patients. This technique stabilizes the aortic annulus and preserves root anatomy for durable outcomes.

Valve sparing root replacement: an update

PURPOSE OF REVIEW

Until the year 2000, the publications concerning aortic valve sparing (AVS) did not exceed 20 articles; in the following years almost 300 publications have appeared. Over 35 years from the introduction of valve sparing techniques and 500 years after the death of Leonardo da Vinci, this review highlights the significant steps in modern imaging techniques and the excellent clinical results in the field of reconstructive aortic root surgery.

RECENT FINDINGS

AVS operations underwent significant modifications over the last few years making it reproducible with satisfactory outcomes. The extraordinary potential of imaging opens new boundless horizons in the perspective of an increasingly patient-tailored surgical planning. The basic surgical concepts include the preservation and resuspension of the aortic valve in a near-normal environment (with the creation of functionally suited neo-aortic sinuses) and the re-establishment of a normal relationship of the aortic root components.

SUMMARY

Today is possible to perform a reimplantation procedure with the creation of neo-sinuses or a remodeling procedure with the addition of annular support. Both procedures can now guarantee an anatomical root reconstruction and an increased long-term durability. AVS operations have become established alternatives to Bentall procedures for patients with aortic root pathology, especially in young patients.

Valve-Sparing Root Replacement Versus Composite Valve Grafting in Aortic Root Dilation: A Meta-Analysis

BACKGROUND

Aortic valve-sparing operations theoretically have fewer stroke and bleeding complications but may increase late reoperation risk versus composite valve grafts.

METHODS

We meta-analyzed all studies comparing aortic valve-sparing (reimplantation and remodelling) and composite valve-grafting (bioprosthetic and mechanical) procedures. Early outcomes were all-cause mortality, reoperation for bleeding, myocardial infarction, and thromboembolism/stroke. Long-term outcomes included all-cause mortality, reintervention, bleeding, and thromboembolism/stroke. Studies exclusively investigating dissection or pediatric populations were excluded.

RESULTS

A total of 3794 patients who underwent composite valve grafting and 2424 who underwent aortic valve-sparing procedures were included from 9 adjusted and 17 unadjusted observational studies. Mean follow-up was 5.8 ± 3.0 years. Aortic valve sparing was not associated with any difference in early mortality, bleeding, myocardial infarction, or thromboembolic complications. Late mortality was significantly lower after valve sparing (incident risk ratio, 0.68; 95% confidence interval [CI], 0.54-0.87; P < .01). Late thromboembolism/stroke (incident rate ratio, 0.36; 95% CI, 0.22-0.60; P < .01) and bleeding (incident rate ratio, 0.21; 95% CI, 0.11-0.42; P < .01) risks were lower after valve sparing. Procedure type did not affect late reintervention.

CONCLUSIONS

Aortic valve sparing appears to be safe and associated with reduced late mortality, thromboembolism/stroke, and bleeding compared with composite valve grafting. Late durability is equivalent. Aortic valve sparing should be considered in patients with favorable aortic valve morphology.

[aortic root remodeling with external aortic ring annuloplasty]

An efficacy and safety of valve-sparing aortic root surgery with aortic ring annuloplasty have been demonstrated in various trials. The main technical features of aortic root remodeling with external aortic ring annuloplasty are reported in the article.

Aortic Valve Surgery in Nonelderly Patients: Insights Gained From AVIATOR

Aortic valve surgery in non-elderly patients represents a very challenging patient population. The younger the patient is at the point of aortic valve intervention, the longer their anticipated life expectancy will be, with longer exposure to valve-related complications and risk for re-operation. Although the latest international guidelines recommend aortic valve repair in patients with aortic valve insufficiency, what we see in the real world is that the vast majority of these aortic valves are replaced. However, current prosthetic valves has now been shown to lead to significant loss of life expectancy for non-elderly patients up to 50% for patients in their 40s undergoing mechanical aortic valve replacement. Bioprostheses carry an even worse long-term survival, with higher rates of re-intervention. The promise of trans-catheter valve-in-valve technology is accentuating the trend of bioprosthetic implantation in younger patients, without yet the appropriate evidence. In contrast, aortic valve repair has shown excellent outcomes in terms of quality of life, freedom from re-operation and freedom from major adverse valve-related events with similar life expectancy to general population as it is also found for the Ross procedure, the only available living valve substitute. We are at a time when the paradigm of aortic valve surgery needs to change for the better. To better serve our patients, we must acquire high quality real-world evidence from multiple centers globally - this is the vision of the AVIATOR registry and our common responsibility.

Aortic Valve Repair: From Concept to Future Targets

Aortic valve repair has become an important treatment alternative to patients with aortic insufficiency. In this paper, we review refinements and advances in the understanding of core concepts of aortic valve anatomy and pathophysiology which have enhanced our approach to aortic valve preservation and repair. With these improvements in understanding and techniques, the outcome for aortic valve repair continues to improve. We also review current challenges in the field and explore potential areas of innovation and future study including timing of surgical intervention for aortic insufficiency, comparisons between aortic valve repair and replacement in randomized trials, and development of personalized surgical management plan based on patient-specific pathologies. These advances will further establish the role of aortic valve repair in the management of aortic valve and aortic disease.

Rationale for aortic annuloplasty to standardise aortic valve repair

Available evidence shows that aortic valve repair reduces valve-related mortality and improves quality of life compared to prosthetic aortic valve replacement. One of the most important predictors of bicuspid and tricuspid aortic valve repair failure is the absence of treating a dilated aortic annulus greater than 25-28 mm. Competency of the aortic valve depends on multiple factors including the diameter of the annulus, sinotubular junction, valve cusps and commissures. Dystrophic aortic insufficiency (AI) is the commonest cause of AI in the Western world and is characterised by dilatation of the aortic annulus (≥25 mm), sinuses and/or sinotubular junction (≥30 mm). Depending on whether the sinuses of Valsalva and/or tubular ascending aorta are dilated, three phenotypes can be identified: dilated aortic root, dilated ascending aorta and isolated AI. All three phenotypes are associated with a dilated aortic annulus. Aortic annuloplasty reduces the dilated aortic annulus and improves the surface of coaptation, as in the case of mitral valve repair. In treating AI, it is also important to restore the physiological sinotubular junction/annulus ratio, which can be carried out with remodeling root repair + subvalvular annuloplasty (for dilated aortic root), tubular ascending aorta replacement + subvalvular annuloplasty (for dilated ascending aorta) and double sub- and supra-valvular annuloplasty (for isolated AI). Aortic annuloplasty is now considered an essential component of aortic valve repair and valve-sparing root surgery.

Valve-sparing root replacement and composite valve graft replacement in patients with aortic regurgitation: From the Japan Cardiovascular Surgery Database

OBJECTIVES

The advantage of valve-sparing root replacement (VSRR) over aortic root replacement with a composite valve graft (CVG) remains unclear. We compared these 2 procedures with regard to early outcomes with propensity score matching using the Japan Cardiovascular Surgery Database.

METHODS

Of 5303 patients from the Japan Cardiovascular Surgery Database who had undergone aortic root replacement in 2008 to 2017, emergent/urgent or redo cases and those with infective endocarditis or aortic stenosis were excluded (included n = 3841). Two propensity score-matched groups treated with VSRR or CVG replacement (n = 1164 each) were established.

RESULTS

Overall, VSRR was more frequently performed for younger patients with Marfan syndrome with lower operative risk and aortic regurgitation grade compared with CVG replacement. After matching, a weaker but similar trend still existed in baseline characteristics. Although more concomitant procedures were performed in the CVG group, myocardial ischemia and cardiopulmonary bypass time was significantly longer in the VSRR group (median, 193 and 245 minutes) than the CVG group (172 and 223 minutes, both P < .01). The CVG group was associated with a significantly greater incidence of postoperative stroke (2.5% vs 1.1%, P = .01) and prolonged ventilation >72 hours (7.0% vs 4.6%, P = .02). In-hospital mortality rates were significantly greater in the CVG group (1.8%) than the VSRR group (0.8%, P = .02).

CONCLUSIONS

In overall Japanese institutions, VSRR was more frequently performed for patients at low risk and was associated with better morbidity and mortality rates than CVG replacement. After matching, VSRR was also associated with better morbidity and mortality rates despite longer procedure time.

Aortic and mitral valve repair for anterior mitral leaflet perforation caused by severe aortic regurgitation

A 23-year-old man presented with acute onset of dyspnea on exert. Preoperative echocardiography showed a severe regurgitation of the bicuspid aortic valve (due to prolapse of the fused cusp) creating a jet directed through the defect in the anterior leaflet of the mitral valve. Both valves were repaired. Endocarditis was excluded with cultures and polymerase chain reaction (PCR). Postoperative course was uneventful.

Impact of aortic root annuloplasty on 3D aortic root geometry

BACKGROUND

The aim was to evaluate the impact of aortic root (AoR) annuloplasty on 3D AoR deformation.

METHODS

In experimental setup, Yacoub procedure and Yacoub with annuloplasty were performed. Results were compared to native AoR. In each AoR modality, six microsonometric (2 mm, 200 Hz) crystals were implanted at the sinotubular junction (STJ) and at the AoR base (AoB). 3D deformation of the AoR was determined by AoR tilt (α) and rotation (β) angle changes.

RESULTS

Tilt angle in Yacoub AoR with annuloplasty and in Yacoub AoR was maximal at ejection, 26.71 ± 0.18° and 24.91 ± 0.13°, respectively, and minimal at diastole, 25.34 ± 0.15° and 21.90 ± 0.15°, respectively. Rotation angle in Yacoub AoR with and without annuloplasty was maximal at ejection, 27.04 ± 0.25° and 23.53 ± 0.54°, respectively, and minimal at diastole, 24.84 ± 0.14° and 21.62 ± 0.16°, respectively. In native AoR, tilt angle and rotation were minimal at ejection, 14.34 ± 0.81° and 18.1 ± 3.20°, respectively, and maximal at diastole, 18.78 ± 0.84° and 21.23 ± 021°, respectively. AoB and STJ had maximal expansion at ejection; 2.59 ± 2.40% and 6.05 ± 0.66 for Yacoub and 3.75 ± 0.66% and 3.08 ± 0.24% for Yacoub with annuloplasty. In native AoR, the expansion at ejection for AoB was 7.13 ± 2.68% and for STJ was 16.42 ± 0.63%.

CONCLUSIONS

AoB annuloplasty reduces AoB deformation and has an impact on STJ dynamics. In both the Yacoub AoR modalities, during ejection, the AoR takes on more of a cone-like geometry, whereas in native AoR, it is of a cylinder-like shape.

Long-Term Outcome of Aortic Root Remodeling for Patients With and Without Acute Aortic Dissection

BACKGROUND

Valve-preserving aortic surgery is increasingly used in acute aortic dissection type A (AADA). The object of this study was to compare the long-term results of aortic root remodeling (remodeling) for patients with and without AADA.Methods and Results:Between October 1995 and December 2013, 776 patients underwent valve-preserving root replacement, of whom 59 patients with AADA (<2 weeks from onset, 56±16 years, 48 male) underwent remodeling (the remodeling-group); 7 patients had bicuspid anatomy (12%), 3 had Marfan syndrome (5%), and 1 had undergone previous cardiac surgery (2%). For this analysis the control group of patients who underwent remodeling for stable aneurysm (n=59) was generated using a propensity score matching. The long-term outcomes regarding survival and reoperation on the aortic valve were compared between the 2 groups. Pre- and intraoperative patients' characteristics were comparable between groups. Early death was 7% in the AADA group and 3% in the control group (P=0.40). Actuarial survival at 10 years of the AADA group (72±6%) was insignificantly lower than that of the control group (83±5%) (P=0.16). Freedom from reoperation at 10 years was similar (AADA group: 98±2%, control group: 97±3%, P=0.99). Multivariable Cox's proportional hazards model could not identify an independent predictor for late reoperation but advanced age for late death.

CONCLUSIONS

Long-term stability of remodeling was comparable between patients with and without AADA.

Impact of synthetic elements on aortic root haemodynamics: computed fluid dynamics of aortic root reconstruction and valve reimplantation

Objectives

The aim was to evaluate the impact of the aortic valve reimplantation (David) and of the aortic root (AoR) remodelling (Yacoub) on the AoR haemodynamics.

Methods

In an experimental setup where the clinical scenario of Yacoub, ( n =  5, domestic pig) and of David ( n =  5, domestic pig) procedure was performed in each AoR, six high-fidelity (200 Hz) sonomicrometric crystals were implanted. Crystals were positioned at three commissures with their projection at the root base. In post-measurement processing 3D deformation of both AoR was determined and used for computed fluid dynamic modelling in order to evaluate pressure, velocity and shear stress profiles.

Results

In David AoR: high pressure (> 150 mmHg) and low to moderate shear stress (0-30 Pa) were found from the period of isovolemic contraction to the closure of the aortic valve. At mid diastole pressure augmentation (> 120 mmHg) a low shear stress (0-10 Pa) was registered at the leaflets, three commissures, and intervalvular triangles. In Yacoub AoR: high pressure (110-130 mmHg) with moderate low shear stress (0-30 Pa) was only registered at isovolemic contraction.

Conclusions

The results show that haemodynamic conditions following a David procedure have a less favourable pattern as compared to a Yacoub AoR. In David AoR, high pressure and low shear stress are present during 2/3 of the cardiac cycle, whereas in Yacoub root, these conditions are present only for a short period of isovolemic contraction.

An Expansible Aortic Ring in Aortic Root Remodeling: Exact Position, Pulsatility, Effectiveness, and Stability in Three-Dimensional CT Study

BACKGROUND

The aim of this study was to assess effectiveness, stability, position, and expansibility of an expansible aortic annuloplasty ring with computed tomography (CT).

METHODS

Ten men (median age 51 years) scheduled for aortic root remodeling with implantation of external annuloplasty ring underwent contrast-enhanced CT of the aortic root preoperatively, postoperatively, and at a median of 21 months after operation. A reconstructed transverse double oblique view of the aortic base (AB) and of the new defined annuloplasty ring base (ARB; plane of the lower edge of the ring) in systole and diastole were obtained. The diameters, perimeter, and area were measured. In addition, the distances between AB and ARB in the nadir of each sinus were measured.

RESULTS

We found 12% reduction of the postoperative AB and 19% of ARB perimeter in both systole (p = 0.004, p < 0.001, respectively) and diastole (p = 0.001, p < 0.001, respectively) compared with preoperative. There was 22% reduction of the postoperative AB area in systole and 24% in diastole (p = 0.002, p = 0.001, respectively) and 33% reduction of the ARB area in systole and 32% in diastole (p < 0.001 for both) compared with the preoperative period. Nearly all measured variables in the follow-up period showed a slight increase compared with the postoperative period; however, they did not reach statistical significance. The postoperative systolic-diastolic differences in the three measured variables at the level of AB and ARB were statistically significant and were maintained throughout the follow-up period. The base of the ring was implanted 2 ± 2 mm at the right, 0 ± 1 mm at the left above the AB, and 2 (-3 to 2) mm at the noncoronary nadir below the AB.

CONCLUSIONS

This study demonstrates imaging evidence of the effectiveness, stability, and pulsatility of the annuloplasty ring in aortic root remodeling in follow-up and describes the exact position of the ring at the base of the aortic root.

Quality of life after aortic valve repair is similar to Ross patients and superior to mechanical valve replacement: a cross-sectional study

Background

In patients after aortic valve surgery, the quality of life is hypothesized to be influenced by the type of the valve procedure. A cross-sectional study on the postoperative quality of life was carried out in patients after aortic valve-sparing surgery (with regards to the age of the patient), Ross procedure and mechanical aortic valve replacement.

Methods

Quality of life was studied in 139 patients after aortic valve surgery divided into four study groups (Y – aortic valve-sparing procedure at the age below 50 years, mean age 36.2 years; O – aortic valve-sparing procedure at the age 50 years and over, mean age 59.2 years; R – Ross procedure, mean age 37.8 years and M – mechanical aortic valve replacement at the age below 50 years, mean age 39.2 years). SF-36 Short Form and valve-specific questionnaires were mailed to the patients after 6 months or later following surgery (median 26.9 months).

Results

In SF-36, the younger aortic valve repair patients and the Ross patients scored significantly better in 4 of 4 physical subscales and in 2 of 4 mental subscales than the older aortic valve repair and mechanical valve replacement patients. In the valve-specific questionnaire; however, all 3 groups free of anticoagulation (Y, O, and R) displayed greater freedom from negative valve-related concerns.

Conclusions

Postoperative quality of life is influenced by the type of aortic valve procedure and is negatively linked with mechanical prosthesis implantation and long-term anticoagulation. Aortic valve-sparing strategy should be considered in cases with suitable valve morphology due to favorable clinical results and beneficial impact on the long-term quality of life.

Year in review: complex valve reconstruction

PURPOSE OF REVIEW

In recent years, great emphasis has been placed on reconstructive techniques for the surgical management of heart valve disease. In this review, we discuss recent data and current practice as it pertains to the subject of reconstructive valve surgery.

RECENT FINDINGS

New techniques and an improved understanding of the mechanisms of aortic insufficiency have led to marked improvement in the early and late outcomes of aortic valve repair. While mitral valve repair is the established approach for the management of degenerative mitral valve disease, surgical technique continues to be refined, with valve reconstruction principles applied to increasingly challenging anatomy. Moreover, the introduction of novel biomaterials has allowed extension of the indication for valve reconstruction to circumstances of extensive tissue defect, including infective endocarditis.

SUMMARY

Valve reconstruction is increasingly being recognized as an alternative to valve replacement. It alleviates the risks of prosthesis-related complications and is especially appealing in young and middle-aged adults. While early and midterm outcomes appear promising, further studies are warranted to assess the clinical benefit and long-term durability of complex valve reconstruction procedures.

Aortic root remodeling and external aortic annuloplasty to treat sinus of Valsalva aneurysm in a patient with complete situs inversus

BACKGROUND

Sinus of Valsalva aneurysm is an uncommon anomaly of the aorta. It occurs most frequently in the right sinus of Valsalva. Complications depend on its size and location. Situs inversus totalis is a rare condition wherein organs are reversed from their normal positions (mirror image).

CASE PRESENTATION

We report the case of a 69-year-old man who presented situs inversus totalis known since his childhood and a sinus of Valsalva aneurysm in the right coronary sinus discovered by echocardiography following a history of infection. This was confirmed by CT-scan and MRI. Valve sparing surgery was performed using the remodeling technique associated with external aortic annuloplasty

CONCLUSIONS

The remodeling technique with exteranl aortic annuloplasty is usual technique to treat SVA.

New Insights Into Unicuspid Aortic Valve Disease in Adults: Not Just a Subtype of Bicuspid Aortic Valves

BACKGROUND

The clinical presentation, echocardiographic features, and patterns of aortic dilatation in unicuspid aortic valves (UAVs) are not well defined.

METHODS

From 2011 to 2015, all data from adult patients with confirmed UAVs (n = 42) who underwent aortic valve surgery were reviewed.

RESULTS

The mean age of the study population was 33.9 ± 1.7 years; 33 were male (78%). Mixed aortic valve disease (stenosis and regurgitation) was the most common mode of presentation (n = 25; 59%). Preoperative diagnosis of UAV was made in only 6 patients (14%). Preoperative transesophageal echocardiography in the operating room increased the diagnosis to 69% of the patients. The peak and mean aortic gradients were 80 ± 29 mm Hg and 50 ± 20 mm Hg, respectively. The aortic valve area was 1.1 ± 0.4 cm(2). Overall, 21% of patients (n = 9) had aortic dilatation (> 45 mm): 6 patients (14%) had isolated ascending aortic dilatation, 1 patient (2%) had isolated aortic root dilatation, and 2 patients (5%) had combined aortic root and ascending aortic dilatation. In contrast, 71% of patients (n = 30) had a dilated aortic annulus (> 25 mm). Mean aortic diameters measured using transesophageal echocardiography were: aortic annulus: 25.8 ± 3.4 mm; sinus of Valsalva: 32.1 ± 5 mm, sinotubular junction: 28.1 ± 5 mm, and ascending aorta: 36.2 ± 5 mm. The valve was repaired using a bicuspidization technique in 8 patients (19%) and replaced using a Ross procedure in 34 patients (81%).

CONCLUSIONS

UAVs remain significantly underdiagnosed in young adults with aortic valve disease. UAVs are associated with a distinct pattern of aortic dilatation, which is mainly present at the level of the aortic annulus. In a small proportion of patients, the valve can be surgically repaired.