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Argaw S, Azizgolshani N, Blitzer D, Takayama H, George I, Pirelli L. Treatment options for isolated aortic valve insufficiency: a review. Front Cardiovasc Med 2024; 11:1381102. [PMID: 38665234 PMCID: PMC11043486 DOI: 10.3389/fcvm.2024.1381102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Aortic insufficiency (AI) is a valvular disease with increasing prevalence in older patients. The modern era provides numerous options for the management of AI which is explored here. Traditional interventions included aortic valve replacement with either mechanical or bioprosthetic aortic valves. While the former is known for its durability, it has grown out of favor due to the potential complications of anticoagulation. The preference for bioprosthetic valves is thus on the rise, especially with the advancements of transcatheter technology and the use of valve-in-valve therapy. Surgical options are also no longer limited to replacement but include complex techniques such as those required for aortic valve repair, Ozaki neocuspidization, Ross procedure and valve-sparring aortic root repair. Transcatheter options for the management of AI are not commercially available currently; however, preliminary data from ad-hoc trials, showed promising results and potential use of transcatheter technology in a variety of patients with pure AI.
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Affiliation(s)
| | | | | | | | | | - Luigi Pirelli
- Division of Cardiovascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, United States
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2
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Valve-Sparing Aortic Root Replacement Technique: Valsalva Graft versus Two Straight Tubular Grafts. Cardiol Res Pract 2023; 2023:4076881. [PMID: 36776960 PMCID: PMC9918367 DOI: 10.1155/2023/4076881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 12/13/2022] [Accepted: 01/04/2023] [Indexed: 02/05/2023] Open
Abstract
Background There are many variations in valve-sparing aortic root replacement techniques. Our aim is to determine the impact of the graft on mid-term outcomes: Valsalva graft vs. two straight tubular grafts. Methods From 2004 to 2020, 332 patients underwent valve-sparing aortic root replacement with either a Valsalva graft (Valsalva group: n = 270) or two straight tubular grafts (two-graft group: n = 62). Data were obtained through chart review and the National Death Index. Primary outcomes were mid-term survival and freedom from reoperation. Results The preoperative characteristics of the groups were similar, but the two-graft group had more type A dissections (32% vs. 19%) and emergent operations (26% vs. 15%) and was younger (45 vs. 50 years). Intraoperatively, the groups were similar, but the two-graft group had longer cross-clamp (245 vs. 215 minutes) and cardiopulmonary bypass times (284 vs. 255 minutes). Postoperative complications including reoperation for bleeding, stroke, pacemaker implantation, and renal failure were slightly more frequent in the Valsalva group, but the differences were not significant. Operative mortality was similar between the Valsalva and two-graft groups (0.7% vs. 0%). Five-year survival in the two-graft group was 100% compared to 96% in the Valsalva group (p=0.56). Five-year freedom from reoperation in the two-graft group was 100% compared to 93% in the Valsalva group (p=0.29). Conclusions The Valsalva and two-graft techniques both have excellent short- and mid-term outcomes. The two-graft technique might have slightly better survival and freedom from reoperation, but a larger sample size and longer follow-up are needed to determine if these advantages are significant.
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Sadri V, Madukauwa-David ID, Yoganathan AP. In vitro evaluation of a new aortic valved conduit. J Thorac Cardiovasc Surg 2019; 161:581-590.e6. [PMID: 31879167 DOI: 10.1016/j.jtcvs.2019.09.181] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/16/2019] [Accepted: 09/19/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study examined whether the presence of a sinus of Valsalva equivalent in the KONECT RESILIA aortic valved conduit (Edwards Lifesciences, Irvine, Calif) improves valve hemodynamics, kinematics, and performance. METHODS A 28-mm KONECT RESILIA aortic valved conduit was used to create an in vitro flow test model, and the same aortic valved conduit model without a sinus section was used as a control. Particle image velocimetry and hydrodynamic characterization experiments were conducted in the vicinity of the valves in a validated left-heart simulator at 3 cardiac output levels. In addition, leaflet kinematics of the valves were determined through en face high-speed imaging. RESULTS The KONECT RESILIA aortic valved conduit model exhibited lower mean and peak transvalvular pressure gradients than the control model at all 3 cardiac outputs. In addition, its leaflets opened more fully than did those of the valved conduit without the sinuses, yielding greater effective and geometric orifice areas. It was found that the presence of the sinuses not only facilitated the development of larger and more stable vortices at the initial stages of the cardiac cycle but also helped to maintain these vortices during the late stages of the cardiac cycle, leading to smoother valve closure. CONCLUSIONS The KONECT RESILIA aortic valved conduit reproduces the bulged section of the aortic root corresponding to the sinuses of Valsalva. With this Valsalva-type conduit, larger orifice areas were observed, improving valve hemodynamics that may enhance performance.
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Affiliation(s)
- Vahid Sadri
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Ga
| | | | - Ajit P Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Ga.
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Cevasco M, McGurk S, Yammine M, Sharma L, Ejiofor J, Norman A, Singh MN, Shekar P. Early and Midterm Outcomes of Valve-Sparing Aortic Root Replacement-Reimplantation Technique. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2019; 6:113-117. [PMID: 30934106 PMCID: PMC6443388 DOI: 10.1055/s-0039-1683383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background
Valve-sparing aortic root replacement (VSARR) is an increasingly popular alternative to traditional aortic root replacement for aortic root aneurysm disease with a normal aortic valve. We evaluated the early and midterm outcomes of VSARR—reimplantation technique (VSARR-RT) done at a single institution over a decade.
Materials and Methods
We performed a retrospective study of all patients who underwent VSARR-RT between January 2004 and July 2014.
Results
A total of 85 patients underwent VSARR-RT. Median time to latest echocardiographic follow-up was 4 years (range: 15–72 months). Total observation time was 491 patient years. Mean age was 44.6 ± 14.3 years, and 13 (15%) were women. Thirty-nine (46%) patients had a connective tissue disorder and 6 (7%) had a bicuspid aortic valve. Thirty-three (39%) patients underwent concomitant procedures, including coronary artery bypass grafting (
n
= 9, 11%), mitral valve repair (
n
= 8, 9%), and aortic hemi-arch replacement (
n
= 7, 8%). There were no operative deaths or in-house mortality and no postoperative strokes. Kaplan-Meier analysis demonstrated survival of 99% (95% confidence interval [CI]: 97–100%) at 2 years and 98% (95% CI: 97–100%) at 8 years. Freedom from reoperation was 95.8% (95% CI: 91.2–100%) at 8 years. Freedom from endocarditis was 100% at 8 years. At the last echocardiographic follow-up, 95% of patients were free of severe aortic regurgitation (AR) and 82% free of moderate AR. Of the four patients who had severe AR, three underwent reoperations and received prosthetic valves and one is being clinically monitored.
Conclusion
This study reports early and midterm outcomes after VSARR-RT at our institution, including those patients who underwent a VSARR-RT procedure combined with other procedures. Further follow-up remains necessary to determine long-term outcomes.
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Affiliation(s)
- Marisa Cevasco
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Maroun Yammine
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lokesh Sharma
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Julius Ejiofor
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Anthony Norman
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael N Singh
- Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Prem Shekar
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Chirichilli I, Irace F, Weltert L, Tsuda K, Scaffa R, Salica A, Galea N, De Paulis R. Morphological modification of the aortic annulus in tricuspid and bicuspid valves after aortic valve reimplantation: an electrocardiography-gated computed tomography study†. Eur J Cardiothorac Surg 2019; 56:778-784. [DOI: 10.1093/ejcts/ezz065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 02/02/2019] [Accepted: 02/07/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
OBJECTIVES:
Aortic valve-sparing operations have been shown to produce fewer valve-related complications than valve replacement. The aortic root is a morphological and functional unit in which the annulus plays an important role on dynamism, shape and geometry of the valve with different results in bicuspid aortic valves (BAVs) or tricuspid aortic valves (TAVs). The aim is to evaluate the differences in the size and shape of the aortic annulus between native BAVs and TAVs using ECG-gated computed tomography (CT) after a reimplantation procedure.
METHODS:
We selected 35 patients scheduled for aortic valve reimplantation who underwent good-quality preoperative and postoperative ECG-gated contrast-enhanced CT scan of the aortic root. Twenty-three patients had TAV, 8 patients type 1 BAV and 4 patients type 0 BAV. Major diameter and minor diameter, perimeter (P) and area (A) were measured. The shape of the aortic annulus was considered ‘circular’ or ‘elliptic’ according to the Ellipticity Index. We also selected a subgroup of 18 patients (9 TAVs and 9 BAVs) to evaluate annular shape and size variations through the cardiac cycle and to study the expansibility both in the preoperative and in the postoperative phases.
RESULTS:
Preoperative CT scans showed an elliptic shape of TAVs (Ellipticity Index 1.3 ± 0.1), a circular shape of type 0 BAVs (1.1 ± 0.1) and an intermediate behaviour of type 1 BAVs, suggesting a possible gradual spectrum of circularity from TAVs to type 1 BAVs to type 0 BAVs. Postoperative CT scans did not show any significant difference in annular shape among the 3 groups, which demonstated a similar roundness, obviating the preoperative differences. Analysing the expansibility of the aortic annulus during the cardiac cycle, we observed that it was completely absent in the preoperative phase in BAVs, while in the postoperative phase, both TAVs and BAVs showed a small but similar expansibility after the annular reduction.
CONCLUSIONS:
There is a possible gradual spectrum in terms of shape, from native TAVs, to type 1 BAVS to type 0 BAVs. These differences are eliminated in the postoperative phase, suggesting an active role of the annuloplasty on the geometry of the aortic annulus. The preoperative analysis showed a complete inelasticity of BAVs, which was partly restored in the postoperative phase.
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Affiliation(s)
| | - Francesco Irace
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Luca Weltert
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Kazumasa Tsuda
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Raffaele Scaffa
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Andrea Salica
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Nicola Galea
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy
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Shehada SE, Benedik J, Serrano M, Lurbaski J, Demircioglu E, Wendt D, Jakob H, Mourad F. Modified sizing technique with newly designed tools to facilitate the valve sparing aortic root replacement "David" procedure with mid-term results. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 60:259-267. [PMID: 30465417 DOI: 10.23736/s0021-9509.18.10690-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Valve sparing root replacement differs in specific points. The main target remains to achieve a perfect intraoperative result and long-term stability. We aimed in this study to present our modified sizing technique for valve-sparing "David" procedure and its mid-term results. METHODS We present a retrospective single-center study. A newly designed sizing ring in addition to triple-armed forceps (Trifeet®) was used to measure the proper size of the Valsalva® prosthesis for patients undergoing David-procedure. Primary endpoints are intraoperative aortic regurgitation (AR) and early postoperative outcomes. Secondary endpoints included freedom from aortic regurgitation or reoperation and overall mortality. RESULTS A total of 63 consecutive patients who underwent David procedure between 09/2012 and 12/2016 were evaluated. Mean age was 52±15 years and 76.2% were male. Moderate to severe aortic regurgitation was reported in 60 (95.2%) patients. Four (6.3%) patients presented with type-A aortic dissection, 20 (31.7%) patients had bicuspid and 3 (4.8%) had a unicuspid aortic valve, 2 (3.2%) patients had a prior aortic valve repair. Intraoperative echocardiography revealed no 34 (54%), trace 26 (41.2%) or moderate 3 (4.8%) AR. Stroke, myocardial infarction, and 30-day mortality occurred in 1 patient (1.6%). During follow-up 5 (7.9%) patients needed reoperation due to recurrent AR within a mean of 35±18 months. One could be re-repaired, and the other four underwent aortic valve replacement. A second patient died in the late follow-up. CONCLUSIONS Our modified sizing technique simplifies the "David-procedure" and allows to achieve a good intraoperative and mid-term results. However, these results have to be confirmed in a larger cohort with a long-term follow-up.
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Affiliation(s)
- Sharaf-Eldin Shehada
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany -
| | - Jaroslav Benedik
- Department of Cardiovascular Surgery, Helios Clinic Krefeld, Krefeld, Germany
| | - Maria Serrano
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany
| | - Juri Lurbaski
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany
| | - Ender Demircioglu
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany
| | - Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany
| | - Fanar Mourad
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany
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Tavakoli R, Lebreton G, Gassmann M, Jamshidi P, Leprince P. Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement. J Vis Exp 2017. [PMID: 29286413 DOI: 10.3791/56790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures prevents a number of cardiac surgeons from incorporating them into their practice. The aim of this protocol is to describe a simplified and user-friendly technique of an aortic valve-sparing root replacement (VSRR) procedure by re-implantation of the aortic valve. Proper selection of patients and limitations of the technique are discussed. In 54 consecutive patients, normal appearing aortic valves were re-implanted in a commercially available polyester prosthesis with pre-shaped sinuses by a simplified and standardized technique. Placement of the first row of the proximal suture line, choice of the prosthesis size, and adjustment of the height of the commissures of the patient to the fixed height of the sinus portion of the prosthesis were slightly modified from the reference techniques with the aim of increasing its feasibility for use by other cardiac surgeons. Early mortality and morbidity as well as 5-year survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were collected in all patients. Thirty-day mortality, re-sternotomy for bleeding, re-sternotomy for mediastinitis, and the incidence of stroke were very low, 1.8% for each (1 of 54). No patient required permanent pace-maker implantation. At 5 years, survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were 97.5%, 95.2%, and 91.6%, respectively. Mid-term results of our standardized technique of re-implantation of the aortic valve for valve-sparing aortic root replacement are very good and compare with more complex techniques reported by experienced surgeons. By following the present protocol of the standardized re-implantation technique, a greater number of cardiac surgeons can perform this procedure with comparable good results.
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Affiliation(s)
- Reza Tavakoli
- Department of Cardiovascular and Thoracic Surgery, Pitie Salpetriere University Hospital, Assistance Publique, Hopitaux de Paris (APHP), Institut de Cardiologie; Institute of Veterinary Physiology and Zurich Center for Integrative Human Physiology, University of Zurich;
| | - Guillaume Lebreton
- Department of Cardiovascular and Thoracic Surgery, Pitie Salpetriere University Hospital, Assistance Publique, Hopitaux de Paris (APHP), Institut de Cardiologie
| | - Max Gassmann
- Institute of Veterinary Physiology and Zurich Center for Integrative Human Physiology, University of Zurich
| | | | - Pascal Leprince
- Department of Cardiovascular and Thoracic Surgery, Pitie Salpetriere University Hospital, Assistance Publique, Hopitaux de Paris (APHP), Institut de Cardiologie
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8
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PRO-CON debate: valve sparing aortic root surgery. PRO: reimplantation. Gen Thorac Cardiovasc Surg 2017; 67:77-81. [DOI: 10.1007/s11748-017-0837-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 09/18/2017] [Indexed: 10/18/2022]
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9
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Long-term outcomes of aortic root operations for Marfan syndrome: A comparison of Bentall versus aortic valve-sparing procedures. J Thorac Cardiovasc Surg 2016; 151:330-6. [DOI: 10.1016/j.jtcvs.2015.10.068] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 09/23/2015] [Accepted: 10/06/2015] [Indexed: 10/22/2022]
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10
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Overview of current surgical strategies for aortic disease in patients with Marfan syndrome. Surg Today 2015; 46:1006-18. [DOI: 10.1007/s00595-015-1278-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 11/02/2015] [Indexed: 01/16/2023]
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11
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De Paulis R, Chirichilli I, Scaffa R, Weltert L, Maselli D, Salica A, Guerrieri Wolf L, Bellisario A, Chiariello L. Long-term results of the valve reimplantation technique using a graft with sinuses. J Thorac Cardiovasc Surg 2015; 151:112-9. [PMID: 26349596 DOI: 10.1016/j.jtcvs.2015.08.026] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 07/27/2015] [Accepted: 08/08/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Aortic valve reimplantation is the most commonly used technique to spare the aortic valve. Long-term results data are scarce and available only with the use of standard straight graft. We examined the long-term results of reimplantation of the aortic valve using a graft incorporating sinuses of Valsalva. METHODS From May 2000 to December 2014, 124 patients had an aortic valve reimplanted into a graft with sinuses of Valsalva. The mean age was 53 ± 13 years and the majority were men (87%). Marfan syndrome was present in 21 patients (17%) and 12% had a bicuspid valve. Patients were prospectively followed by means of transthoracic echocardiography. The mean follow-up was 63 ± 52 months. RESULTS Overall survival at 5, 10, and 13 years was 94.4% ± 2.2%, 90.5% ± 4.4%, and 81.4% ± 7.3%, respectively. Six patients required reoperation within a time frame of 6 to 96 months. None of the patients died at reoperation. Freedom from reoperation was 95.4% ± 2.3% at 5 years and 90.1% ± 4.3% at 10 and 13 years. All patients who needed reoperation had surgery during the first 5 years. Three patients had residual aortic insufficiency >2. Considering also all patients who underwent reoperation because of aortic insufficiency, freedom from moderate to severe residual aortic insufficiency was 94.1% ± 2.6% at 5 years, and 87.1% ± 4.7% at 10 and 13 years. CONCLUSIONS The majority of patients who had their valve reimplanted in a graft with sinuses continue to perform well after 10 years.
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Affiliation(s)
| | | | | | - Luca Weltert
- Cardiac Surgery Department, European Hospital, Rome, Italy
| | | | - Andrea Salica
- Cardiac Surgery Department, European Hospital, Rome, Italy
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12
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Benedik J, Mourad F, Eißmann M, Jakob H. Minimally invasive David reimplantation of bicuspid aortic valve. Ann Cardiothorac Surg 2015; 4:206-7. [PMID: 25870823 DOI: 10.3978/j.issn.2225-319x.2015.02.08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 02/10/2015] [Indexed: 11/14/2022]
Affiliation(s)
- Jaroslav Benedik
- 1 Department of Thoracic and Cardiovascular Surgery, 2 Department of Cardiology, West German Heart Center, University of Essen, Essen, Germany
| | - Fanar Mourad
- 1 Department of Thoracic and Cardiovascular Surgery, 2 Department of Cardiology, West German Heart Center, University of Essen, Essen, Germany
| | - Mareike Eißmann
- 1 Department of Thoracic and Cardiovascular Surgery, 2 Department of Cardiology, West German Heart Center, University of Essen, Essen, Germany
| | | | - Heinz Jakob
- 1 Department of Thoracic and Cardiovascular Surgery, 2 Department of Cardiology, West German Heart Center, University of Essen, Essen, Germany
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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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14
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David TE. Current readings: Aortic valve-sparing operations. Semin Thorac Cardiovasc Surg 2014; 26:231-8. [PMID: 25527017 DOI: 10.1053/j.semtcvs.2014.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2014] [Indexed: 11/11/2022]
Abstract
It has been more than 2 decades since aortic valve-sparing operations were introduced to preserve the aortic valve in patients with aortic root aneurysm. Remodeling of the aortic root is physiologically superior to reimplantation of the aortic valve, mostly because it preserves the aortic annulus movement during the cardiac cycle. However, several comparative studies have shown that reimplantation of the aortic valve has provided more stable aortic valve function than remodeling of the aortic root. This difference in outcomes is largely because of patients׳ selection. Remodeling of the aortic root has been associated with high failure rates in patients with aneurysms associated with genetic syndromes and bicuspid aortic valves with dilated aortic annulus, but it has provided excellent long-term results in older patients with aortic root aneurysms secondary to ascending aortic aneurysms and normal aortic annulus. Thus, both techniques are useful in preserving the aortic valve. With either technique, restoration of normal aortic annulus and cusp geometry is the single most important technical aspect of these operations. In addition to having a competent valve with no or trivial aortic insufficiency at the end of the operation, there must be no cusp prolapse and the coaptation level of the cusps has to be well above the level of the nadir of the aortic annulus.
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Affiliation(s)
- Tirone E David
- Division of Cardiovascular Surgery of Peter Munk Cardiac Centre at Toronto, General Hospital; Department of Surgery, University of Toronto, Toronto, Ontario, Canada..
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15
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A quarter of a century of experience with aortic valve-sparing operations. J Thorac Cardiovasc Surg 2014; 148:872-9; discussion 879-80. [DOI: 10.1016/j.jtcvs.2014.04.048] [Citation(s) in RCA: 147] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 03/29/2014] [Accepted: 04/02/2014] [Indexed: 11/19/2022]
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16
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Inoue T, Ogawa T, Yugami S, Saga T. Autologous pericardial reinforcement after detachment of the coronary buttons of the proximal anastomosis in the Bentall procedure. Can J Cardiol 2013; 29:1532.e15-7. [PMID: 23932329 DOI: 10.1016/j.cjca.2013.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Revised: 05/13/2013] [Accepted: 05/13/2013] [Indexed: 11/17/2022] Open
Abstract
The present report describes a simple modification to the reinforcement technique by Copeland et al. using autologous pericardium for the Bentall procedure. Our modified technique may decrease the probability of leaks at the aortic root. Further, this technique preserves the advantages of the Valsalva graft, including tension-free coronary anastomosis and anatomical adaptability.
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Affiliation(s)
- Takehiro Inoue
- Department of Cardiovascular Surgery, Mimihara General Hospital, Osaka, Japan.
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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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Benedik J, Wendt D, Perrey M, Price V, Jakob H. Adjustment of aortic annulus size during David re-implantation (how to do it). SCAND CARDIOVASC J 2013; 47:245-6. [PMID: 23544363 DOI: 10.3109/14017431.2013.779018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Stability of the aortic annulus is a key factor in achieving long-term durability of the aortic valve re-implantation. We propose a new method of sub-annular fixation of the root prosthesis, enabling post-procedural transesophageal echocardiography (TEE)-guided adjustment of the aortic annulus dimensions.
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Affiliation(s)
- Jaroslav Benedik
- Departments of Thoracic and Cardiovascular Surgery, West German Heart Center, University of Essen, Essen, Germany.
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Midterm Results of David Reimplantation in Patients With Connective Tissue Disorder. Ann Thorac Surg 2013; 95:555-62. [DOI: 10.1016/j.athoracsur.2012.08.043] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 07/24/2012] [Accepted: 08/01/2012] [Indexed: 11/18/2022]
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David TE. Aortic valve sparing operations: a review. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2012; 45:205-12. [PMID: 22880164 PMCID: PMC3413824 DOI: 10.5090/kjtcs.2012.45.4.205] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 07/25/2012] [Accepted: 07/26/2012] [Indexed: 11/16/2022]
Abstract
Aortic valve sparing operations were developed to preserve the native aortic valve during surgery for aortic root aneurysm as well as surgery for ascending aortic aneurysms with associated aortic insufficiency. There are basically two types of aortic valve sparing oprations: remodeling of the aortic root and reimplantation of the aortic valve. These operations have been performed for over two decades and the clinical outcomes have been excellent in experienced hands. Although remodeling of the aortic root is physiologically superior to reimplantation of the aortic valve, long-term follow-up suggests that the latter is associated with lower risk of developing aortic insufficiency. Failure of remodeling of the aortic root is often due to dilatation of the aortic annulus. Thus, this type of aortic valve sparing should be reserved for older patients with ascending aortic aneurysm and normal aortic annulus whereas reimplantation of the aortic valve is more appropriate for young patients with inherited disorders that cause aortic root aneurysms. This article summarizes the published experience with these two operations. They are no longer experimental procedures and should be part of the surgical armamentarium to treat patients with aortic root aneurysm and ascending aortic aneurysms with associated aortic insufficiency.
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Affiliation(s)
- Tirone E David
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Canada
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Abstract
The aortic root has a unique 3-dimensional configuration and the distinctive function of supporting the aortic valve and blood vessels. The sinuses of Valsalva are crucial to create appropriate eddy currents that are important in initiating and coordinating aortic valve closure and promoting coronary artery blood flow. Most aneurysms in the aortic root are associated with degenerative changes in the elastic media rather than atherosclerosis. Valve-sparing root repair has become widely accepted, although the Bentall procedure remains the gold standard. Because reimplantation using the Valsalva graft allows root geometry to be retained and theoretically and practically prevents recurrent aortic valve regurgitation, it is considered the most reliable and preferred technique among various valve-sparing aortic root repair procedures.
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Affiliation(s)
- Hideyuki Shimizu
- Division of Cardiovascular Surgery, School of Medicine, Keio University, Shinjuku-ku, Tokyo, Japan.
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Song MH. A Learning Curve in Bentall and De Bono Procedure with the Use of the Risk-Adjusted Cumulative Sum Analysis Based on the Japan SCORE. Heart Surg Forum 2011; 14:E380-3. [DOI: 10.1532/hsf98.20111053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
<p><b>Objective:</b> The risk-adjusted cumulative sum analysis of an individual surgical learning curve for the Bentall and De Bono procedure on aortic root pathologies was used to monitor and enhance quality control.</p><p><b>Methods:</b> From April 2004 to March 2009, 20 consecutive patients were operated upon by a single surgeon for aortic root pathologies by means of the Bentall and De Bono procedure. Operative variables, mortality, and major morbidities were analyzed. The learning curve was calculated using descriptive statistics and cumulative sum failure observed minus expected failure rate derived from the Japan SCORE calculator.</p><p><b>Results:</b> In this series, the Japan SCORE calculator expected 3.91% � 5.14% of 30-day operative mortality rate and 16.74 � 13.47% of 30-day operative mortality and morbidity. In reality, there was no operative and in-hospital death. Major postoperative morbidity rate was 15.0% (3 patients). The risk-adjusted cumulative sum analysis revealed that the learning curve of mortality was downward below the lower 95% confidence interval throughout all the patients and that of morbidity was upward till the seventh case and remained downward thereafter. The polynomial approximation coefficient analysis revealed a significant negative correlation between aortic cross-clamp time, cardiopulmonary time, and operation time and case load.</p><p><b>Conclusions:</b> The Bentall and De Bono procedure for aortic root pathologies was performed at the professionally permissive level from the beginning, even in a low-volume environment. It showed one good example of a learning curve. The risk-adjusted cumulative sum analysis based on the Japan SCORE was a very useful tool for monitoring the performance.</p>
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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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Nardi P, Pellegrino A, Versaci F, Mantione L, Polisca P, Iorio FS, Chiariello L. Aortic root surgery in Marfan syndrome: Bentall procedure with the composite mechanical valved conduit versus aortic valve reimplantation with Valsalva graft. J Cardiovasc Med (Hagerstown) 2010; 11:648-54. [DOI: 10.2459/jcm.0b013e3283379998] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Simplified David Reimplantation With Reduction of Anular Size and Creation of Artificial Sinuses. Ann Thorac Surg 2010; 89:1443-7. [DOI: 10.1016/j.athoracsur.2010.01.058] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Revised: 01/18/2010] [Accepted: 01/20/2010] [Indexed: 11/17/2022]
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Aortic Valve-Sparing in 37 Patients With Marfan Syndrome: Midterm Results With David Operation. Ann Thorac Surg 2010; 89:93-6. [DOI: 10.1016/j.athoracsur.2009.09.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Revised: 09/04/2009] [Accepted: 09/08/2009] [Indexed: 11/19/2022]
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Long-term results of aortic valve–sparing operations in patients with Marfan syndrome. J Thorac Cardiovasc Surg 2009; 138:859-64; discussion 863-4. [DOI: 10.1016/j.jtcvs.2009.06.014] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Revised: 04/12/2009] [Accepted: 06/15/2009] [Indexed: 11/21/2022]
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Smith RL, Kron IL. Valve-sparing aortic root reconstruction. Surg Clin North Am 2009; 89:837-44, viii. [PMID: 19782840 DOI: 10.1016/j.suc.2009.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The aortic valve-sparing root reconstruction procedure remains an ideal concept, but it has not yet become an ideal operation. There is still great variation and evolution in techniques, which mirrors the increasing understanding of the aortic root's functional anatomy and the disease processes that affect it. These operations remain complex, and the surgeons who perform them well are often times best armed with an experienced eye for what looks right more than a mathematical model that can predetermine who will do well, with what repair type and with what percentage chance of long-term success. Because of this, it will likely still be a while before these operations are more routinely used by a broader group of surgeons, as compared with the very reproducible Bentall and De Bono repair.
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Affiliation(s)
- Robert L Smith
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, PO Box 800709, Charlottesville, VA 22908-0709, USA.
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Borghetti V, Dionisi D, Principi M, Buratta MM, Fiaschini P, Fioriello F, D'addario G, Patella M, Camilli G, Bovelli D, Pardini A. Aortic valve re-implantation technique with Gelweave Valsalva prosthesis: safety, reproducibility and pitfalls of a geometric reconstruction. J Cardiovasc Med (Hagerstown) 2009; 10:834-41. [PMID: 19521255 DOI: 10.2459/jcm.0b013e32832e0acc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND To evaluate the safety, reproducibility and pitfalls of an aortic valve re-implantation (AVRei) technique. METHODS From June 2005 to December 2008, 30 patients underwent aortic valve-sparing re-implantation with Gelweave Valsalva prosthesis. Mean age was 66 +/- 7 years (range 47-81). Mean aortic root diameter was 49 +/- 6 mm (range 37-70) and 12 patients had an aortic insufficiency more than 2+. All the patients were elective, except three who underwent surgery for type A aortic dissection. Two patients had Marfan syndrome and one had a bicuspid aortic valve. Isolated aortic root replacement was performed in 26 patients, whereas hemiarch extension was required in four. All the survivors underwent serial echocardiographic assessment for functional results and multi-detector computed tomography (MDCT) for aortic root morphology evaluation. RESULTS There was one early death and one re-exploration for bleeding. Two patients suffered from a perioperative stroke and four required a pacemaker implantation because of a complete atrio-ventricular block. Mean follow-up was 12 +/- 10 months (range 1-42) with no late deaths, whereas freedom from reoperation was 100% and freedom from aortic insufficiency 2+ or more was 96.5%. MDCT aortic root reconstruction showed a pseudo-normalization of the neo-sinuses of Valsalva mimicking the human normal aortic root morphology. CONCLUSION AVRei with Valsalva conduit is a well-tolerated procedure both in elective and emergency situations. In well-selected patients, good functional and clinical results can be achieved, regardless of the cause of the aortic root disease. Application of simple surgical manoeuvres allows durable clinical efficacy to be obtained without the risk of major complications.
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Cameron DE, Alejo DE, Patel ND, Nwakanma LU, Weiss ES, Vricella LA, Dietz HC, Spevak PJ, Williams JA, Bethea BT, Fitton TP, Gott VL. Aortic Root Replacement in 372 Marfan Patients: Evolution of Operative Repair Over 30 Years. Ann Thorac Surg 2009; 87:1344-9; discussion 1349-50. [DOI: 10.1016/j.athoracsur.2009.01.073] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Revised: 01/26/2009] [Accepted: 01/30/2009] [Indexed: 10/20/2022]
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Suzuki S, Masuda M. An update on surgery for acute type A aortic dissection: Aortic root repair, endovascular stent graft, and genetic research. Surg Today 2009; 39:281-9. [PMID: 19319633 DOI: 10.1007/s00595-008-3887-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Accepted: 07/09/2008] [Indexed: 11/26/2022]
Affiliation(s)
- Shinichi Suzuki
- Department of Surgery, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004, Japan
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Dyamenahalli U, Abraham B, Fontenot E, Prasad V, Imamura M. Pathologic aneurysmal dilation of the ascending aorta and dilation of the main pulmonary artery in patients with Kabuki syndrome: valve-sparing aortic root replacement. CONGENIT HEART DIS 2008; 2:424-8. [PMID: 18377436 DOI: 10.1111/j.1747-0803.2007.00136.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report the aneurysmal dilation of the ascending aorta and the main pulmonary artery in 2 children with Kabuki syndrome. In 1 patient, there was progressive aneurysmal dilation of the ascending aorta necessitating aortoplasty. Histologic examination of the resected aorta revealed disrupted and fragmented elastic fibers in the medial layer, along with mucinous degeneration of the aortic wall. This is the first recognition and report of these findings as part of the Kabuki syndrome.
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Affiliation(s)
- Umesh Dyamenahalli
- Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas, USA.
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Patel ND, Weiss ES, Alejo DE, Nwakanma LU, Williams JA, Dietz HC, Spevak PJ, Gott VL, Vricella LA, Cameron DE. Aortic Root Operations for Marfan Syndrome: A Comparison of the Bentall and Valve-Sparing Procedures. Ann Thorac Surg 2008; 85:2003-10; discussion 2010-1. [DOI: 10.1016/j.athoracsur.2008.01.032] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2007] [Revised: 01/04/2008] [Accepted: 01/07/2008] [Indexed: 11/26/2022]
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Verhey JF, Bara C. Influence on fluid dynamics of coronary artery outlet angle variation in artificial aortic root prosthesis. Biomed Eng Online 2008; 7:9. [PMID: 18307786 PMCID: PMC2275278 DOI: 10.1186/1475-925x-7-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2007] [Accepted: 02/28/2008] [Indexed: 11/17/2022] Open
Abstract
Background Because of higher life expectancy, the number of elderly patients today with degenerative aortic diseases is on the increase. Often artificial aortic roots are needed to replace the native tissue. This surgical procedure requires re-implantation of the previous separated coronary arteries into the wall of the prosthesis. Regardless of the prosthesis type, changes in the reinsertion technique, e.g., the variation of the outlet angle of the coronary arteries, could influence the coronary blood flow. Whether the prosthesis type or the outlet angle variation significantly improves the blood circulation and lowers the risk of coronary insufficiency is still an open question. The numerical calculations presented can help to clear up these disputable questions. Methods Two simplified base geometries are used for simulating the blood flow in order to determine velocity and pressure distributions. One model uses a straight cylindrical tube to approximate the aortic root geometry; the other uses a sinus design with pseudosinuses of Valsalva. The coronary outlet angle of the right coronary artery was discretely modified in both models in the range from 60° to 120°. The pressure and velocity distributions of both models are compared in the ascending aorta as well as in the right and the left coronary artery. Results The potentially allowed and anatomic limited variation of the outlet angle influences the pressure only a little bit and shows a very slight relative maximum between 70° and 90°. The sinus design and variations of the outlet angle of the coronary arteries were able to minimally optimize the perfusion pressure and the velocities in the coronary circulation, although the degree of such changes is rather low and would probably not achieve any clinical influence. Conclusion Our results show that surgeons should feel relatively free to vary the outlet angle within the anatomic structural conditions when employing the technique of coronary reinsertion.
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Manso PH, Amaral FTV, Vicente WVDA, Granzotti JA. Ascending aorta dissecting aneurysm in a teenager with isolated systemic hypertension. Int J Cardiol 2007; 118:e72-4. [PMID: 17395306 DOI: 10.1016/j.ijcard.2007.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2006] [Accepted: 01/01/2007] [Indexed: 10/23/2022]
Abstract
A teenager with longstanding arterial hypertension was admitted for acute pneumonia treatment. New onset atypical chest pain for the last months and aortic valve regurgitation were also present. A dissecting aneurysm of the ascending aorta with moderate aortic valve regurgitation was evidenced by laboratorial diagnostic. Aneurismectomy with aortic valve preservation and coronary artery reimplantation was carried out.
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Forteza A, Cortina JM, Sánchez V, Centeno J, Jesús López M, de la Sota EP, Rufilanchas JJ. Experiencia inicial con la preservación de la válvula aórtica en el síndrome de Marfan. Rev Esp Cardiol 2007. [DOI: 10.1016/s0300-8932(07)75063-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Settepani F, Szeto WY, Pacini D, De Paulis R, Chiariello L, Di Bartolomeo R, Gallotti R, Bavaria JE. Reimplantation valve-sparing aortic root replacement in Marfan syndrome using the Valsalva conduit: an intercontinental multicenter study. Ann Thorac Surg 2007; 83:S769-73; discussion S785-90. [PMID: 17257924 DOI: 10.1016/j.athoracsur.2006.10.084] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2006] [Revised: 10/05/2006] [Accepted: 10/24/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND Introduced by DePaulis in 2000, the Gelweave Valsalva graft (Sulzer Vascutek, Refrewshire, Scotland) is a modified Dacron conduit (DuPont, Wilmington, DE), with prefashioned sinuses of Valsalva. The aim of this study was to evaluate the mid-term results of the reimplantation valve-sparing aortic root replacement using the Gelweave Valsalva prosthesis in Marfan syndrome patients. METHODS A retrospective review was performed of 35 patients with Marfan syndrome in four centers who underwent the reimplantation valve-sparing aortic root replacement using the Gelweave Valsalva prosthesis. RESULTS The patients were predominantly men, with a mean age of 36.5 +/- 12.6 years (range, 14 to 62 years). Two patients presented with acute type A dissections and underwent emergent operations. Elective hemiarch reconstruction using hypothermic circulatory arrest was required in 11 patients. Aortic valve cusp repair was performed in 2 patients. There were no operative or hospital deaths, and no patients died during follow-up. The mean follow-up was 19 months (range, 1 to 60 months). Significant (>2+) aortic insufficiency (AI), requiring aortic valve replacement, developed in 3 patients during follow-up that requiring aortic valve replacement. The 5-year freedom from reoperation owing to structural valve deterioration was 88.9% +/- 8.1%. There were no episodes of clinically significant thromboembolism. CONCLUSIONS Reimplantation valve-sparing aortic root replacement with the Gelweave Valsalva prosthesis in Marfan patients provides satisfactory mid-term results, thus encouraging further use of this type of repair. However, long-term results are needed in order to define the durability of this technique.
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Miller DC. Valve-Sparing Aortic Root Replacement: Current State of the Art and Where Are We Headed? Ann Thorac Surg 2007; 83:S736-9; discussion S785-90. [PMID: 17257918 DOI: 10.1016/j.athoracsur.2006.10.101] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2006] [Revised: 10/22/2006] [Accepted: 10/24/2006] [Indexed: 10/23/2022]
Affiliation(s)
- D Craig Miller
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University Medical School, Stanford, California 94305, USA.
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Jeanmart H, de Kerchove L, Glineur D, Goffinet JM, Rougui I, Van Dyck M, Noirhomme P, El Khoury G. Aortic Valve Repair: The Functional Approach to Leaflet Prolapse and Valve-Sparing Surgery. Ann Thorac Surg 2007; 83:S746-51; discussion S785-90. [PMID: 17257920 DOI: 10.1016/j.athoracsur.2006.10.089] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2006] [Revised: 10/11/2006] [Accepted: 10/23/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND Combined aortic valve repair and aortic valve-sparing surgery requires an approach determined by the leaflets and aortic root anatomy. METHODS Among patients referred for aortic root aneurysm, 114 patients underwent an aortic valve-sparing procedure in which a reimplantation or remodelling technique was used. The Gelweave Valsalva prosthesis (Sulzer Vascutek, Renfrewshire, UK) was used in 45 patients. Better molding of the prosthesis on the aortic annulus was achieved by a low proximal dissection and incisions on the prosthesis to respect the anatomy of the aortoventricular junction. The reimplantation technique was used in 58%, and 62% of all patients underwent an associated leaflet procedure. RESULTS The operative mortality rate was 1%, with a 2% immediate reoperation rate. During the mean follow-up 50 +/- 35 months, 3 patients (2.6%) needed reoperation for recurrent aortic regurgitation (n = 2) or aortic stenosis (n = 1). At the end of follow-up, aortic regurgitation grade exceeding 2 had occurred in 2.6% of patients (n = 3), and 98.2% were in New York Heart Association functional class 1 or 2. Neither the early nor mid-term results showed any differences among the different surgical techniques used (reimplantation, remodeling, Valsalva prosthesis, additional leaflet repair). CONCLUSIONS A complete approach to the different components of the aortic root allows good clinical results at mid-term.
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Affiliation(s)
- Hugues Jeanmart
- Department of Cardiovascular and Thoracic Surgery, UCL-Cliniques Universitaires Saint-Luc, Brussels, Belgium.
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Patel ND, Williams JA, Barreiro CJ, Bethea BT, Fitton TP, Dietz HC, Lima JAC, Spevak PJ, Gott VL, Vricella LA, Cameron DE. Valve-Sparing Aortic Root Replacement: Early Experience With the De Paulis Valsalva Graft in 51 Patients. Ann Thorac Surg 2006; 82:548-53. [PMID: 16863761 DOI: 10.1016/j.athoracsur.2006.03.073] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Revised: 03/21/2006] [Accepted: 03/22/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Valve-sparing aortic root replacement for treatment of aortic sinus disease avoids the problems of prosthetic valves, but some patients suffer late valve incompetence as a result of leaflet distortion or annular dilatation. The reimplantation technique using the De Paulis Valsalva graft might improve late results of valve-sparing aortic root replacement by maintaining annular stability and re-creating sinuses that minimize leaflet stress. METHODS Retrospective review was conducted of all patients at our institution who underwent valve-sparing aortic root replacement using the Valsalva graft. Clinical data were obtained from hospital and clinic charts and patient contacts; echocardiograms were analyzed for aortic root dimensions and valve function. RESULTS Between May 2002 and June 2005, 51 patients underwent valve-sparing aortic root replacement using the reimplantation technique with the Valsalva graft. Mean age was 33 +/- 15 years; 22% (11 of 51) were children, and 80% (41 of 51) were male. Primary indication for surgery was root aneurysm in all patients. Preoperative mean root diameter was 5.0 +/- 0.5 cm. Marfan syndrome was present in 67% (34 of 51), and 10% (5 of 51) had the newly described Loeys-Dietz syndrome. There were no operative or late deaths, and no patient required reoperation for bleeding. At mean follow-up of 1.8 years, there were no episodes of endocarditis or thromboembolism. Echocardiograms showed stability of the annulus and root dimensions on follow-up. No patient had more than 0 to 1+ aortic insufficiency or progression of aortic insufficiency. All were in New York Heart Association class I. CONCLUSIONS Valve-sparing aortic root replacement using the Valsalva graft and reimplantation technique has excellent early results. Preservation of valve competence is encouraging, but long-term results will determine whether the anatomic design of this aortic root prosthesis is superior for preservation of valve integrity.
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Affiliation(s)
- Nishant D Patel
- Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Zeitani J, Scafuri A, de Peppo AP, Gaspardone A, Polisca P, Di Marzio E, Sgrò S, De Vico P, Chiariello L. Thrombosis of the Left Anterior Descending Artery Due to Compression from Giant Pseudoaneurysm Late After a Bentall Operation. J Card Surg 2006; 21:195-7. [PMID: 16492287 DOI: 10.1111/j.1540-8191.2006.00206.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND A postoperative pseudoaneurysm may develop and gradually expand in the mediastinal space even late following Bentall operation for aortic root replacement, particularly in patients with dissection of the aorta. METHODS A very large (148 mm) pseudoaneurysm originating of the right coronary ostium suture line was observed in a patient admitted with unstable angina 6 years after Bentall procedure for type A aortic dissection. Angiograms showed reduced flow in the right coronary and thrombotic subocclusion of the left anterior descending (LAD) coronary artery due to extrinsic compression from the expanding mediastinal mass. RESULTS Reoperation was performed during femoro-femoral cardiopulmonary bypass and brief period of circulatory arrest to clamp the tubular graft. After closure of the detected right coronary ostium in the tubular graft double bypass, grafting to the right coronary and LAD arteries was required. Postoperative course was uneventful. CONCLUSIONS Close long-term follow-up after a Bentall procedure is required to minimize the risk of developing a large pseudoaneurysmal mass, in particular, after dissection of the aorta.
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Affiliation(s)
- Jacob Zeitani
- Division of Cardiac Surgery, Tor Vergata University of Rome, Rome, Italy.
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Abstract
Marfan's syndrome is a systemic disorder of connective tissue caused by mutations in the extracellular matrix protein fibrillin 1. Cardinal manifestations include proximal aortic aneurysm, dislocation of the ocular lens, and long-bone overgrowth. Important advances have been made in the diagnosis and medical and surgical care of affected individuals, yet substantial morbidity and premature mortality remain associated with this disorder. Progress has been made with genetically defined mouse models to elucidate the pathogenetic sequence that is initiated by fibrillin-1 deficiency. The new understanding is that many aspects of the disease are caused by altered regulation of transforming growth factor beta (TGFbeta), a family of cytokines that affect cellular performance, highlighting the potential therapeutic application of TGFbeta antagonists. Insights derived from studying this mendelian disorder are anticipated to have relevance for more common and non-syndromic presentations of selected aspects of the Marfan phenotype.
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Affiliation(s)
- Daniel P Judge
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
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Vricella LA, Williams JA, Ravekes WJ, Holmes KW, Dietz HC, Gott VL, Cameron DE. Early Experience With Valve-Sparing Aortic Root Replacement in Children. Ann Thorac Surg 2005; 80:1622-6; discussion 1626-7. [PMID: 16242427 DOI: 10.1016/j.athoracsur.2005.04.062] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2005] [Revised: 04/24/2005] [Accepted: 04/26/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Aortic valve-sparing root replacement has become an established treatment for adults with aneurysms of the ascending aorta, but there is limited experience in children, for whom the advantages of avoiding valve prostheses are particularly attractive. METHODS A retrospective clinical study was undertaken to examine results of aortic valve-sparing operations in pediatric patients at a single institution. Clinical and echocardiographic data were obtained from chart review and outpatient follow-up examination. RESULTS Between 1997 and 2004, 19 children underwent aortic valve-sparing root replacement. Mean age was 12.2 +/- 4.4 years, and mean weight was 51.5 +/- 22.9 kg. Median length of clinical follow-up was 58 months (range, 5 to 91). Fifteen of 19 patients (78.9%) had Marfan syndrome and 1 had aortic root dilation late after the arterial switch operation. Mean preoperative root diameter was 4.7 +/- 0.6 cm, with an average Z score of 7.7 +/- 1.9. Fourteen patients (73.7%) underwent root remodeling, whereas 5 (26.3%) had a reimplantation procedure. One patient required concomitant mitral valve repair. There was no operative mortality and only 1 reoperation for bleeding (5.3%). Median length of hospital stay was 5 days (range, 3 to 12). At latest follow-up, 3 of 19 patients (15.8%) have required late aortic valve replacement. Fifteen patients have no or mild aortic valve insufficiency, and 1 has moderate but stable valve regurgitation. No patient with a reimplantation procedure has had a reoperation or more than mild insufficiency, and no patient has suffered endocarditis or thromboembolism. CONCLUSIONS Valve-sparing aortic root replacement is a viable alternative to root replacement with mechanical or biological prostheses in children, and can be accomplished with minimal morbidity and mortality. Reimplantation procedures appear to have more durable results than root remodeling techniques, and should be strongly considered for pediatric patients with aortic root enlargement secondary to connective tissue disorders and other forms of congenital heart disease.
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Affiliation(s)
- Luca A Vricella
- Division of Pediatric Cardiac Surgery, The Johns Hopkins University Hospital, Baltimore, Maryland, USA.
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De Paulis R, Scaffa R, Forlani S, Chiariello L. The Valsalva graft in aortic valve repair and replacement. Multimed Man Cardiothorac Surg 2005; 2005:mmcts.2004.000992. [PMID: 24415218 DOI: 10.1510/mmcts.2004.000992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Presentation of the use of the new Valsalva graft that incorporates sinuses of Valsalva: its use is mostly recommended for the reimplantation type of valve sparing procedure where it combines the advantages of proper anatomical reconstruction with those of annular stabilization. Its advantages when used in the remodeling technique or in a classical Bentall procedure are also shown. The problem of graft sizing and of proper geometrical reconstruction of the aortic root are addressed.
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Affiliation(s)
- Ruggero De Paulis
- Department of Cardiac Surgery, University of Tor Vergata, Cattedra di Cardiochirurgia Policlinico Tor Vergata, via Oxford 81, 00133 Rome, Italy
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Cameron DE, Vricella LA. Valve-sparing aortic root replacement in Marfan syndrome. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2005:103-11. [PMID: 15818365 DOI: 10.1053/j.pcsu.2005.03.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Marfan syndrome is the most common inherited connective tissue disorder, affecting approximately 1 in 10,000 live births. The cardinal features of Marfan syndrome are the abnormalities of the skeleton (tall stature, arachnodactyly, and joint hyperelasticity), eye (lens subluxation), and aorta (root aneurysm with proclivity toward rupture and dissection). Aortic catastrophe accounts for most of the premature mortality among Marfan patients, a risk that climbs steeply during adolescence and results in death of half of Marfan patients by the age of 40 years. Most of the improvement in life expectancy that has been achieved in Marfan syndrome is attributable to early recognition of aortic root aneurysms and prophylactic replacement with composite grafts (mechanical valve prostheses within Dacron conduits) before rupture or dissection occurs. Despite the excellent early and late results with composite grafts, there has been growing interest in operative procedures that replace the sinuses but preserve the aortic valve leaflets, to avoid anticoagulation and minimize the risk of prosthesis-related endocarditis. These procedures are still in evolution and late results are not yet known, but as with mitral repair in the setting of myxomatous disease, valve-sparing procedures in Marfan syndrome have weathered a storm of initial criticism and skepticism and are steadily gaining acceptance.
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Affiliation(s)
- Duke E Cameron
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
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Tweddell JS, Pelech AN, Jaquiss RDB, Frommelt PC, Mussatto KA, Hoffman GM, Litwin SB. Aortic valve repair. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2005:112-21. [PMID: 15818366 DOI: 10.1053/j.pcsu.2005.01.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Aortic valve replacement options are limited in children, and all of them have disadvantages. Aortic valve repair techniques have evolved slowly and have not gained wide acceptance; however, large series using a variety of techniques demonstrate that valve repair is possible with excellent early hemodynamics and satisfactory intermediate durability. The results of aortic valve repair at the Children's Hospital of Wisconsin are presented. Simple repairs (blunt valvotomy, commissurotomy, or commissurotomy with leaflet thinning) directed at congenital aortic stenosis resulted in 86% +/- 5% freedom from reintervention at 10 years. Repair of aortic insufficiency with ventricular septal defect (VSD) resulted in 93.3% +/- 6% freedom from reoperation at 10 years. Complex repairs included a combination of techniques and yielded 5-year freedom from reintervention of 83% +/- 7% compared with 73% +/- 11% for patients undergoing aortic valve replacement (P = .62). Aortic valve repair provides an alternative to aortic valve replacement in selected patients. The utility of aortic valve repair and aortic valve replacement must be measured not only in freedom from reintervention but also in regression of left ventricular mass and exercise testing. Improvement in outcome depends on better patient selection and suitable bioprosthetic materials.
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Affiliation(s)
- James S Tweddell
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee 53226, USA
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Bethea BT, Fitton TP, Alejo DE, Barreiro CJ, Cattaneo SM, Dietz HC, Spevak PJ, Lima JAC, Gott VL, Cameron DE. Results of aortic valve-sparing operations: Experience with remodeling and reimplantation procedures in 65 patients. Ann Thorac Surg 2004; 78:767-72; discussion 767-72. [PMID: 15336989 DOI: 10.1016/j.athoracsur.2004.03.040] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Valve-sparing operations for aortic root aneurysms are increasing in frequency, but techniques and results are still in evolution. We reviewed our experience with 65 patients (adults and children) who had this operation at our institution to determine early and late outcomes. METHODS A retrospective clinical review was undertaken using hospital records, clinical and echocardiographic, computed tomography, magnetic resonance imaging data, and telephone interviews with patients and their physicians. RESULTS Between July 1994 and December 2002, 65 patients (46 adults and 19 children) underwent a valve-sparing operation for aortic root aneurysm. Forty-four of the patients had the Marfan syndrome; the remaining 21 had either a nonspecific connective tissue disorder (14 patients) or a miscellaneous disease process such as Ehlers-Danlos syndrome (7 patients). Fifty-eight (89%) had a David II (remodeling) procedure and 7 had a David I (reimplantation) procedure. The DePaulis "Valsalva graft" was used in six of the David I patients. There were no operative or hospital deaths; only one late death occurred in an adult due to salmonella meningitis. Overall, survival was 100% at one year and 98% at 3 and 5 years. Ten patients (7 adults and 3 children) developed significant late aortic insufficiency (AI). Nine of these patients had a David II procedure and in 8 of these cases, AI was secondary to significant late annular dilatation. One of the 10 patients developed late AI 8.2 years after a David I procedure; his AI was secondary to aortic leaflet extension and prolapse. Six of the 10 patients who developed significant late AI required aortic valve replacement (4 adults and 2 children). Freedom from late aortic valve replacement (AVR) in this series of 65 patients was 91% at 3 and 84% at 5 years. At the close of this study, 58 patients were New York Heart Association (NYHA) class I and 6 were NYHA class II; no patients were class III or IV. There were no episodes of endocarditis or clinically significant thromboembolism. CONCLUSIONS Valve-sparing operations provide satisfactory results for many patients with an aortic root aneurysm, but the David II remodeling procedure has a greater risk of late annular dilatation and AI. The David I reimplantation procedure utilizing the DePaulis Valsalva graft may obviate this problem.
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Affiliation(s)
- Brian T Bethea
- Division of Cardiac Surgery, Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Furukawa K, Ohteki H, Cao ZL, Narita Y, Okazaki Y, Ohtsubo S, Itoh T. Evaluation of native valve-sparing aortic root reconstruction with direct imaging--reimplantation or remodeling? Ann Thorac Surg 2004; 77:1636-41. [PMID: 15111157 DOI: 10.1016/j.athoracsur.2003.09.045] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2003] [Indexed: 11/26/2022]
Abstract
BACKGROUND Aortic root reimplantation and remodeling have been used to preserve the native aortic valve. However, direct observation of valve motions with these techniques has not been performed. METHODS Mongrel dogs were studied. The beating heart model was created using modified Tyrode's solution. Normal aortic valves and aortic valves preserved with the remodeling or reimplantation procedure were observed with an endoscope, and behavior was recorded on a high-speed video (200 frames/s). The aortic valve orifice area was measured at 11 data points per beat. A predictable maximum valve orifice area was defined as an area encircled by the three commissures. A ratio of each aortic valve orifice area to the predictable maximum valve orifice area was calculated. The control group, the reimplantation group, and the remodeling group were compared. RESULTS The preserved aortic valve with reimplantation showed bending and asymmetric motion. The ratio of aortic valve orifice area and predictable maximum valve orifice area in the reimplantation group was significantly smaller compared with the control and remodeling groups. CONCLUSIONS The opening and closing behavior of the aortic valve preserved with the reimplantation procedure was impaired. It was speculated that the remodeling procedure may preserve more physiologic root function compared with the reimplantation procedure.
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Affiliation(s)
- Kojiro Furukawa
- Department of Thoracic and Cardiovascular Surgery, Saga Medical School, and Department of Cardiovascular Surgery, Saga Prefectural Hospital, Koseikan, Saga, Japan.
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