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Xiang F, Chen L, Chemtob R, Roselli EE, Unai S, Vargo P, Koprivanac M, Gillinov AM, Blackstone EH, Rajeswaran J, Firth A, Desai MY, Griffin B, Kalahasti V, Svensson LG. Long-term outcome of bicuspid aortic valve repair using figure-of-8 hitch-up stitches. JTCVS Tech 2024; 24:27-40. [PMID: 38835563 PMCID: PMC11145234 DOI: 10.1016/j.xjtc.2024.01.012] [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: 10/06/2023] [Revised: 12/20/2023] [Accepted: 01/03/2024] [Indexed: 06/06/2024] Open
Abstract
Objective To maximize successful repair of bicuspid aortic valves by adding figure-of-8 hitch-up stitches at commissures. Methods From 2000 to 2022, bicuspid aortic valve repair was performed on 1112 patients at Cleveland Clinic, with 367 patients receiving figure-of-8 hitch-up stitches along with classical techniques, including Cabrol suture, cusp plication, raphe resection, and valve-sparing root replacement. Operative outcomes, repair durability, and survival were assessed in the figure-of-8 hitch-up stitches cohort, and outcomes were compared among 195 balancing-score-matched patient pairs who underwent bicuspid aortic valve repair with and without figure-of-8 hitch-up stitches. Results Patients who underwent bicuspid aortic valve repair with figure-of-8 stitches had an operative mortality of 0.3% (1 of 367) and in-hospital reoperation for aortic valve dysfunction of 1.1% (4 of 367). At 10 years, prevalence of severe aortic regurgitation was 8.6%, mean gradient 24 mm Hg, freedom from aortic valve reoperation 75%, and survival 98%. In matched cohorts, operative mortality was similar (0.51% vs 0%; P > .9) as were morbidities, including in-hospital reoperation due to aortic valve dysfunction (1.0% vs 1.5%; P > .9). Comparable long-term outcomes were observed at 10 years (prevalence of severe aortic regurgitation of 8.7% vs 5.0% [P = .11], mean gradient 18 vs 17 mm Hg [P = .40]; freedom from aortic valve reoperation 80% vs 81% [P = .73]; and survival 99.5% vs 94.6% [P = .18]). Conclusions Figure-of-8 hitch-up stitch is a safe bicuspid aortic valve repair technique. It increases the likelihood of a successful repair without increasing risk of cusp tear and achieves satisfactory long-term survival and durability when added to classical repair techniques.
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Affiliation(s)
- Fei Xiang
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing, China
| | - Lin Chen
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Raphaelle Chemtob
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E. Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick Vargo
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - A. Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H. Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Lerner Research institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Lerner Research institute, Cleveland Clinic, Cleveland, Ohio
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Austin Firth
- Department of Quantitative Health Sciences, Lerner Research institute, Cleveland Clinic, Cleveland, Ohio
| | - Milind Y. Desai
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian Griffin
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vidyasagar Kalahasti
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G. Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Ehrlich T, Abeln KB, Froede L, Schmitt F, Giebels C, Schäfers HJ. Twenty-five years' experience with isolated bicuspid aortic valve repair: impact of commissural orientation. Eur J Cardiothorac Surg 2024; 65:ezae163. [PMID: 38608189 DOI: 10.1093/ejcts/ezae163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/04/2024] [Accepted: 04/10/2024] [Indexed: 04/14/2024] Open
Abstract
OBJECTIVES Repair of the bicuspid aortic valve (BAV) has evolved in the past 25 years. The aim of this study was to review and analyse the long-term durability of isolated BAV repair with particular focus on commissural orientation (CO). METHODS All patients who underwent BAV repair for severe aortic regurgitation between October 1998 and December 2022 were included. The study group consists of all patients operated after 2009, i.e. since CO modification. The control group includes patients who were operated before 2009. CO was classified as symmetric, asymmetric and very asymmetric. RESULTS Overall, 594 adult patients (93% male; mean age 42 years) were included. At 15 years, survival was 94.8% [standard deviation (SD): 2.2]; freedom from reoperation was 86.8% (SD: 2.3). Freedom from aortic insufficiency ≥II was 70.8% (SD: 4.7) at 15 years. Modification of CO by sinus plication was performed in 200 (33.7%) instances. Using competing risks analysis, the absence of effective height measurement (P = 0.018), very asymmetric CO (P = 0.028), the presence of calcification (P < 0.001), the use of pericardial patch (P < 0.001), the use of subcommissural sutures (P < 0.001) and preoperative endocarditis (P = 0.005) were identified as independent predictors for reoperation. Follow-up was 97% complete (4228 patient-years); mean follow-up was 7 years (SD: 5). CONCLUSIONS Isolated BAV repair leads to good survival and durability in all morphologic types if cusp repair is guided by effective height, suture annuloplasty is performed, and CO is modified using sinus plication in asymmetrical valves. Very asymmetrical valves may should be treated with a lower threshold for replacement.
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Affiliation(s)
- Tristan Ehrlich
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
- Department of Cardiovascular Surgery and Heart Transplantation, University Hospital of Nancy-Brabois, Vandoeuvre-lès-Nancy, France
| | - Karen B Abeln
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
| | - Lennart Froede
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
| | - Flora Schmitt
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
| | - Christian Giebels
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
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Kalra A, Das R, Alkhalil M, Dykun I, Candreva A, Jarral O, Rehman SM, Majmundar M, Patel KN, Rodes-Cabau J, Reardon MJ, Puri R. Bicuspid Aortic Valve Disease: Classifications, Treatments, and Emerging Transcatheter Paradigms. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2024; 8:100227. [PMID: 38283572 PMCID: PMC10818151 DOI: 10.1016/j.shj.2023.100227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 09/02/2023] [Accepted: 09/14/2023] [Indexed: 01/30/2024]
Abstract
Bicuspid aortic valve (BAV) is a common congenital valvular malformation, which may lead to early aortic valve disease and bicuspid-associated aortopathy. A novel BAV classification system was recently proposed to coincide with transcatheter aortic valve replacement being increasingly considered in younger patients with symptomatic BAV, with good clinical results, yet without randomized trial evidence. Procedural technique, along with clinical outcomes, have considerably improved in BAV patients compared with tricuspid aortic stenosis patients undergoing transcatheter aortic valve replacement. The present review summarizes the novel BAV classification systems and examines contemporary surgical and transcatheter approaches.
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Affiliation(s)
- Ankur Kalra
- Department of Cardiology, Franciscan Health, Lafayette, Indiana, USA
| | - Rajiv Das
- Department of Cardiothoracic Services, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Mohammad Alkhalil
- Department of Cardiothoracic Services, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Iryna Dykun
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alessandro Candreva
- Department of Cardiology, University Heart Centre, University Hospital Zurich, Zurich, Switzerland
| | - Omar Jarral
- Department of Cardiothoracic Surgery, St. Thomas Hospital, London, UK
| | - Syed M. Rehman
- Department of Cardiothoracic Surgery, OLV Hospital, Aalst, Belgium
| | - Monil Majmundar
- Department of Cardiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Kunal N. Patel
- Department of Cardiology, West Virginia University Hospital, Morgantown, West Virginia, USA
| | - Josep Rodes-Cabau
- Department of Interventional Cardiology, Quebec Heart & Lung Institute, Quebec City, Canada
| | - Michael J. Reardon
- Department of Cardiothoracic Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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4
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Gerdisch MW, Reece TB, Emerson D, Downey RS, Blossom GB, Singhal A, Baker JN, Fischlein TJ, Badhwar V. Early results of geometric ring annuloplasty for bicuspid aortic valve repair during aortic aneurysm surgery. JTCVS Tech 2022; 14:55-65. [PMID: 35967205 PMCID: PMC9367630 DOI: 10.1016/j.xjtc.2022.03.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/02/2022] [Accepted: 03/30/2022] [Indexed: 12/04/2022] Open
Abstract
Objectives Geometric ring annuloplasty has shown promise during bicuspid aortic valve repair for aortic insufficiency. This study examined early outcomes of bicuspid aortic valve repair associated with proximal aortic aneurysm replacement. Methods From September 2017 to November, 2021, 127 patients underwent bicuspid aortic valve repair with concomitant proximal aneurysm reconstruction. Patient age was 50.6 ± 12.7 years (mean ± standard deviation), male gender was 83%, New York Heart Association Class was 2 (1-2) (median [interquartile range]), and preoperative aortic insufficiency grade was 3 (2-4). Ascending aortic diameter was 50 (46-54) mm, and all patients had ascending aortic replacement. Forty patients had sinus diameters greater than 45 mm, prompting remodeling root procedures. A total of 105 patients had Sievers type 1 valves, 3 patients had type 0, and 7 patients had type 2. A total of 118 patients had primarily right/left fusion, 8 patients had right/nonfusion, and 1 patient had left/nonfusion. Leaflet reconstruction used central leaflet plication and cleft closure, with limited ultrasonic decalcification in 31 patients. Results Ring size was 23 (21-23) mm, and 26 of 40 root procedures were selective nonfused sinus replacements. Aortic clamp time was 139 (112-170) minutes, and bypass time was 178 (138-217) minutes. Postrepair aortic insufficiency grade was 0 (0-0) (P < .0001), and mean valve gradient was 10 (7-14) mm Hg. No early and 1 late mortality occurred. Four patients required reoperation for bleeding, and 4 patients required pacemakers. At a mean follow-up of 20 months (maximal 93), there were no valve-related complications, 5 late repair failures prompting valve replacement, and 1 death due to Coronavirus Disease 2019. Conclusions Geometric ring annuloplasty for bicuspid aortic valve repair with proximal aortic aneurysm reconstruction is safe and associated with good early outcomes. Further experience and follow-up will help inform long-term durability.
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Affiliation(s)
- Marc W. Gerdisch
- Department of Cardiac Surgery, Franciscan Health Indianapolis, Indianapolis, Ind
- Address for reprints: Marc W. Gerdisch, MD, Department of Cardiac Surgery, Franciscan Health Indianapolis, Indianapolis, IN 46237.
| | - T. Brett Reece
- Department of Cardiac Surgery, University of Colorado, Aurora, Colo
| | - Dominic Emerson
- Department of Cardiac Surgery, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Richard S. Downey
- Department of Cardiac Surgery, University of Michigan, Muskegon, Mich
| | - Geoffrey B. Blossom
- Department of Cardiac Surgery, Ohio Health Riverside Methodist Hospital, Columbus, Ohio
| | - Arun Singhal
- Department of Cardiac Surgery, University of Iowa, Iowa City, Iowa
| | - Joshua N. Baker
- Department of Cardiac Surgery, Missouri Baptist Hospital, St Louis, Mo
| | - Theodor J.M. Fischlein
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Nürnberg, Germany
| | - Vinay Badhwar
- Department of Cardiac Surgery, West Virginia University, Morgantown, WVa
| | - BAVr Working GroupTrentoAlfredoaChikweJoannaaWeiLawrence M.bGlotzbachJason P.cJamesTimothy W.dQuinnReed D.eWolfeJ. AlanfYamaneKentarogCopeJeffrey T.gSolemaniBehzadgTakayamaHiroohRodriguezVictor M.iMurashitaTakashijVoellerRochus K.kSiMing-SinglLevackMelissamBurkeChris R.nMoonMarc R.oKraevAlexanderpJasinskiMarek J.qStavridisGeorgiosrRankinJ. ScottbCedars Sinai Medical Center, Los Angeles, CalifWest Virginia University, Morgantown, WVaUniversity of Utah, Salt Lake City, UtahSt Joseph's Medical Center, Tacoma, WashMaine Medical Center, Portland, MaineNortheast Georgia Medical Center, Gainesville, GaPennsylvania State University, Hershey, PaColumbia Presbyterian Medical Center, New York, NYUniversity of California Davis, Sacramento, CalifUniversity of Missouri, Columbia, MoUniversity of Minnesota, Minneapolis, MinnUniversity of Michigan, Ann Arbor, MichVanderbilt University Medical Center, Nashville, TennUniversity of Washington, Seattle, WashWashington University Medical Center, St Louis, MoBillings Clinic, Billings, MontWroclaw Medical University, Wroclaw, PolandOnassis Heart Center, Athens, Greece
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5
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Zhu Y, Imbrie-Moore AM, Paulsen MJ, Priromprintr B, Wang H, Lucian HJ, Farry JM, Woo YJ. Novel bicuspid aortic valve model with aortic regurgitation for hemodynamic status analysis using an ex vivo simulator. J Thorac Cardiovasc Surg 2022; 163:e161-e171. [PMID: 32747120 PMCID: PMC7769867 DOI: 10.1016/j.jtcvs.2020.06.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective was to design and evaluate a clinically relevant, novel ex vivo bicuspid aortic valve model that mimics the most common human phenotype with associated aortic regurgitation. METHODS Three bovine aortic valves were mounted asymmetrically in a previously validated 3-dimensional-printed left heart simulator. The non-right commissure and the non-left commissure were both shifted slightly toward the left-right commissure, and the left and right coronary cusps were sewn together. The left-right commissure was then detached and reimplanted 10 mm lower than its native height. Free margin shortening was used for valve repair. Hemodynamic status, high-speed videography, and echocardiography data were collected before and after the repair. RESULTS The bicuspid aortic valve model was successfully produced and repaired. High-speed videography confirmed prolapse of the fused cusp of the baseline bicuspid aortic valve models in diastole. Hemodynamic and pressure data confirmed accurate simulation of diseased conditions with aortic regurgitation and the subsequent repair. Regurgitant fraction postrepair was significantly reduced compared with that at baseline (14.5 ± 4.4% vs 28.6% ± 3.4%; P = .037). There was no change in peak velocity, peak gradient, or mean gradient across the valve pre- versus postrepair: 293.3 ± 18.3 cm/sec versus 325.3 ± 58.2 cm/sec (P = .29), 34.3 ± 4.2 mm Hg versus 43.3 ± 15.4 mm Hg (P = .30), and 11 ± 1 mm Hg versus 9.3 ± 2.5 mm Hg (P = .34), respectively. CONCLUSIONS An ex vivo bicuspid aortic valve model was designed that recapitulated the most common human phenotype with aortic regurgitation. These valves were successfully repaired, validating its potential for evaluating valve hemodynamics and optimizing surgical repair for bicuspid aortic valves.
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Affiliation(s)
- Yuanjia Zhu
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA,Department of Bioengineering, Stanford University, Stanford, CA
| | - Annabel M. Imbrie-Moore
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA,Department of Mechanical Engineering, Stanford University, Stanford, CA
| | | | - Bryant Priromprintr
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Stanford, CA
| | - Hanjay Wang
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA
| | - Haley J. Lucian
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA
| | - Justin M. Farry
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA
| | - Y. Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA,Department of Bioengineering, Stanford University, Stanford, CA
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6
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Safari M, Monsefi N, Karimian-Tabrizi A, Miskovic A, Van Linden A, Zacek P, Moritz A, Walther T, Holubec T. Longer-term outcomes after bicuspid aortic valve repair in 142 patients. J Card Surg 2021; 36:4645-4651. [PMID: 34547142 DOI: 10.1111/jocs.16006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/22/2021] [Accepted: 09/06/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the longer-term results of bicuspid aortic valve (BAV) repair with or without aortic root replacement. METHODS From 1999 to 2017, 142 patients with or without aortic root dilatation who underwent repair of a regurgitant BAV were included in the study. Ninety-four patients underwent isolated BAV repair (Group 1; median age 43 years) and 48 patients underwent valve-sparing aortic root replacement plus BAV repair (aortic valve reimplantation-Group 2; median age 48 years). Median clinical follow-up time was 5.9 years (range 0.5-15) in Group 1 and 3 years (range 0.5-16) in Group 2, respectively. RESULTS In-hospital mortality was 1% in Group 1, and 2% in Group 2 (p = .6). The 5- and 10-year survival was 93 ± 2.9% and 81 ± 5.8% in Group 1 and 96 ± 3.1% and 96 ± 3.1% in Group 2, respectively (p = .31). Eleven patients of Group 1 (1.7%/patient-year) and five patients of Group 2 (2.2%/patient-year) underwent reoperation of the aortic valve (p = .5). The 5- and 10-year freedom from reoperation were 93.0 ± 2.1% and 77.1 ± 7.1% in Group 1 and 93.0 ± 5.0% and 76.7 ± 9.6% in Group 2 (p = .83), respectively. At the latest follow-up, only two patients of Group 1 and 1 patient of Group 2 had AV regurgitation = 2° (p = .7). The cumulative linearized incidence of all valve-related complications (bleeding, stroke, endocarditis, and reoperation) was 2.9%/patient-year in Group 1% and 4%/patient-year in Group 2, respectively (p = .6). CONCLUSIONS Isolated BAV repair and combined aortic valve reimplantation plus BAV repair provide good clinical longer-term outcomes with relatively low reoperation rate and durable valve function.
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Affiliation(s)
- Mojyan Safari
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Nadejda Monsefi
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Afsaneh Karimian-Tabrizi
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Alexandra Miskovic
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Arnaud Van Linden
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Pavel Zacek
- Department of Cardiac Surgery, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove and Charles University, Hradec Kralove, Czech Republic
| | - Anton Moritz
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Thomas Walther
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Tomas Holubec
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
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7
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Casselman FP. Case closed? Eur J Cardiothorac Surg 2021; 60:295-296. [PMID: 34051079 DOI: 10.1093/ejcts/ezab013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Filip P Casselman
- Department of Cardiovascular and Thoracic Surgery, OLV Clinic, Aalst, Belgium
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8
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de Meester C, Vanovershelde JL, Jahanyar J, Tamer S, Mastrobuoni S, Van Dyck M, Navarra E, Poncelet A, Astarci P, El Khoury G, de Kerchove L. Long-term durability of bicuspid aortic valve repair: a comparison of 2 annuloplasty techniques. Eur J Cardiothorac Surg 2021; 60:286-294. [PMID: 33495781 DOI: 10.1093/ejcts/ezaa471] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/14/2020] [Accepted: 11/22/2020] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES To compare long-term outcomes after bicuspid aortic valve (BAV) repair utilizing the Cabrol annuloplasty versus valve sparing Reimplantation technique. METHODS From 1996 to 2018, 340 consecutive patients underwent BAV repair. Eighty underwent Cabrol annuloplasty and 189 underwent Reimplantation. Exclusion criteria were re-repairs (n = 6), active endocarditis (n = 4), no annuloplasty (n = 41) and ring or suture annuloplasty (n = 20). We compared both groups for survival, reoperations, valve related events and recurrent severe aortic regurgitation (AR > 2+). Inverse probability weighting (IPW) was used to balance the 2 groups. Cox regression analysis was used to identify outcome predictors. RESULTS After weighting, pre- and intraoperative characteristics were similar between groups, except for aorta replacement techniques and operative time, which was longer in the Reimplantation group (P < 0.001). At 12 years, overall survival was similar between groups (IPW: Cabrol 97 ± 2% vs Reimplantation 94 ± 3%, P = 0.52). Freedom from reoperation and freedom from AR > 2+ were significantly lower in the Cabrol group (reoperation IPW: 69 ± 9% vs 91 ± 4%, P = 0.004 and AR > 2+ IPW: 71 ± 8% vs 97 ± 2%, P < 0.001). The Reimplantation technique was the only independent predictor of reoperation (hazard ratio 0.31; confidence interval 0.19-0.7; P = 0.005). CONCLUSIONS In this study, comparing 2 annuloplasty strategies for BAV repair, we found statistically significant differences in long-term durability favouring the Reimplantation technique, and no differences in overall survival. The results support our current strategy of Reimplantation technique and repair of AR in patients with BAV. Cabrol annuloplasty is obsolete and should be generally abandoned in patients undergoing BAV repair for AR.
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Affiliation(s)
- Christophe de Meester
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCL), Louvain-la-Neuve, Belgium
| | - Jean-Louis Vanovershelde
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCL), Louvain-la-Neuve, Belgium.,Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jama Jahanyar
- Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Saadallah Tamer
- Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Stefano Mastrobuoni
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCL), Louvain-la-Neuve, Belgium.,Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Michel Van Dyck
- Division of Anesthesiology, Department of Acute Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Emiliano Navarra
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCL), Louvain-la-Neuve, Belgium.,Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Alain Poncelet
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCL), Louvain-la-Neuve, Belgium.,Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Parla Astarci
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCL), Louvain-la-Neuve, Belgium.,Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Gebrine El Khoury
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCL), Louvain-la-Neuve, Belgium.,Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Laurent de Kerchove
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCL), Louvain-la-Neuve, Belgium.,Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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9
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Schneider U, Hofmann C, Schöpe J, Niewald AK, Giebels C, Karliova I, Schäfers HJ. Long-term Results of Differentiated Anatomic Reconstruction of Bicuspid Aortic Valves. JAMA Cardiol 2020; 5:1366-1373. [PMID: 32936224 DOI: 10.1001/jamacardio.2020.3749] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Bicuspid aortic valve (BAV) repair has been used in limited cohorts, but its long-term results in a large population are unknown. Objectives To analyze the long-term stability of BAV repair for survival and the factors associated with repair failure and to evaluate whether a differentiated anatomic repair approach may improve repair stability. Design, Setting, and Participants In this case series, 1024 patients underwent BAV repair for aortic regurgitation or aneurysm between October 1995 and June 2018, with a mean (SD) follow-up time of 56 (49) months and maximum follow-up of 271 months. Systematic modifications in technique based on anatomic principles were introduced in 2009 and applied for the last 727 patients. Data were acquired prospectively and analyzed retrospectively. Exposures Repair of BAV with or without concomitant aortic replacement, as well as postoperative clinical and echocardiographic follow-up. Main Outcomes and Measures Survival and incidence of reoperation or recurrent aortic regurgitation, as well as factors associated with valve repair failure. Results Among the 1024 patients in the study (920 male [89.8%]; mean [SD] age, 47 [13] years [range, 15-86 years]), the survival rate at 15 years was 82.1%. The cumulative incidence of reoperation was 30.7% (95% CI, 22.7%-38.7%) at 15 years. Cusp calcification (subdistribution hazard ratio, 1.78; 95% CI, 1.14-2.77; P = .01), asymmetric commissural orientation (subdistribution hazard ratio, 1.95; 95% CI, 1.02-3.72; P = .04), and use of a pericardial patch for cusp repair (subdistribution hazard ratio, 5.25; 95% CI, 3.52-7.82; P < .001) were associated with time to reoperation. At 10 years, the incidence of reoperation was significantly reduced among patients who received the anatomic repair concept compared with those who had undergone surgery in the earlier period (8.8% vs 24.6%; P < .001). Conclusions and Relevance This study suggests that survival after BAV repair is excellent and that a large proportion of BAV repairs will remain stable. Repair stability can be markedly improved by an anatomic repair concept. Cusp calcification and the need for cusp repair using a patch remain the factors most strongly associated with valve failure. In those instances, valve replacement should be preferred.
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Affiliation(s)
- Ulrich Schneider
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Christopher Hofmann
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Jakob Schöpe
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg/Saar, Germany
| | - Ann-Kristin Niewald
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg/Saar, Germany
| | - Christian Giebels
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Irem Karliova
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
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Aortenklappenrekonstruktion. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2020. [DOI: 10.1007/s00398-020-00390-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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11
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Si MS, Conte JV, Romano JC, Romano MA, Andersen ND, Gerdisch MW, Kupferschmid JP, Fiore AC, Bakhos M, Bonilla JJ, Burke JR, Rankin JS, Wei LM, Badhwar V, Turek JW. Unicuspid Aortic Valve Repair Using Geometric Ring Annuloplasty. Ann Thorac Surg 2020; 111:1359-1366. [PMID: 32619617 DOI: 10.1016/j.athoracsur.2020.04.147] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 02/01/2020] [Accepted: 04/02/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Unicuspid aortic valves (Sievers type 2 bicuspid) are characterized by major fusion and clefting of the right-left coronary commissure, and minor fusion of the right-noncoronary commissure. Repair has been difficult because of two fusions, variable relative sinus sizes, and peripheral leaflet deficiencies or tears after balloon valvuloplasty. METHODS Twenty unicuspid aortic valves patients underwent valve repair in nine institutions. Right-left major fusion and right-noncoronary minor fusion occurred in 17 of 20 (85%). Commissurotomy was performed on the minor fusion, and a bicuspid annuloplasty ring with circular base geometry and two 180-degree subcommissural posts was sutured beneath the annulus, equalizing the annular circumferences of the fused and nonfused cusps. The nonfused leaflet was plicated, and the cleft in the major fusion was closed linearly until leaflet effective heights and lengths became greater than 8 mm and equal, respectively. RESULTS Average age (mean ± SD) was 22.3 ± 12.3 years (range, 13 to 58), 12 of 20 (60%) were symptomatic, 10 of 20 (50%) required aortic aneurysm resection. Pre-repair hemodynamic data included mean systolic valve gradient 25.8 ± 12.9 mm Hg, aortic insufficiency grade 2.9 ± 1.2, and annular diameter 24.7 ± 3.3 mm. No mortality or major complications occurred. Post-repair annular (ring) size was 20.5 ± 1.3 mm, mean gradient fell to 16.2 ± 5.9 mm Hg, and aortic insufficiency grade decreased to 0.1 ± 0.3 (P < .001). At an average follow-up of 11 months (range, 1 to 22), all 20 patients were asymptomatic and had returned to full activity. CONCLUSIONS Aortic ring annuloplasty reduced annular diameter effectively, recruiting more leaflet to midline coaptation. Minor fusion commissurotomy and annular remodeling to 180-degree commissures converted UAV repair to a simple and reproducible procedure.
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Affiliation(s)
| | - John V Conte
- Pennsylvania State University, Hershey, Pennsylvania
| | | | | | | | | | | | - Andrew C Fiore
- St Louis University Cardinal Glennon Children's Hospital, St Louis, Missouri
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12
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Ehrlich T, de Kerchove L, Vojacek J, Boodhwani M, El-Hamamsy I, De Paulis R, Lansac E, Bavaria JE, El Khoury G, Schäfers HJ. State-of-the art bicuspid aortic valve repair in 2020. Prog Cardiovasc Dis 2020; 63:457-464. [PMID: 32380025 DOI: 10.1016/j.pcad.2020.04.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 02/07/2023]
Abstract
Patients with a bicuspid aortic valve (BAV) frequently require surgical intervention for aortic regurgitation (AR) and/or aneurysm. Valve-preserving surgery and repair of regurgitant BAVs have evolved into an increasingly used alternative to replacement. Anatomic predictors of possible repair failures have been identified and solutions developed. Using current techniques most non-calcified BAVs can be preserved or repaired. Excellent repair durability and freedom from valve-related complications can be achieved if all pathologic components of aortic valve and root including annular dilatation are corrected. Anatomic variations must be addressed using tailored approaches.
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Affiliation(s)
- Tristan Ehrlich
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - 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
| | - Jan Vojacek
- Department of Cardiac Surgery, University Hospital Hradec K0ralove, Czech Republic
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Canada
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn Scholl of Medicine at Mount Sinai, New York, USA
| | | | - Emmanuel Lansac
- Departement of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Joseph E Bavaria
- Division of Cardiac Surgery, University of Pennsylvania, Philadelphia, United States of America
| | - 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
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany.
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13
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Concepts of Bicuspid Aortic Valve Repair: A Review. Ann Thorac Surg 2020; 109:999-1006. [DOI: 10.1016/j.athoracsur.2019.09.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/16/2019] [Accepted: 09/03/2019] [Indexed: 12/27/2022]
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14
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Arnaoutakis GJ, Sultan I, Siki M, Bavaria JE. Bicuspid aortic valve repair: systematic review on long-term outcomes. Ann Cardiothorac Surg 2019; 8:302-312. [PMID: 31240174 DOI: 10.21037/acs.2019.05.08] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Many patients with bicuspid aortic valve (BAV) develop aortic regurgitation but are not considered for valve repair. This is partly due to limited long term data regarding repair durability. The purpose of the review is to summarize the long-term (1 year) outcomes of BAV repair. Methods A systematic review was performed to evaluate durability and survival following BAV repair. OVID SP versions of MEDLINE and Embase were searched using 'aortic valve', 'bicuspid', 'repair', 'David' 'Yacoub', 'reimplantation' and 'remodeling'. Results Initial search produced 770 abstracts, reduced to 92 full papers for review after excluding duplications and abstract review for relevance. Twenty-six studies met full inclusion criteria. BAV repair revealed low operative mortality, with excellent 5-year survival, and low freedom from reoperation. Differences in surgical technique between reimplantation and remodeling do not appear to confer protection against reintervention. Systematic assessment of cusp height and annular stabilization in some form do appear to favor improved long term durability. Leaflet calcification is associated with higher rates of reintervention. Conclusions BAV repair is associated with acceptable long term survival. Ongoing standardized outcome assessments will further refine surgical techniques associated with excellent repair durability.
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Affiliation(s)
- George J Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mary Siki
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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David TE. Almost All Incompetent BAV Should Be Repaired. Semin Thorac Cardiovasc Surg 2019; 31:661-663. [PMID: 30980931 DOI: 10.1053/j.semtcvs.2019.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/18/2019] [Indexed: 11/11/2022]
Abstract
The short answer to this topic is "No, most incompetent bicuspid aortic valve should not be repaired." Aortic valve repair certainly plays an important role in the management of incompetent bicuspid aortic valve of young patients, and the selection criteria are like those for incompetent tricuspid aortic valve. The tissue that makes the cusps should normal or have minor abnormalities easily corrected by surgery such as plication of the free margin. In addition, the anatomic orientation of the conjoint and the normal cusps should be approximately at 180°. If the root is dilated, reimplantation of the aortic valve is likely the most reproducible approach, and if the root is not dilated but the annulus is, a subannular annuloplasty and correction of the cusp prolapse is adequate. Most patients with incompetent bicuspid aortic valve have malformed, fibrotic and calcified cusps and replacement with either pulmonary autograft or a mechanical aortic valve in young patients and a bioprosthetic aortic valve are likely to provide better long-term outcomes than aortic valve repair.
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Affiliation(s)
- Tirone E David
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada.
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16
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Matsushima S, Karliova I, Gauer S, Miyahara S, Schäfers HJ. Geometry of cusp and root determines aortic valve function. Indian J Thorac Cardiovasc Surg 2019; 36:64-70. [PMID: 33061186 DOI: 10.1007/s12055-019-00813-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/15/2019] [Accepted: 02/18/2019] [Indexed: 10/27/2022] Open
Abstract
The aortic valve is the functional unit of cusp and root. Various geometrical and functional analyses for the aortic valve unit have been executed to understand normal valve configuration and improve aortic valve repair. Different concepts and procedures have then been proposed for reparative approach, and aortic valve repair is still not standardized like mitral valve repair. It has become apparent, however, that interpretation of the geometry of the aortic cusp and root and its appropriate application to operative strategy lead to creating a functioning aortic valve. Herein, the aortic valve geometry and its clinical implications are reviewed to provide information for the selection of appropriate operative strategies.
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Affiliation(s)
- Shunsuke Matsushima
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saarland Germany
| | - Irem Karliova
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saarland Germany
| | - Simon Gauer
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saarland Germany
| | - Shunsuke Miyahara
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saarland Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saarland Germany
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de Kerchove L, Mastrobuoni S, Froede L, Tamer S, Boodhwani M, van Dyck M, El Khoury G, Schäfers HJ. Variability of repairable bicuspid aortic valve phenotypes: towards an anatomical and repair-oriented classification. Eur J Cardiothorac Surg 2019; 56:ezz033. [PMID: 30789231 DOI: 10.1093/ejcts/ezz033] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 01/03/2019] [Accepted: 01/06/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES: The bicuspid aortic valve (BAV) exists in a wide variety of valve phenotypes. The aim of this study was to assess the anatomical characteristics of the different phenotypes and develop a classification system to aid surgical repair. METHODS: In 178 consecutive patients operated on for aortic insufficiency or aortic dilatation in 2 centres, 11 anatomical parameters of BAV were measured by echocardiography and intraoperatively. All BAV judged potentially repairable were included in the study. RESULTS: Commissural orientation correlated positively with fusion length (R2 = 0.6, P < 0.001) and negatively with non-functional commissure height (R2 = 0.45, P < 0.001). The cohort was divided into 3 groups according to their commissural orientation (type A: symmetrical, 160-180°, n = 73; type B: asymmetrical, 140-159°, n = 74; and type C: very asymmetrical, 120-139°, n = 31). The patterns of cusp fusion, annulus and aortic size were similar among the groups. Fusion length and the geometric height of the cusps decreased from type A to C; non-functional commissure height increased from type A to C (P < 0.05). Patient age increased from type A to type C. Isolated aortic dilatation was more frequent in type A, and severe aortic insufficiency was more frequent in types B and C (P < 0.05). Valve repair techniques and management of commissural orientation varied among the 3 groups (P < 0.05). Aortic valve replacement and residual aortic insufficiency after repair were more frequent in type C (P < 0.05). CONCLUSIONS: The BAV phenotypes follow a continuous spectrum that extends from symmetrical to very asymmetrical BAV. We describe the main anatomical parameters (including commissure orientation, length of fusion and non-functional commissure height) and their variation across this spectrum. We propose a new repair-oriented classification system based on those parameters that can be used to predict valve repair techniques. This classification needs further validation with regards to surgical techniques and long-term outcomes.
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Affiliation(s)
- Laurent de Kerchove
- Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Stefano Mastrobuoni
- Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Lennart Froede
- Department of Cardiothoracic Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Saadallah Tamer
- Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Munir Boodhwani
- Department of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Canada
| | - Michel van Dyck
- Division of Anesthesiology, Department of Acute Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Gebrine El Khoury
- Division of Cardiothoracic and Vascular Surgery, Department of Cardiovascular Medicine, Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Hans-Joachim Schäfers
- Department of Cardiothoracic Surgery, Saarland University Medical Center, Homburg/Saar, Germany
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Miyahara S, Schneider U, Morgenthaler L, Schäfers HJ. (Almost) All Nonstenotic Bicuspid Aortic Valves Should Be Preserved or Repaired. Semin Thorac Cardiovasc Surg 2019; 31:656-660. [DOI: 10.1053/j.semtcvs.2019.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/18/2019] [Indexed: 11/11/2022]
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19
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Durability of Aortic Valve Cusp Repair With and Without Annular Support. Ann Thorac Surg 2018; 105:739-748. [DOI: 10.1016/j.athoracsur.2017.09.019] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 09/11/2017] [Indexed: 11/23/2022]
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20
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Izzat MB, Hamzeh K, Almohammad F. Precise moulded autologous pericardial configurations for aortic cusp reconstruction. Interact Cardiovasc Thorac Surg 2017; 24:819-822. [PMID: 28329206 DOI: 10.1093/icvts/ivx023] [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] [Received: 10/19/2016] [Accepted: 01/03/2017] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES In order to facilitate surgical repair of complex aortic cusp deformities and restoration of aortic valve competence, new moulds were developed to shape the glutaraldehyde-treated autologous pericardium into precise cusp-like configurations that can be used in aortic cusp reconstruction. METHODS The new moulds embodied the natural geometry of single aortic cusps, and a series of moulds were made available to correspond with all potential aortic cusp sizes. Aortic valve reconstruction using moulded autologous pericardial cusps was performed in 2 patients (both males, aged 14 and 19 years) with large outlet-type ventricular septal defects, extensive deformation of prolapsed right coronary cusps and severe aortic valve insufficiency. In each patient, the diseased right aortic cusp was excised and was replaced by a moulded autologous pericardial cusp that equalled the size of adjacent undiseased native cusps. RESULTS Excellent coaptation with adjoining native aortic cusps could be readily observed and intraoperative transoesophageal echocardiography confirmed satisfactory aortic valve repair (aortic insufficiency <1+ and low-transvalvular gradients). Follow-up transthoracic echocardiography confirmed that aortic valve function remained stable in both patients 2 years postoperatively. CONCLUSIONS Initial clinical experience indicated that constructing geometrically perfect cusp-like configurations was uncomplicated and implantation of the moulded autologous pericardial cusps restored adequate aortic valve competence. We believe that the simplicity and reproducibility of this approach may assist in the dissemination of aortic cusp reconstruction procedures.
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Affiliation(s)
| | - Khaled Hamzeh
- Damascus University Cardiac Surgery Hospital, Damascus, Syria
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21
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Thudt M, Papadopoulos N, Monsefi N, Miskovic A, Karimian-Tabrizi A, Zierer A, Moritz A. Long-Term Results Following Pericardial Patch Augmentation for Incompetent Bicuspid Aortic Valves: A Single Center Experience. Ann Thorac Surg 2017; 103:1186-1192. [DOI: 10.1016/j.athoracsur.2016.08.082] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2016] [Indexed: 11/28/2022]
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Kirklin JK. The regurgitant bicuspid aortic valve: Recalibrating our surgical strategies. J Thorac Cardiovasc Surg 2017; 153:S72-S73. [PMID: 28359375 DOI: 10.1016/j.jtcvs.2017.01.037] [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: 01/30/2017] [Accepted: 01/30/2017] [Indexed: 11/30/2022]
Affiliation(s)
- James K Kirklin
- Division of Cardiothoracic Surgery, Kirklin Institute for Research in Surgical Outcomes (KIRSO), University of Alabama at Birmingham, Birmingham, Ala; Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala.
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David TE, David CM, Feindel CM, Manlhiot C. Reimplantation of the aortic valve at 20 years. J Thorac Cardiovasc Surg 2017; 153:232-238. [DOI: 10.1016/j.jtcvs.2016.10.081] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 09/28/2016] [Accepted: 10/13/2016] [Indexed: 11/30/2022]
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Schneider U, Hofmann C, Aicher D, Takahashi H, Miura Y, Schäfers HJ. Suture Annuloplasty Significantly Improves the Durability of Bicuspid Aortic Valve Repair. Ann Thorac Surg 2017; 103:504-510. [DOI: 10.1016/j.athoracsur.2016.06.072] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 06/08/2016] [Accepted: 06/20/2016] [Indexed: 11/25/2022]
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Szymanski T, Maslow A, Mahmood F, Singh A. Three-Dimensional Imaging of the Repaired Aortic Valve. J Cardiothorac Vasc Anesth 2016; 30:1599-1610. [DOI: 10.1053/j.jvca.2016.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Indexed: 11/11/2022]
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26
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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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Abstract
The key for successful valve repair is full understanding of the regurgitant mechanism and sufficient evaluation of the valve. Currently, multidetector computed tomography has been introduced for evaluation. The aortic valve can be analyzed in details preoperatively. The main causes of aortic regurgitation (AR) in the adult population are degenerative leaflet change and annulus dilatation. Restoration to normal structure can be accomplished mainly by plication. Central leaflet plication near the Arantius nodule is a simple technique for redundant tissue. For leaflet deficiency, pericardial patch plasty may be an option. No universal technique exists for plication of the aortic annulus. The valve-sparing aortic root replacement firmly stabilizes the ventriculo-aortic junction (VAJ) and assures repair durability even in patients with mild to moderate root dilatation. Subcommissural annuloplasty (Cabrol stitch) does not seem sufficient for the prevention of VAJ dilatation. Circumferential annuloplasties may have a greater potential. However, convenient device for annular plication is still in development. The bicuspid aortic valve is a congenital heart valve lesion. A basic technique is free margin plication of the fused leaflet. Aortic root dilatation may contribute to AR severity. Valve-sparing aortic root replacement may improve repair durability. Considering the great advances in valve repair, young patients with AR should be informed that valve repair is a promising option for surgical treatment.
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Bicuspid aortic valve repair by complete conversion from “raphe'd” (type 1) to “symmetric” (type 0) morphology. J Thorac Cardiovasc Surg 2014; 148:2862-8.e1-2. [DOI: 10.1016/j.jtcvs.2014.05.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 04/20/2014] [Accepted: 05/09/2014] [Indexed: 11/18/2022]
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Mazzitelli D, Stamm C, Rankin JS, Pfeiffer S, Fischlein T, Pirk J, Choi YH, Detter C, Kroll J, Beyersdorf F, Shrestha M, Schreiber C, Lange R. Leaflet reconstructive techniques for aortic valve repair. Ann Thorac Surg 2014; 98:2053-60. [PMID: 25468084 DOI: 10.1016/j.athoracsur.2014.06.052] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 05/30/2014] [Accepted: 06/09/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Refining leaflet reconstruction has become a primary issue in aortic valve repair. This descriptive analysis reviews leaflet pathology, repair techniques, and early results in a prospective regulatory trial of aortic valve repair. METHODS Sixty-five patients underwent valve repair for predominant moderate to severe aortic insufficiency (AI). The mean age was 63 ± 13 years, and 69% of the patients were male. Ascending aortic/root replacement was required in 62%. As a first step, ring annuloplasty was performed, and then leaflet repair included leaflet plication for prolapse, nodular unfolding, double pericardial patching of commissural defects or holes, complete pericardial leaflet replacement, leaflet extension, and Gore-Tex reinforcement. Leaflet techniques and causes of adverse outcomes were evaluated. RESULTS The follow-up time was 2-years maximal and 0.9 years mean, with a survival of 97%. Eighty percent of patients required repair of leaflet defects: leaflet prolapse (52/65-80%), ruptured commissures (6/65-9%), leaflet holes (4/65-6%), and nodular retraction (6/65-9%). The average preoperative AI grade of 2.9 ± 0.8 fell to 0.7 ± 0.7 (p < 0.0001). Three patients (4.6%) required interval valve replacement because of (1) suture untying, (2) iatrogenic leaflet tear, or (3) diphtheroid endocarditis. Five other patients experienced grade 2 or grade 3 AI: probable suture untying in 1 patient, ineffective leaflet extensions in 2 patients, and unsuccessful Gore-Tex reinforcements in 2 patients. Two patients with single pericardial leaflet replacements and all those with double pericardial reconstructions did well. CONCLUSIONS Leaflet defects are common in patients with moderate to severe AI. Leaflet plication, nodular unfolding, and double pericardial patching performed well. Gore-Tex and leaflet extension seemed less satisfactory. Standardization and experience with leaflet reconstruction will be important for optimizing the outcomes of aortic valve repair.
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Affiliation(s)
| | | | | | | | | | - Jan Pirk
- Institute for Clinical and Experimental Medicine, Prague, Czechoslovakia
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Aortic valve reconstruction using autologous pericardium for patients aged less than 60 years. J Thorac Cardiovasc Surg 2014; 148:934-8. [DOI: 10.1016/j.jtcvs.2014.05.041] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/10/2014] [Accepted: 05/16/2014] [Indexed: 11/17/2022]
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Regeer MV, Kamperidis V, Versteegh MIM, Klautz RJM, Scholte AJHA, Bax JJ, Schalij MJ, Marsan NA, Delgado V. Aortic valve and aortic root features in CT angiography in patients considered for aortic valve repair. J Cardiovasc Comput Tomogr 2014; 8:299-306. [PMID: 25151922 DOI: 10.1016/j.jcct.2014.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 06/19/2014] [Accepted: 06/23/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND The underlying mechanism of aortic regurgitation and aortic valve and root characteristics are associated with the durability of surgical repair. OBJECTIVE We investigated whether multidetector CT (MDCT) identifies the characteristics of the aortic valve and root that may be associated with the ability to perform successful surgical repair. METHODS Sixty-one patients with aortic regurgitation and/or aortic root pathology who were evaluated for aortic valve or root repair and underwent clinically indicated gated or nongated MDCT of the aortic valve and aortic root were included in the present analysis. Patients with endocarditis were excluded. MDCT data of aortic valve anatomy and calcification and thoracic aorta dimensions were analyzed. RESULTS The aortic valve and root was successfully repaired in 36 patients (55 ± 13 years; 61% male; median EuroSCORE II, 3.8%) whereas in 25 patients (56 ± 15 years; 52% male; median EuroSCORE II, 2.5%) repair was not attempted (n = 20) or valve repair was converted to aortic valve replacement during surgery (n = 5). In patients in whom repair was considered not possible or failed, there was a higher percentage of bicuspid aortic valves (48% vs 17%; P = .019), more severe commissural calcification, and more severe annular calcification. CONCLUSION The degree of commissural and annular calcification of the aortic valve determined by MDCT is inversely related to the ability to perform surgical valve repair instead of replacement. Similarly, bicuspid valve anatomy predicts failure to perform repair.
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Affiliation(s)
- Madelien V Regeer
- Department of Cardiology, Heart Center Leiden, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Vasileios Kamperidis
- Department of Cardiology, Heart Center Leiden, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Michel I M Versteegh
- Department of Cardiology, Heart Center Leiden, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Robert J M Klautz
- Department of Cardiology, Heart Center Leiden, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Arthur J H A Scholte
- Department of Cardiology, Heart Center Leiden, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Heart Center Leiden, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Martin J Schalij
- Department of Cardiology, Heart Center Leiden, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Heart Center Leiden, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Heart Center Leiden, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands.
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Svensson LG, Al Kindi AH, Vivacqua A, Pettersson GB, Gillinov AM, Mihaljevic T, Roselli EE, Sabik JF, Griffin B, Hammer DF, Rodriguez L, Williams SJ, Blackstone EH, Lytle BW. Long-Term Durability of Bicuspid Aortic Valve Repair. Ann Thorac Surg 2014; 97:1539-47; discussion 1548. [DOI: 10.1016/j.athoracsur.2013.11.036] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 11/13/2013] [Accepted: 11/19/2013] [Indexed: 02/03/2023]
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Ozaki S, Kawase I, Yamashita H, Uchida S, Nozawa Y, Takatoh M, Hagiwara S, Kiyohara N. Reconstruction of bicuspid aortic valve with autologous pericardium--usefulness of tricuspidization. Circ J 2014; 78:1144-51. [PMID: 24614492 DOI: 10.1253/circj.cj-13-1335] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND This study describes the surgical treatment of bicuspid aortic valve with original aortic valve reconstruction. METHODS AND RESULTS Aortic valve reconstruction was done in 102 patients with bicuspid aortic valve from April 2007 through September 2011. Thirty-four patients with ascending aortic diameter >45 mm underwent hemi-arch aortic replacement concomitantly. Seventy-seven patients had aortic stenosis, and 25 had aortic regurgitation (AR). Mean age was 63.7±10.0 years old. There were 55 men and 47 women. Harvested pericardium is treated with 0.6% glutaraldehyde solution. The distance between commissures is measured with an original sizing instrument. For bicuspid valve with raphe, the raphe is considered as a commissure in order to measure the distance between each commissure. Without a raphe, we create a new annular margin and commissure using coronary ostium and the sizing instrument as a guide. Then, pericardium is trimmed with original template. Three cusps are sutured independently. The preoperative averaged peak pressure gradient of 71.1±39.0 mmHg was decreased to 16.2±8.8, 13.3±6.0, and 13.9±5.6 mmHg, respectively 1 week, 1 year, and 3 years after operation. AR was trivial. One reoperation was recorded. Mean follow-up was 733 days. There were 5 late mortalities. No thromboembolic event was recorded. CONCLUSIONS Medium-term results were excellent. Tricuspidization gave good opening and closure of aortic valve with excellent hemodynamics.
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Affiliation(s)
- Shigeyuki Ozaki
- Department of Cardiovascular Surgery, Toho University Ohashi Medical Center
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Fedak PWM, David TE, Borger M, Verma S, Butany J, Weisel RD. Bicuspid aortic valve disease: recent insights in pathophysiology and treatment. Expert Rev Cardiovasc Ther 2014; 3:295-308. [PMID: 15853603 DOI: 10.1586/14779072.3.2.295] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Bicuspid aortic valve is a common congenital cardiac malformation with a broad spectrum of clinical outcomes. Bicuspid aortic valve may go undetected throughout an individual's lifetime or, alternatively, they may have devastating clinical consequences, resulting in death. Both clinicians and medical scientists have taken a renewed interest in the development, pathophysiology and treatment options for this subtle but often substantial clinical entity. Evidence is mounting to suggest that an underlying disease of the aorta is inherited with bicuspid aortic valve, although considerable controversy surrounds this theory. Novel molecular mechanisms underlying the valve and vascular pathologies, as well as new surgical therapies for these patients have been proposed in the past 10 years.
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Affiliation(s)
- Paul W M Fedak
- University of Toronto, Division of Cardiac Surgery, Toronto General Hospital, 14EN-200 Elizabeth Street, Toronto, Ontario, M5C 2G4, Canada.
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Abstract
Stentless aortic xenografts were introduced into clinical practice as aortic valve substitutes over a decade ago. Stentless prosthetic valves were expected to provide enhanced durability and more physiologic hemodynamic behavior when compared with stented bioprostheses. Whilst the former expectation has not been fulfilled, partly due to concomitantly improved durability of second-generation stented bioprostheses, the latter has consistently been satisfied in early and late clinical observation. Evidence is accumulating suggesting improved long-term survival due to more timely and thorough regression of ventricular hypertrophy. In addition, stentless xenografts have shown extreme versatility when adopted in a variety of complex clinical conditions associated with aortic valve disease, including small aortic anulus, ascending aortic aneurysm, endocarditis and left ventricular dysfunction. Future research in the form of prospective, multicenter, randomized trials must address the issues of very long-term durability and survival, while simplification in valve design is required to promote wider use of stentless valves.
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Tourmousoglou C, Lalos S, Dougenis D. Is aortic valve repair or replacement with a bioprosthetic valve the best option for a patient with severe aortic regurgitation? Interact Cardiovasc Thorac Surg 2013; 18:211-8. [PMID: 24203980 DOI: 10.1093/icvts/ivt453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is best to repair or replace the aortic valve with a bioprosthesis in young patients with severe aortic regurgitation as the patients do not like to take warfarin for the rest of life. Altogether 74 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The results of the reported studies provided interesting results. All the studies identified are retrospective. Three papers reported the results about the Ross operation for aortic valve (AV) disease. Freedom from autograft reoperation at 10 years was from 81 to 84%, at 15 years 92% and at 18 years 51%. Freedom from aortic insufficiency (AI) (moderate to severe) at 15 years was 89.7%. Four papers reported that freedom from AV reoperation after AV repair at 5 years was from 86 to 94% and at 8 years was from 83 to 93%. Freedom from recurrent AI (>2+) at 5 years was from 85 to 94%. One study showed that reoperation-free survival after AV repair for rheumatic valve disease at 160 months was 85%. Two papers compared AV repair with aortic valve replacement (AVR) with a bioprosthetic valve and found that freedom from AV reoperation at 5 years was from 90 to 91% for the repair group and 94 to 98% for AVR. Freedom from AI (moderate or severe) at 5 years was 79% for the repair group and 94% for AVR. Aortic valve repair yielded good early and mid-term results. It is a viable alternative to replacement with a bioprosthesis, especially for young patients who did not like to take warfarin. The Ross operation appeared to be a good choice for selected patients with AV disease.
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Bradley SM. Aortic Valve Insufficiency in the Teenager and Young Adult. World J Pediatr Congenit Heart Surg 2013; 4:397-402. [DOI: 10.1177/2150135113488781] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The contents of this article were presented in the session “Aortic insufficiency in the teenager” at the congenital parallel symposium of the 2013 Society of Thoracic Surgeons (STS) annual meeting. The accompanying articles detail the approaches of aortic valve repair and the Ross procedure.1,2 The current article focuses on prosthetic valve replacement. For many young patients requiring aortic valve surgery, either aortic valve repair or a Ross procedure provides a good option. The advantages include avoidance of anticoagulation and potential for growth. In other patients, a prosthetic valve is an appropriate alternative. This article discusses the current state of knowledge regarding mechanical and bioprosthetic valve prostheses and their specific advantages relative to valve repair or a Ross procedure. In current practice, young patients requiring aortic valve surgery frequently undergo valve replacement with a prosthetic valve. In STS adult cardiac database, among patients ≤30 years of age undergoing aortic valve surgery, 34% had placement of a mechanical valve, 51% had placement of a bioprosthetic valve, 9% had aortic valve repair, and 2% had a Ross procedure. In the STS congenital database, among patients 12 to 30 years of age undergoing aortic valve surgery, 21% had placement of a mechanical valve, 18% had placement of a bioprosthetic valve, 30% had aortic valve repair, and 24% had a Ross procedure. In the future, the balance among these options may be altered by design improvements in prosthetic valves, alternatives to warfarin, the development of new patch materials for valve repair, and techniques to avoid Ross autograft failure.
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Affiliation(s)
- Scott M. Bradley
- Pediatric Cardiac Surgery, Medical University of South Carolina, Charleston, SC, USA
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Aicher D, Schäfers HJ. Aortic valve repair--current status, indications, and outcomes. Semin Thorac Cardiovasc Surg 2013. [PMID: 23200074 DOI: 10.1053/j.semtcvs.2012.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Aortic valve repair is a new development with old roots. In the past 20 years, marked progress has been made in understanding the normal anatomy of the aortic valve and the interrelation between cusps and root. Aortic dilatation is the single most frequent pathogenetic factor in aortic regurgitation, accompanied by cusp pathology, that is, prolapse or congenital anomaly in most industrialized countries. Frequently, aortic and cusp pathology coexist. Different operative techniques have been established for correction of aortic and cusp pathology. Experience has shown that the combined application of repair procedures will lead to good results if normal valve and cusp configuration is achieved. Some congenital anomalies may require design alteration of the aortic valve. Low-operative mortality rates have been reported consistently. When adequate repair durability is achieved, the incidence of valve-related complications is lower than what has been reported for valve replacement. Aortic valve repair is currently in transition from surgical improvisation to a reproducible operation and an option for many patients with aortic regurgitation. Current research focuses on some special aspects, such as stabilization of the basal ring, ideal material and technique for cusp replacement, and more objective information on ideal valve configuration.
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Affiliation(s)
- Diana Aicher
- Department of Thoracic and Cardiovascular Surgery, University of Saarland Medical Center, Homburg/Saar, Germany
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Svensson LG, Adams DH, Bonow RO, Kouchoukos NT, Miller DC, O'Gara PT, Shahian DM, Schaff HV, Akins CW, Bavaria JE, Blackstone EH, David TE, Desai ND, Dewey TM, D'Agostino RS, Gleason TG, Harrington KB, Kodali S, Kapadia S, Leon MB, Lima B, Lytle BW, Mack MJ, Reardon M, Reece TB, Reiss GR, Roselli EE, Smith CR, Thourani VH, Tuzcu EM, Webb J, Williams MR. Aortic Valve and Ascending Aorta Guidelines for Management and Quality Measures. Ann Thorac Surg 2013; 95:S1-66. [DOI: 10.1016/j.athoracsur.2013.01.083] [Citation(s) in RCA: 160] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 12/24/2012] [Accepted: 01/15/2013] [Indexed: 12/31/2022]
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Vohra HA, Whistance RN, De Kerchove L, Punjabi P, El Khoury G. Valve-preserving surgery on the bicuspid aortic valve. Eur J Cardiothorac Surg 2013; 43:888-98. [DOI: 10.1093/ejcts/ezs664] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Aicher D, Schneider U, Schmied W, Kunihara T, Tochii M, Schäfers HJ. Early results with annular support in reconstruction of the bicuspid aortic valve. J Thorac Cardiovasc Surg 2012; 145:S30-4. [PMID: 23260458 DOI: 10.1016/j.jtcvs.2012.11.059] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2012] [Revised: 08/03/2012] [Accepted: 11/28/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Repair of the bicuspid aortic valve may be performed in aortic regurgitation and aneurysm. Dilatation of the atrioventricular junction has been identified as a risk factor for repair failure, and we have used suture annuloplasty to correct atrioventricular junction enlargement. The objective was to compare the early results of aortic repair with and without annuloplasty. METHODS Between November 1995 and January 12, a total of 559 patients were treated with bicuspid aortic valve repair for predominant regurgitation (n = 389), aortic aneurysm (n = 158), or acute dissection (n = 12). Isolated valve repair (aortic valve repair) was performed for aortic valve regurgitation with preserved aortic dimensions (n = 208) and sinotubular junction remodeling plus valve repair for aortic aneurysm and preserved root size (n = 116). Root remodeling was used for dilatation involving the root (n = 235). In 193 patients, dilatation of the atrioventricular junction (>27 mm) was corrected with suture annuloplasty. RESULTS Hospital mortality was 0.5% (n = 3); 2 patients required pacemaker implantation. Reoperation was necessary for recurrent regurgitation (n = 54) or stenosis (n = 2); 10-year freedom from reoperation was 82% but was inferior after isolated valve repair (70%, P = .007) compared with the 2 other techniques. Application of suture annuloplasty improved 3-year freedom from reoperation after isolated repair (84%) to 92% (P = .07). In all groups, the proportion of patients with no or trivial regurgitation was significantly higher with annuloplasty. CONCLUSIONS Preservation of the bicuspid aortic valve is feasible in many patients. Long-term stability of the repaired valves is good; the negative impact of a dilated atrioventricular junction can be reduced by suture annuloplasty.
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Affiliation(s)
- Diana Aicher
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
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Fattouch K, Murana G, Castrovinci S, Nasso G, Mossuto C, Corrado E, Ruvolo G, Speziale G. Outcomes of aortic valve repair according to valve morphology and surgical techniques. Interact Cardiovasc Thorac Surg 2012; 15:644-50. [PMID: 22761124 DOI: 10.1093/icvts/ivs195] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess the impact of aortic valve morphology and different surgical aortic valve repair techniques on long-term clinical outcomes. METHODS Between February 2003 and May 2010, 216 patients with aortic insufficiency underwent aortic valve repair in our institution. Ages ranged between 26 and 82 years (mean 53 ± 15 years). Aortic valve dysfunctions, according to functional classification, were: type I in 55 patients (25.5%), type II in 126 (58.3%) and type III in 35 (16.2%). Sixty-six patients (27.7%) had a bicuspid valve. Aortic valve repair techniques included sub-commissural plasty in 138 patients, plication in 84, free-edge reinforcement in 80, resection of raphe plus re-suturing in 40 and the chordae technique in 52. Concomitant surgical procedures were CABG in 22 (10%) patients, mitral valve repair in 12 (5.5%), aortic valve-sparing re-implantation in 78 (36%) and ascending aorta replacement in 69 (32%). Mean follow-up was 42 ± 16 months and was 100% complete. RESULTS There were six early deaths (2.7%). Overall late survival was 91.5% (18 late deaths). There were 15 (6.9%) late cardiac-related deaths. NYHA functional class was ≤ II in all patients. At follow-up, 28 (14.5%) patients had recurrent aortic insufficiency ≥ grade II. The freedom from valve-related events was significantly different between bicuspid and tricuspid valve implantation (P < 0.01), between type I + II and type III (P < 0.001) dysfunction and between the chordae technique and plication, compared to free-edge reinforcement (P < 0.01). Statistically-significant differences were found between patients who underwent aortic valve repair plus root re-implantation, compared to those who underwent isolated aortic valve repair (P = 0.02). CONCLUSIONS Aortic valve repair including aortic annulus stabilization is a safe surgical option with either tricuspid or bicuspid valves; even more so if associated with root re-implantation. Patients with calcified bicuspid valves have poor results.
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Affiliation(s)
- Khalil Fattouch
- Department of Cardiac Surgery, University of Palermo, Palermo, Italy.
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Results of matching valve and root repair to aortic valve and root pathology. J Thorac Cardiovasc Surg 2011; 142:1491-8.e7. [DOI: 10.1016/j.jtcvs.2011.04.025] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Revised: 04/13/2011] [Accepted: 04/26/2011] [Indexed: 11/22/2022]
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Oka T, Okita Y, Matsumori M, Okada K, Minami H, Munakata H, Inoue T, Tanaka A, Sakamoto T, Omura A, Nomura T. Aortic regurgitation after valve-sparing aortic root replacement: modes of failure. Ann Thorac Surg 2011; 92:1639-44. [PMID: 21945227 DOI: 10.1016/j.athoracsur.2011.06.080] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2011] [Revised: 06/19/2011] [Accepted: 06/22/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND Despite the positive clinical results of valve-sparing aortic root replacement, little is known about the causes of reoperations and the modes of failure. METHODS From October 1999 to June 2010, 101 patients underwent valve-sparing aortic root replacement using the David reimplantation technique. The definition of aortic root repair failure included the following: (1) intraoperative conversion to the Bentall procedure; (2) reoperation performed because of aortic regurgitation; and (3) aortic regurgitation equal to or greater than a moderate degree at the follow-up. Sixteen patients were considered to have repair failure. Three patients required intraoperative conversion to valve replacement, 3 required reoperation within 3 months, and another 8 required reoperation during postoperative follow-up. At initial surgery 5 patients had moderate to severe aortic regurgitation, 6 patients had acute aortic dissections, 3 had Marfan syndrome, 2 had status post Ross operations, 3 had bicuspid aortic valves, and 1 had aortitis. Five patients had undergone cusp repair, including Arantius plication in 3 and plication at the commissure in 2. RESULTS The causes of early failure in 6 patients included cusp perforation (3), cusp prolapse (3), and severe hemolysis (1). The causes of late failure in 10 patients included cusp prolapse (4), commissure dehiscence (3), torn cusp (2), and cusp retraction (1). Patients had valve replacements at a mean of 23 ± 20.9 months after reimplantation and survived. CONCLUSIONS Causes of early failure after valve-sparing root replacement included technical failure, cusp lesions, and steep learning curve. Late failure was caused by aortic root wall degeneration due to gelatin-resorcin-formalin glue, cusp degeneration, or progression of cusp prolapse.
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Affiliation(s)
- Takanori Oka
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Bicuspid aortic valve surgery with proactive ascending aorta repair. J Thorac Cardiovasc Surg 2011; 142:622-9, 629.e1-3. [DOI: 10.1016/j.jtcvs.2010.10.050] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Revised: 09/22/2010] [Accepted: 10/24/2010] [Indexed: 11/30/2022]
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Fattouch K, Sampognaro R, Speziale G, Ruvolo G. New Technique for Aortic Valve Functional Annulus Reshaping Using a Handmade Prosthetic Ring. Ann Thorac Surg 2011; 91:1154-8. [DOI: 10.1016/j.athoracsur.2010.12.050] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Revised: 12/24/2010] [Accepted: 12/29/2010] [Indexed: 11/26/2022]
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Quality of life after aortic valve surgery: replacement versus reconstruction. J Thorac Cardiovasc Surg 2011; 142:e19-24. [PMID: 21450311 DOI: 10.1016/j.jtcvs.2011.02.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 01/12/2011] [Accepted: 02/09/2011] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Quality of life has been shown to be influenced by aortic valve replacement, particularly in younger patients. Aortic valve repair is a recent alternative to replacement. We investigated quality of life and anxiety and depression after aortic valve repair and compared with 2 established replacement alternatives, mechanical valve and pulmonary autograft. METHODS In a cross-sectional study, 166 patients (age, 18-45 years) were studied after isolated elective aortic valve surgery. They had undergone aortic valve repair (group I, n = 86), replacement with mechanical prosthesis (group II, n = 41), or pulmonary autograft (group III, n = 39). Assessment was performed by Short Form Health Survey, Hospital Anxiety and Depression Scale, Cardiac Anxiety Questionnaire, and valve-specific questions. RESULTS In Short Form Health Survey, groups I and III revealed similar or identical scores better than group II in physical functioning (P = .02), general health (P = .03), and mental health (P = .05). No differences were found in Hospital Anxiety and Depression Scale score. In cardiac anxiety, there was less heart-focused attention in groups I and III than in group II (P = .043, P = .053). In response to valve-specific questions, there were no differences between groups I and III. Interestingly, fear of reoperation was identical in all 3 groups. CONCLUSIONS In young patients after aortic valve surgery quality of life is influenced by type of operation. Although differences are limited, aortic valve reconstruction and pulmonary autograft replacement lead to less long-term alteration from normal values.
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Are bicuspid aortic valves a limitation for aortic valve repair? Eur J Cardiothorac Surg 2011; 40:1097-104. [PMID: 21420874 DOI: 10.1016/j.ejcts.2011.02.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2010] [Revised: 01/31/2011] [Accepted: 02/01/2011] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To compare the mid-term results after aortic valve (AV) repair in bicuspid AVs with those in tricuspid AVs. METHODS Between 2000 and 2010, 100 patients (mean age 47.2 years) underwent AV repair procedures for insufficient bicuspid AV (n=43) and tricuspid AV (n=57). Aortic regurgitation (AR) more than moderate was present in 31/43 and 21/57 patients in the bicuspid AV and the tricuspid AV group, respectively. Concomitant root replacement by either the reimplantation or the remodeling technique was performed in 42 patients (bicuspid AV 17/43, tricuspid AV 25/57). All patients were prospectively studied with postoperative and further annual clinical assessment and echocardiography. Follow-up was 99% complete with a mean follow-up time of 22 months. RESULTS Three patients died during the initial hospitalization, all due to postoperative cardiac failure. Overall actuarial 3 years' survival was 93±4.2% without significant differences between the two groups. Overall actuarial 3 years' freedom from AV-related reoperation was 86±5.1% without significant differences between the groups (85±9.7% for bicuspid AV, 86±6.0% for tricuspid AV; log-rank test: p=0.98). Overall actuarial 3 years' freedom from recurrent AR≥moderate was 100% and AR>trace was 71.3±8.2% without significant differences between the groups (76.5±11.7% for bicuspid AV, 71.4±9.4 for tricuspid AV; log-rank test: p=0.97). CONCLUSIONS The mid-term outcome in terms of survival, freedom from reoperation or recurrent AR is similar for both groups of patients after AV repair procedures. Therefore, we advocate valve repair also in patients presenting with an insufficient bicuspid AV.
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Aicher D, Kunihara T, Abou Issa O, Brittner B, Gräber S, Schäfers HJ. Valve Configuration Determines Long-Term Results After Repair of the Bicuspid Aortic Valve. Circulation 2011; 123:178-85. [DOI: 10.1161/circulationaha.109.934679] [Citation(s) in RCA: 273] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Reconstruction of the regurgitant bicuspid aortic valve has been performed for >10 years, but there is limited information on long-term results. We analyzed our results to determine the predictors of suboptimal outcome.
Methods and Results—
Between November 1995 and December 2008, 316 patients (age, 49±14 years; male, 268) underwent reconstruction of a regurgitant bicuspid aortic valve. Intraoperative assessment included extent of fusion, root dimensions, circumferential orientation of the 2 normal commissures (>160°, ≤160°), and effective height after repair. Cusp pathology was treated by central plication (n=277), triangular resection (n=138), or pericardial patch (n=94). Root dilatation was treated by subcommissural plication (n=100), root remodeling (n=122), or valve reimplantation (n=2). All patients were followed up echocardiographically (cumulative follow-up, 1253 years; mean, 4±3.1 years). Clinical and morphological parameters were analyzed for correlation with 10-year freedom from reoperation with the Cox proportional hazards model. Hospital mortality was 0.63%; survival was 92% at 10 years. Freedom from reoperation at 5 and 10 years was 88% and 81%; freedom from valve replacement, 95% and 84%. By univariable analysis, statistically significant predictors of reoperation were age (hazard ratio [HR]=0.97), aortoventricular diameter (HR=1.24), effective height (HR=0.76), commissural orientation (HR=0.95), use of a pericardial patch (HR=7.63), no root replacement (HR=3.80), subcommissural plication (HR=2.07), and preoperative aortic regurgitation grade 3 or greater. By multivariable analysis, statistically significant predictors for reoperation were age (HR=0.96), aortoventricular diameter (HR=1.30), effective height (HR=0.74), commissural orientation (HR=0.96), and use of a pericardial patch (HR=5.16).
Conclusions—
Reconstruction of bicuspid aortic valve can be performed reproducibly with good early results. Recurrence and progression of regurgitation, however, may occur, depending primarily on anatomic features of the valve.
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Affiliation(s)
- Diana Aicher
- From the Department of Thoracic and Cardiovascular Surgery (D.A., T.K., O.A.I., B.B., H.-J.S.) and Institute of Medical Biometry, Epidemiology and Medical Informatics, (S.G.) University Hospital of Saarland, Homburg, Germany
| | - Takashi Kunihara
- From the Department of Thoracic and Cardiovascular Surgery (D.A., T.K., O.A.I., B.B., H.-J.S.) and Institute of Medical Biometry, Epidemiology and Medical Informatics, (S.G.) University Hospital of Saarland, Homburg, Germany
| | - Omar Abou Issa
- From the Department of Thoracic and Cardiovascular Surgery (D.A., T.K., O.A.I., B.B., H.-J.S.) and Institute of Medical Biometry, Epidemiology and Medical Informatics, (S.G.) University Hospital of Saarland, Homburg, Germany
| | - Brigitte Brittner
- From the Department of Thoracic and Cardiovascular Surgery (D.A., T.K., O.A.I., B.B., H.-J.S.) and Institute of Medical Biometry, Epidemiology and Medical Informatics, (S.G.) University Hospital of Saarland, Homburg, Germany
| | - Stefan Gräber
- From the Department of Thoracic and Cardiovascular Surgery (D.A., T.K., O.A.I., B.B., H.-J.S.) and Institute of Medical Biometry, Epidemiology and Medical Informatics, (S.G.) University Hospital of Saarland, Homburg, Germany
| | - Hans-Joachim Schäfers
- From the Department of Thoracic and Cardiovascular Surgery (D.A., T.K., O.A.I., B.B., H.-J.S.) and Institute of Medical Biometry, Epidemiology and Medical Informatics, (S.G.) University Hospital of Saarland, Homburg, Germany
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