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Schizas N. Cusp repair during valve-sparing aortic root replacement with reimplantation. Repair or replace? Indian J Thorac Cardiovasc Surg 2024; 40:394-395. [PMID: 38681716 PMCID: PMC11045676 DOI: 10.1007/s12055-023-01675-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 12/21/2023] [Indexed: 05/01/2024] Open
Affiliation(s)
- Nikolaos Schizas
- National and Kapodistrian University, Mikras Asias 75, Athens, 11527 Greece
- 4th Cardiac Surgery Department, Hygeia Hospital, Marousi, Greece
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Kubo S, Tanaka A, Omura A, Tsunemi K, Oka T, Okada K, Okita Y. Long-term Results of Valve-Sparing Aortic Root Replacement and Aortic Cusp Repair. Ann Thorac Surg 2024; 117:78-85. [PMID: 37541561 DOI: 10.1016/j.athoracsur.2023.05.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/19/2023] [Accepted: 05/30/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Long-term results of valve-sparing aortic root replacement (VSRR) and aortic cusp repair for aortic regurgitation are unclear. METHODS VSRR by reimplantation was performed in 363 patients. Tricuspid aortic valve (TAV) and bicuspid aortic valve were found in 285 and 71 patients, respectively. RESULTS Aortic cusp repair was performed in 268 patients. Of patients with TAV 129 had central plication of the Arantius node, 36 had free margin resuspension, and 71 had reinforcement. Mean follow-up was 71.4 months. Among TAV patients freedom from aortic valve reoperation at 10 and 15 years was 85.1% and 78.3%, respectively. Freedom from aortic valve reoperation at 10 years was lower in patients with cusp prolapse than without (77.4% vs 93.2%, P = .007). The overall freedom from more than mild aortic regurgitation at 10 and 15 years was 72.4% and 64.0%, respectively. It was also significantly greater in patients without cusp prolapse (78.4% vs 67.7%, P = .02). As for the cusp repair technique the freedom from aortic valve reoperation at 10 years was significantly better in patients who underwent only resuspension or reinforcement techniques compared with patients who underwent only central plication technique (100% vs 72.8%, P = .008). CONCLUSIONS Long-term results of VSRR with aortic cusp repair were satisfactory. The resuspension technique appears to be useful for repairing aortic cusp prolapse in patients with TAV.
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Affiliation(s)
- Sara Kubo
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Aya Tanaka
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Atsushi Omura
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Kotaro Tsunemi
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Takanori Oka
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Kenji Okada
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University, Kobe, Hyogo, Japan
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan.
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Hodges K, Rosinski BF, Roselli EE, Rajeswaran J, Griffin B, Vargo PR, Koprivanac M, Tong M, Blackstone EH, Svensson LG. Aortic valve cusp repair does not affect durability of modified aortic valve reimplantation for tricuspid aortic valves. JTCVS OPEN 2023; 16:105-122. [PMID: 38204640 PMCID: PMC10774985 DOI: 10.1016/j.xjon.2023.06.021] [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: 02/28/2023] [Revised: 06/09/2023] [Accepted: 06/27/2023] [Indexed: 01/12/2024]
Abstract
Objective During aortic valve reimplantation, cusp repair may be needed to produce a competent valve. We investigated whether the need for aortic valve cusp repair affects aortic valve reimplantation durability. Methods Patients with tricuspid aortic valves who underwent aortic valve reimplantation from January 2002 to January 2020 at a single center were retrospectively analyzed. Propensity matching was used to compare outcomes between patients who did and did not require aortic valve cusp repair. Results Cusp repair was performed in 181 of 756 patients (24%). Patients who required cusp repair were more often male, were older, had more aortic valve regurgitation, and less often had connective tissue disease. Patients who underwent cusp repair had longer aortic clamp time (124 ± 43 minutes vs 107 ± 36 minutes, P = .001). In-hospital outcomes were similar between groups and with no operative deaths. A total of 98.3% of patients with cusp repair and 99.3% of patients without cusp repair had mild or less aortic regurgitation at discharge. The median follow-up was 3.9 and 3.2 years for the cusp repair and no cusp repair groups, respectively. At 10 years, estimated prevalence of moderate or more aortic regurgitation was 12% for patients with cusp repair and 7.0% for patients without cusp repair (P = .30). Mean aortic valve gradients were 6.2 mm Hg and 8.0 mm Hg, respectively (P = .01). Ten-year freedom from reoperation was 99% versus 99% (P = .64) in the matched cohort and 97% versus 97%, respectively (P = .30), in the unmatched cohort. Survival at 10 years was 98% after cusp repair and 93% without cusp repair (P = .05). Conclusions Aortic valve reimplantation for patients with tricuspid aortic valves has excellent long-term results. Need for aortic valve cusp repair does not affect long-term outcomes and should not deter surgeons from performing valve-sparing surgery.
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Affiliation(s)
- Kevin Hodges
- Department of Thoracic and Cardiovascular Surgery, Aortic Valve Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bradley F. Rosinski
- Department of Thoracic and Cardiovascular Surgery, Aortic Valve Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E. Roselli
- Department of Thoracic and Cardiovascular Surgery, Aortic Valve Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Science, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian Griffin
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick R. Vargo
- Department of Thoracic and Cardiovascular Surgery, Aortic Valve Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Aortic Valve Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael Tong
- Department of Thoracic and Cardiovascular Surgery, Aortic Valve Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H. Blackstone
- Department of Thoracic and Cardiovascular Surgery, Aortic Valve Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Science, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G. Svensson
- Department of Thoracic and Cardiovascular Surgery, Aortic Valve Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Abstract
The clinical outcome of severe aortic regurgitation (AR) remains suboptimal, but surgery has been shown to have survival benefit over medical therapy. Postoperative survival is inferior in patients with reduced left ventricular function, and therefore early surgical intervention is recommended. Aortic valvuloplasty (AVP) is an attractive option to avoid the major drawbacks of prosthetic valves but has not been widely adopted. The etiology of AR is classified functionally into three groups: normal leaflet motion (type I), cusp prolapse (type II), and restriction (type III). Type I with dilatation of the sinus of Valsalva (type Ib) can be repaired by aortic valve reimplantation or aortic root remodeling with similar valve stability. Type I with dilatation of the aortic annulus (type Ic) can be managed by annuloplasty. Type II can be corrected by plication or resuspension techniques. Pericardial patch is necessary in AVP for type Id (perforation/fenestration) and type III but is associated with risk of recurrence. Bicuspid aortic valve is classified according to commissure angle: symmetrical, asymmetrical, and very asymmetrical. Tricuspidization is recommended for repair of very asymmetrical valves to avoid postoperative stenosis. Recent progress has achieved similar reoperation rates between bicuspid and tricuspid aortic valve repair. For Marfan syndrome, valve-sparing root replacement is advantageous compared to Bentall operation regarding late survival, thromboembolic and hemorrhagic events, and endocarditis. Similar findings have been reported in acute aortic dissection. Both remodeling and reimplantation procedures provide similar favorable outcomes in these settings. Recent advances in AVP are summarized by quantitative assessment of cusp configuration (effective height and geometric height), graft size decision, use of template to cut the graft, and videoscopic assessment of post-repair cusp configuration. Due to these advances, AVP shows superior results to replacement surgery. Further concrete evidence with larger case volumes and longer observation periods are necessary to popularize AVP.
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