Aortic valve repair: Easy and reproducible?

Aortic Root Replacement with Reimplantation of the Aortic Valve: A Low-Volume Center Experience

BACKGROUND

 Most data after root replacement with reimplantation of the aortic valve originate from high-volume centers. This raises concerns about the generalizability of these data and the reproducibility of this complex procedure. Aim of this study is to assess the perioperative and midterm outcomes of this procedure in a low-volume center.

METHODS

 We performed a retrospective analysis of the data of 72 patients, who underwent root replacement with reimplantation of the aortic valve in a single center between 2011 and 2020. Time to event analysis was performed with Kaplan-Meier curves. Longitudinal analysis of serial echocardiographic data was performed with a mixed-effects ordinal logistic regression model.

RESULTS

 In-hospital mortality was 1.4%, with absence of any neurological events during the perioperative period. At midterm follow-up, two further patients died. Overall survival rates at 1 and 5 years were 98.5% (95% confidence interval [CI]: 97-100%) and 96.3% (95% CI: 93.8-98.8%), respectively. During follow-up, five patients (6.9%) required reoperation on the aortic valve. The incidence of moderate and severe aortic regurgitation at 5 years was 6.6% (95% CI: 2.4-13.6%) and 0.6% (95% CI: 0.1-3.2%), respectively. Mild aortic regurgitation at hospital discharge (p < 0.001) and cusp plication (p = 0.0121) were associated with a higher incidence of moderate or severe aortic regurgitation at follow-up.

CONCLUSION

 Reimplantation of the aortic valve is safe and feasible even in a low-volume center. Mortality, freedom from reoperation, and incidence of moderate or severe aortic regurgitation at follow-up are comparable to those of high-volume centers.

Reimplantation versus remodeling in valve-sparing surgery for aortic root aneurysms: a meta-analysis

Background

Valve-sparing aortic root replacement (VSARR), which includes reimplantation and remodeling techniques, has been developed as an important treatment for aortic root aneurysms. We aimed to evaluate the outcomes of reimplantation versus remodeling techniques in valve-sparing surgery for aortic root aneurysms.

Methods

A systematic review and meta-analysis was performed by searching PubMed, Embase and the Cochrane Library until November 2019. Fourteen retrospective cohort studies comparing reimplantation with remodeling techniques for aortic root aneurysms were included and contained at least one of the following outcomes: early mortality, late mortality, aortic valve-related reoperation, and postoperative moderate to severe aortic regurgitation (AR).

Results

The outcomes of 1,672 patients (1,011 underwent reimplantation surgery, and 661 underwent remodeling) were analyzed. Compared with remodeling, the reimplantation technique was associated with a significantly lower risk of late mortality (RR =0.34; 95% CI, 0.17–0.71; P=0.004; I²=37%) and reoperation (RR =0.31; 95% CI, 0.12–0.76; P=0.01; I²=55%). There was no significant difference in early mortality (RR =0.69; 95% CI, 0.31–1.53; P=0.36; I²=0%), postoperative moderate to severe AR (RR =0.64; 95% CI, 0.31–1.32; P=0.22; I²=36%) or postoperative stroke (RR =1.26; 95% CI, 0.58–2.75; P=0.56; I²=0%) between the two groups. No evidence of publication bias was detected.

Conclusions

The current meta-analysis indicate that patients who undergo reimplantation procedures have a significantly lower risk of late mortality and reoperation than those who undergo remodeling procedures. Early mortality, postoperative moderate to severe AR and stroke were comparable between the two techniques.

20 years experience with the Ross operation in middle-aged patients: the autologous principle is still alive

Objectives

Review our long-term results with the Ross operation in middle-aged patients.

Methods

Between 1995 and 2016, 129 consecutive patients (106 males); mean age (47.2 ± 5.2 years) underwent a Ross operation. Right ventricular outflow tract (RVOT) reconstruction was performed with cryopreserved (n = 45) or decellularized allografts (n = 84). Mean follow-up was 8.4 ± 5.3 years (0.1 20.5 years). We analyzed early and late mortality, as well as valve related events and the need for reoperations.

Results

Early mortality was 1.6% and late survival was 87.6% at 16 years. There were 4 reoperations on the pulmonary autograft (96% freedom at 16 years) and 2 on the pulmonary allografts (99% freedom at 16 years). The 16-year freedom from more than mild aortic insufficiency (AI) and a late root diameter >45 mm was 64% and 71%, respectively. Patients with the preoperative diagnosis of AI are at greater risk for these complications. Among the allografts, decellularized allografts showed superior freedom from structural valve dysfunction.

Conclusions

The Ross operation in this cohort was associated with long-term survival similar to the general population and low incidence of reoperations. Patients with the preoperative diagnosis of AI are at increased risk for late autograft insufficiency and root dilatation. Decellularized allografts presented the best results for reconstruction of the RVOT. These results support the conclusion that the Ross operation has an important role in the treatment of middle-aged patients with aortic valve disease, especially those with pure aortic stenosis.

Initial Surgical Experience with Aortic Valve Repair: Clinical and Echocardiographic Results

Introduction

Due to late complications associated with the use of conventional prosthetic heart valves, several centers have advocated aortic valve repair and/or valve sparing aortic root replacement for patients with aortic valve insufficiency, in order to enhance late survival and minimize adverse postoperative events.

Methods

From March/2012 thru March 2015, 37 patients consecutively underwent conservative operations of the aortic valve and/or aortic root. Mean age was 48±16 years and 81% were males. The aortic valve was bicuspid in 54% and tricuspid in the remaining. All were operated with the aid of intraoperative transesophageal echocardiography. Surgical techniques consisted of replacing the aortic root with a Dacron graft whenever it was dilated or aneurysmatic, using either the remodeling or the reimplantation technique, besides correcting leaflet prolapse when present. Patients were sequentially evaluated with clinical and echocardiographic studies and mean follow-up time was 16±5 months.

Results

Thirty-day mortality was 2.7%. In addition there were two late deaths, with late survival being 85% (CI 95% - 68%-95%) at two years. Two patients were reoperated due to primary structural valve failure. Freedom from reoperation or from primary structural valve failure was 90% (CI 95% - 66%-97%) and 91% (CI 95% - 69%-97%) at 2 years, respectively. During clinical follow-up up to 3 years, there were no cases of thromboembolism, hemorrhage or endocarditis.

Conclusions

Although this represents an initial series, these data demonstrates that aortic valve repair and/or valve sparing aortic root surgery can be performed with satisfactory immediate and short-term results.

Aortic cusp sizers to establish the functional classification of aortic insufficiency: algorithm and midterm outcome of operative repair

OBJECTIVES

Wider adoption of aortic valve repair procedures is held up by the difficulty in recognizing the exact alterations that are responsible for aortic valve insufficiency. New aortic cusp sizers were developed to assist in aortic valve assessment in the operating theatre. Our objectives were to examine the efficacy of the aortic cusp sizers in establishing the functional classification of aortic valve insufficiency, and to report the midterm outcome in a group of patients who had undergone aortic valve repair guided by this device.

METHODS

A prospective clinical study was performed involving 33 consecutive patients (18 males, age range: 8-74 years) with severe aortic valve insufficiency (mean severity: 3.4 ± 0.5). The aortic cusp sizers were used as a template to identify existing cusp and root alterations. Consequently, the functional classification of aortic insufficiency was determined, and the appropriate techniques of aortic valve repair were implemented.

RESULTS

Aortic valve repair was successful in all patients. Procedures performed were 37 functional aortic annulus corrections, 9 cusp free-edge plications, 2 cusp repairs with autologous pericardium, 9 replacements of the ascending aorta and 2 reimplantation procedures. At a mean follow-up time of 18.3 ± 13.7 months, 1 patient underwent aortic valve replacement for recurrent aortic valve regurgitation, while aortic valve function remained stable in 32 patients, with aortic insufficiency <1+ in 27 (84.4%) patients and 1-1.5 in 5 (15.6%) patients, and no significant gradients across the aortic valves.

CONCLUSIONS

The aortic cusp sizers are valuable in establishing the functional classification of aortic insufficiency, and can guide implementation of aortic valve repair techniques successfully. This approach is analogous to that accredited for the success and wide adoption of mitral valve repair techniques, and is likely to assist in increasing the percentage of aortic valves that are repaired when compared with current practice.