Aortic root reconstruction with preservation of native aortic valve and sinuses in aortic root dilatation with aortic regurgitation

The Geometrical Modeling of Aortic Root Complex

Background:

This study was designed to investigate the anatomical relationship of the different levels of aortic root.

Materials and Methods:

The morphological features of the aortic root were examined using of 12 adult hearts from fixed male cadavers who had expired due to noncardiac causes by magnetic resonance imaging and applied mathematical analyses to the results. The measurements of the aortic root were done at four levels: at the ventriculoarterial junction (annulus), at the largest level of the Valsalva sinuses (sinus), at the level of commissures (sinotubular junction [STJ]), and at 1 cm above the STJ (aorta ascendens). We derived an equation that allows calculation of the appropriate diameter of the aortic root from four levels. Statistical analysis among the variation of the diameters at the four levels of aortic root was achieved using test one-way analysis of variance.

Results:

The data showed a geometric pattern of the aortic root. The comparison of the values from four levels showed that the narrowest at the sinotubular junctional level and the widest at the sinus level.

Conclusion:

The analysis of our data shows that the aortic root has a consistent shape with varying size and that is a definable mathematical relationship between root diameter.

Reverse graft placement in the Florida sleeve procedure for aortic root aneurysm

Since August 2009, 22 patients with aortic root aneurysm have been successfully operated on with our new aortic remodeling technique as follows: after placement of the Gelweave (Vascutek, Ltd., Inchinnan, UK) Valsalva vascular graft in the reverse manner to the Florida sleeve procedure, the aortic annulus was fixed with the collar of this prosthesis at the level of the basal ring and the aortic root was wrapped with the prosthesis. Furthermore, the aortic valve commissures were resuspended. The distal end of the graft and the transected aortic wall were sutured together with running sutures when they were anastomosed to the stump of the distal ascending aorta.

Aortic valve-sparing operations: state of the art

PURPOSE OF REVIEW

Aortic valve-sparing (AVS) operations include an armamentarium of procedures, which preserve the aortic cusps in aortic root dilation with aortic insufficiency. The purpose of this review article is to specifically outline the surgical indications, to describe the various techniques, and to present results from the most current series in AVS operations.

RECENT FINDINGS

In the worldwide literature, there is promising data on AVS operations. Patients undergoing AVS operations not only have better long-term survival but also appear to have a reduced risk of aortic insufficiency and thromboembolic complications.

SUMMARY

AVS operations are an excellent option for patients with an aortic root aneurysm and normal/minimally diseased aortic cusps.

New aortic root remodeling surgery in aortic root aneurysm

PURPOSE

We have introduced a new surgical technique for aortic root remodeling in aortic root aneurysm, comprised of aortic annuloplasty, reduction of sinus of Valsalva, and wrapping of the aortic root.

DESCRIPTION

At the level of the basal ring, the aortic annulus is fixed with the collar of a Gelweave Valsalva vascular graft (Vascutek, Ltd, Inchinnan, UK). After plication of the dilated sinuses of Valsalva from outside the aorta, the aortic root is wrapped with this prosthesis. The distal end of the graft and the transected aortic wall are sutured together with running sutures.

EVALUATION

Since September 2006, 10 patients suffering from aortic root aneurysm were successfully operated on using this technique. After a median follow-up of 20.7 months, there were no early deaths and no reoperations due to failure of remodeling surgery. Median diameter of the sinus of Valsalva was reduced from 49.5 mm to 34.0 mm. All patients showed aortic regurgitation of grade 0 or grade 1 at follow-up.

CONCLUSIONS

Long-term follow-up is necessary to prove the durability of this operation.

Valve-sparing aortic root reconstruction

The aortic valve-sparing root reconstruction procedure remains an ideal concept, but it has not yet become an ideal operation. There is still great variation and evolution in techniques, which mirrors the increasing understanding of the aortic root's functional anatomy and the disease processes that affect it. These operations remain complex, and the surgeons who perform them well are often times best armed with an experienced eye for what looks right more than a mathematical model that can predetermine who will do well, with what repair type and with what percentage chance of long-term success. Because of this, it will likely still be a while before these operations are more routinely used by a broader group of surgeons, as compared with the very reproducible Bentall and De Bono repair.

Restitution of the Aortic Valve: What is New, What is Proven, and What is Obsolete?

Restitution strategies of the insufficient aortic valve belong to the clinical armamentarium. To date, the accumulated body of evidence comprises 126 articles dealing with restitution strategies on the insufficient aortic valve with concomitant aortic surgery. In a cumulative analysis an almost identical number of reimplantation (506) and remodeling (489) procedures were found in the literature, whereas 357 patients underwent aortic valve resuspension. The cumulative results tend to favor the reimplantation technique in terms of longevity of the reconstruction, particularly in congenital degenerative disorders of the aortic wall, whereas remodeling appears to exhibit a more physiologic behavior of the reconstructed valve and re-suspension serves as a simplified approach particularly in acute type A dissection. Although restitution of the native aortic valve has its place in current treatment options, the accumulated worldwide numbers indicate that it is not yet routinely implemented in the vast majority of cardiac institutions.

Surgical management of heart failure

Surgical therapy for congestive heart failure can offer gratifying results in selected elderly patients. Several trials have shown a survival advantage for surgical revascularization compared with medical therapy in the treatment of ischemic cardiomyopathy. Aortic valve replacement is highly effective in treating elderly patients with heart failure caused by severe aortic stenosis, and stentless aortic valves seem to provide a survival advantage in elderly patients with low-gradient aortic stenosis. Mitral valve repair with or without coronary revascularization has been used successfully in patients with severe mitral regurgitation. Transplantation is a viable but rarely used option for elderly patients with congestive heart failure. Totally implantable ventricular assist devices are an exciting new option for elderly patients with congestive heart failure who are not heart transplantation candidates.