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Giebels C, Schulze-Berge J, Wagenpfeil G, Groß R, Ehrlich T, Schäfers HJ. Prolapse repair for aortic regurgitation in tricuspid aortic valves. J Thorac Cardiovasc Surg 2024; 168:1025-1034.e3. [PMID: 37302467 DOI: 10.1016/j.jtcvs.2023.06.002] [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: 03/15/2023] [Revised: 05/24/2023] [Accepted: 06/02/2023] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Cusp prolapse is an important cause of aortic regurgitation (AR) in tricuspid aortic valves (TAVs) and can be caused by myxomatous degeneration or cusp fenestration. Long-term data for prolapse repair in TAVs are scarce. We analyzed the results of aortic valve repair in patients with TAV morphology and AR caused by prolapse and compared the results for cusp fenestration and myxomatous degeneration. METHODS Between October 2000 and December 2020, 237 patients (221 male; 15-83 years) underwent TAV repair for cusp prolapse. Prolapse was associated with fenestrations in 94 (group I) and myxomatous degeneration in 143 patients (group II). Fenestrations were closed using a pericardial patch (n = 75) or suture (n = 19). In myxomatous degeneration, prolapse was corrected by free margin plication (n = 132) or triangular resection (n = 11). Follow-up was 97% complete (cumulatively 1531, mean 6.5, median 5.8 years). Cardiac comorbidities were present in 111 patients (46.8%), and more frequent in group II (P = .003). RESULTS Ten-year survival was better in group I (I: 84.5%; II: 72.4%; P = .037), and patients without cardiac comorbidities (89.2% vs 67.0%; P = .002). Ten-year freedom from reoperation (P = .778), moderate or greater AR (P = .070), and valve-related complications (P = .977) were similar in both groups. AR at discharge was the only significant predictor for reoperation (P = .042). The type of annuloplasty did not affect repair durability. CONCLUSIONS Repair of cusp prolapse in TAVs with preserved root dimensions can be performed with acceptable durability, even in the presence of fenestrations.
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Affiliation(s)
- Christian Giebels
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saar, Germany
| | - Julia Schulze-Berge
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saar, Germany
| | - Gudrun Wagenpfeil
- Institute for Medical Biometrics, Epidemiology and Medical Computer Science, Saarland University Medical School, Homburg, Saar, Germany
| | - Raphael Groß
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saar, Germany
| | - Tristan Ehrlich
- 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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Desai ND, Kelly JJ, Iyengar A, Zhao Y, Cannon BJ, Grimm JC, Patrick WL, Ibrahim M, Freas M, Siki M, Szeto WY, Bavaria JE. Midterm Results of an Algorithmic 3-Pronged Approach to Bicuspid Aortic Valve Repair. Ann Thorac Surg 2024; 117:950-957. [PMID: 37517532 DOI: 10.1016/j.athoracsur.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/27/2023] [Accepted: 07/08/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND This study evaluated midterm outcomes of a 3-pronged algorithm for bicuspid aortic valve (BAV) repair. Valve-sparing root reimplantation (VSRR) was performed for patients with aortic root dilatation. In those without a root aneurysm, external subannular ring (ESAR) was performed for annuli ≥28 mm and subcommissural annuloplasty (SCA) for annuli <28 mm. METHODS This was a retrospective review of prospectively collected data of 242 patients undergoing primary BAV repair from April 29, 2004, to March 1, 2023, at a single institution. Primary end points were mortality, structural valve degeneration (SVD), which was defined as a composite of more than moderate aortic insufficiency or severe aortic stenosis, and reintervention. RESULTS The algorithm was used to treat 201 patients; of these, 130 underwent VSRR, 35 had ESAR, and 36 underwent SCA. Most were men with mean age of 43.8 years (SD, 12.0 years), which was similar between groups. Preoperative aortic insufficiency more than moderate was more common for ESAR compared with VSRR and SCA (74.3% vs 37.7% vs 44.4%, P < .001). At 30 days, mortality was 0.8% (n = 1) for VSRR and 0% for ESAR and SCA. At 6 years, overall Kaplan-Meier survival was 98.9% (95% CI, 97.3%-100%), with no differences between groups (P = .5). The cumulative incidence of SVD was 4.7% (95% CI, 0.1%-9.2%) for VSRR, 6.4% (95% CI, 0%-14.6%) for ESAR, and 0% for SCA (P = .4). Similarly, the cumulative incidence of reintervention with all-cause mortality as a competing risk was 2.2% (95% CI, 0.4%-6.9%), 6.1% (95% CI, 1%-17.9%), and 0% for VSRR, ESAR, and SCA, respectively (P = .506). CONCLUSIONS A 3-pronged algorithmic approach to BAV repair results in excellent survival and freedom from reoperation at 6 years.
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Affiliation(s)
- Nimesh D Desai
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania.
| | - John J Kelly
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yu Zhao
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brittany J Cannon
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua C Grimm
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - William L Patrick
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Michael Ibrahim
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melanie Freas
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary Siki
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
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3
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Kelly JJ, Desai ND, Mendes S, Zhao Y, Cannon BJ, Iyengar A, Berezowski M, Mosbahi S, Szeto WY, Bavaria JE. Isolated aortic regurgitation in normal-appearing aortic root: what do I do? Ann Cardiothorac Surg 2023; 12:383-385. [PMID: 37554712 PMCID: PMC10405334 DOI: 10.21037/acs-2023-avs2-16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/12/2023] [Indexed: 08/10/2023]
Affiliation(s)
- John J Kelly
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Shanelle Mendes
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Yu Zhao
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Brittany J Cannon
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Mikolaj Berezowski
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Selim Mosbahi
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Aortic root anatomy after aortic valve reimplantation. J Thorac Cardiovasc Surg 2023; 165:1335-1342.e2. [PMID: 33985805 DOI: 10.1016/j.jtcvs.2021.03.115] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/17/2021] [Accepted: 03/24/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE During the last decade, special concerns have been raised about the anatomic relationships among the sinotubular junction, ventricular-aortic junction, and virtual basal ring to improve the results of root reconstruction. The aim of this study is to evaluate the in vivo anatomy of the aortic root after reimplantation with the Valsalva graft and the anatomic relationship between its components. METHODS We analyzed 10 consecutive patients with tricuspid aortic valves who underwent reimplantation with the Valsalva graft between September and December 2019. Surgical clips were applied as markers at the level of proximal annular knots and at the distal reimplanted commissures on the neo-sinotubular junction. Electrocardiogram-gated computed tomography scan of the aortic root was performed. Coordinates of the markers were exported on a 3-dimensional modeling software, and the distances between the virtual basal ring and the Dacron graft basal landmarks were measured. RESULTS The mean heights of Dacron graft basal landmarks from virtual basal ring were right-left commissure 7.1 ± 5.1 mm; right sinus 4.7 ± 4.1 mm; right-noncoronary commissure 2.8 ± 2.2 mm; noncoronary sinus 1.4 ± 1.6 mm; left-noncoronary commissure 2.2 ± 2.3 mm; and left sinus 2.0 ± 0.9 mm. The mean planar distances of basal Dacron graft landmarks from virtual basal ring (thickness) were right-left commissure 5.3 ± 3.1 mm; right sinus 2.8 ± 1.4 mm; right-noncoronary commissure 2.2 ± 1.5 mm; noncoronary sinus 1.5 ± 1.5 mm; left-noncoronary commissure 1.3 ± 1.0 mm; and left sinus 3.4 ± 2.5 mm. CONCLUSIONS After reimplantation, despite a complete dissection of the root, slight asymmetry of graft proximal seating exists. The inner annuloplasty is on the virtual basal ring, and the proximal edge of the Dacron graft is on the ventricular-aortic junction at a slightly different thickness and height along the annular circumference. At the level of the right sinus and left/right commissure, the Dacron graft is higher than the virtual basal ring and the relative wall thickness is increased. The annular stabilization is unaffected.
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5
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Tamer S, Mastrobuoni S, Vancraeynest D, Lemaire G, Navarra E, Khoury GE, de Kerchove L. Late results of aortic valve repair for isolated severe aortic regurgitation. J Thorac Cardiovasc Surg 2023; 165:995-1006.e3. [PMID: 34049711 DOI: 10.1016/j.jtcvs.2021.04.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 03/09/2021] [Accepted: 04/05/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The objectives were to analyze the long-term outcomes of tricuspid aortic valve repair for isolated severe aortic regurgitation and the impact of different annuloplasty techniques. METHODS The study cohort consists of 127 consecutive patients who received aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve between 1996 and 2019 in our institution. Exclusion criteria were aorta dilatation (≥45 mm), connective tissue disease, active endocarditis, type A dissection, and rheumatic disease. Mean age of patients was 55.6 ± 16 years, and 80% were male. Median follow-up was 6.4 years. Time-to-event analysis was performed, as well as risk of death, reoperation, and aortic regurgitation recurrence. RESULTS Cusp repair was performed in 117 patients (92%), and annuloplasty was performed in 126 patients (99%) with Cabrol stitch (73%), reimplantation technique (19.7%), or ring annuloplasty (6.3%). There was no hospital mortality. At 10 and 14 years, overall survival was 81% ± 5% and 71% ± 6%, respectively, and freedom from reoperation was 80% ± 5% and 73% ± 6%, respectively. Age and left coronary cusp repair were independent predictors of reoperation. Freedom from recurrent severe aortic regurgitation (>2+) was 73% ± 5% and 66% ± 7% at 10 and 12 years, respectively. Age, left ventricular end-diastolic diameter, and patch repair were independent predictors of recurrent aortic regurgitation. Type of annuloplasty had no impact on survival or reoperation. CONCLUSIONS Aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve is a safe procedure, and durability at 14 years is acceptable. In this study, the annuloplasty technique did not influence repair durability as was found in bicuspid aortic valve repair or aortic valve-sparing surgery. Severity of cusp pathology seems to be the main determinant of repair durability.
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Affiliation(s)
- Saadallah Tamer
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Stefano Mastrobuoni
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - David Vancraeynest
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Guillaume Lemaire
- Division of Anesthesiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Emiliano Navarra
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Gebrine El Khoury
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Laurent de Kerchove
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
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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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7
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De Paulis R. Editorial: Looking for the best treatment ofbicuspid aortic valves. Interact Cardiovasc Thorac Surg 2022; 35:6760131. [PMID: 36226806 PMCID: PMC9583848 DOI: 10.1093/icvts/ivac253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ruggero De Paulis
- Corresponding author. Dept. of Cardiac Surgery, European Hospital, Via Portuense 700, 00149 Rome, Italy. Tel: +39-0665975224; e-mail: (R. De Paulis)
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8
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Irace FG, Chirichilli I, Folino G, Salica A, Guerrieri Wolf L, Scaffa R, D'Aleo S, Weltert LP, De Paulis R. Reimplantation versus aortic ring annuloplasty in bicuspid valve with borderline aortic root ectasia. JTCVS Tech 2022; 15:36-45. [PMID: 36276689 PMCID: PMC9579730 DOI: 10.1016/j.xjtc.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/05/2022] [Indexed: 11/01/2022] Open
Abstract
Objective Methods Results Conclusions
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Manganiello S, Soquet J, Mugnier A, Rousse N, Juthier F, Banfi C, Loobuyck V, Coisne A, Richardson M, Marechaux S, Moussa MD, Robin E, Pinçon C, Prat A, Vincentelli A. David Procedure: A 21-Year Experience with 300 Patients. Ann Thorac Surg 2022; 115:1403-1410. [DOI: 10.1016/j.athoracsur.2022.04.058] [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: 07/18/2021] [Revised: 04/02/2022] [Accepted: 04/23/2022] [Indexed: 11/01/2022]
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10
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Quintessenza J. Commentary: Aortic valve reconstruction: Embrace it and master it … for your patients' sake … and your future. JTCVS Tech 2022; 11:62-63. [PMID: 35169739 PMCID: PMC8828955 DOI: 10.1016/j.xjtc.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/08/2021] [Accepted: 11/12/2021] [Indexed: 12/01/2022] Open
Affiliation(s)
- James Quintessenza
- Department of Cardiovascular Surgery, JHACH Heart Institute, Johns Hopkins All Children's Hospital, St Petersburg, Fla
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11
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Acharya M, Sherzad H, Tan SZCP, Bashir M, Mariscalco G. External or subcomissural annuloplasty in bicuspid aortic valve repair: Which is better? J Card Surg 2021; 37:532-534. [PMID: 34820900 DOI: 10.1111/jocs.16152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 11/27/2022]
Abstract
Patients with a bicuspid aortic valve (BAV) are at increased risk of valvular regurgitation compared to their counterparts with a tri-leaflet aortic valve. There is now increasing emphasis to offer BAV repair to mitigate the risks of prosthesis-related complications, including thromboembolism, hemorrhage and endocarditis, as well as structural valve deterioration and future reoperation with conventional valve replacement, particularly in younger populations. Furthermore, over the preceding two decades, our greater understanding of the functional anatomy of the BAV, pathophysiological mechanisms of BAV insufficiency, and the development of a functional classification of aortic regurgitation have significantly contributed to the evolution of aortic valve reconstructive surgery. In this commentary, we discuss a recent article from the Journal of Cardiac Surgery comparing external annuloplasty and subcommissural annuloplasty as techniques for BAV repair.
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Affiliation(s)
- Metesh Acharya
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, UK
| | - Hiwa Sherzad
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, UK
| | | | - Mohamad Bashir
- Division of Vascular and Endovascular Surgery, Health Education and Improvement Wales, Nantgarw, UK
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12
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Jasinski M, Plonek T, Gocol R, Pysz P, Hudziak D, Wenzel-Jasinska I, Kansy A, Deja M. Bicuspid aortic valve repair with external or subcommissural annuloplasty-echocardiographic prospective trial. J Card Surg 2021; 37:526-531. [PMID: 34821415 DOI: 10.1111/jocs.16154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/16/2021] [Accepted: 10/20/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The incompetent bicuspid aortic valve (BAV) can be repaired using various techniques. This study presents a prospective comparison of external and subcommissural aortic annuloplasty. METHODS Fifty consecutive patients (38 males, age: 43.9 ± 15.8 years) with BAV insufficiency with or without aortic dilatation underwent valve repair in a single institution. They were prospectively allocated to one of two groups based on the aortic annulus stabilization technique: 25 patients were operated on using the subcommissural annuloplasty (SCA) and 25 using the external complete annuloplasty (EA). Transthoracic echocardiography was performed in all patients before the operation and 1 and 3 years after the operation. Moreover, mortality and morbidity at 7 years were evaluated. RESULTS In prospective echocardiographic comparison, EA was associated with smaller diameter of the aortic annulus (24.1 ± 2.6 mm vs. 25.8±2.1 mm, p < .05) and lower mean and peak transvalvular gradients (7 ± 4 mmHg vs. 13 ± 4 mmHg, p = .02 and 15.3 ± 9.7 mmHg vs. 20.7 ± 5.6 mmHg, p = .03, respectively). No patients died or required reoperation due to recurrent insufficiency at 6,81 (interquartile range-0,17) years after the operation. The Kaplan-Meier actuarial freedom from aortic regurgitation (AR) grade ≥2 or gradient > 20 mmHg at 35.1 ± 3.6 months years was 96% (24 out of 25) for patients who had external annuloplasty and amounted to 76% (19 out of 25) for those who had SCA, p = .05). CONCLUSIONS External annuloplasty performed during repair of the BAV is associated with better hemodynamics at medium-term follow-up compared to SCA.
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Affiliation(s)
- Marek Jasinski
- Department of Cardiothoracic Surgery, Wroclaw Medical University, Wroclaw, Poland.,Department of Cardiac Surgery, Children's Memorial Pediatric Health Institute, Warsaw, Poland
| | - Tomasz Plonek
- Department of Cardiothoracic Surgery, Wroclaw Medical University, Wroclaw, Poland.,Department Cardiac Surgery, Thorax Centrum Twente, Enschede, The Netherlands
| | - Radoslaw Gocol
- Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland
| | - Piotr Pysz
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Damian Hudziak
- Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland
| | | | - Andrzej Kansy
- Department of Cardiac Surgery, Children's Memorial Pediatric Health Institute, Warsaw, Poland
| | - Marek Deja
- Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland
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13
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Hou Q, Liu G, Liu N, Zhang H, Qu Z, Zhang H, Li H, Pan Y, Qiao A. Effect of Valve Height on the Opening and Closing Performance of the Aortic Valve Under Aortic Root Dilatation. Front Physiol 2021; 12:697502. [PMID: 34526908 PMCID: PMC8435789 DOI: 10.3389/fphys.2021.697502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 08/04/2021] [Indexed: 12/13/2022] Open
Abstract
Patients with aortic valve disease can suffer from valve insufficiency after valve repair surgery due to aortic root dilatation. The paper investigates the effect of valve height (Hv) on the aortic valve opening and closing in order to select the appropriate range of Hv for smoother blood flow through the aortic valve and valve closure completely in the case of continuous aortic root dilatation. A total of 20 parameterized three-dimensional models of the aortic root were constructed following clinical surgical guidance. Aortic annulus diameter (DAA) was separately set to 26, 27, 28, 29, and 30 mm to simulate aortic root dilatation. HV value was separately set to 13.5, 14, 14.5, and 15 mm to simulate aortic valve alterations in surgery. Time-varying pressure loads were applied to the valve, vessel wall of the ascending aorta, and left ventricle. Then, finite element analysis software was employed to simulate the movement and mechanics of the aortic root. The feasible design range of the valve size was evaluated using maximum stress, geometric orifice area (GOA), and leaflet contact force. The results show that the valve was incompletely closed when HV was 13.5 mm and DAA was 29 or 30 mm. The GOA of the valve was small when HV was 15 mm and DAA was 26 or 27 mm. The corresponding values of the other models were within the normal range. Compared with the model with an HV of 14 mm, the model with an HV of 14.5 mm could effectively reduce maximum stress and had relatively larger GOA and less change in contact force. As a result, valve height affects the performance of aortic valve opening and closing. Smaller HV is adapted to smaller DAA and vice versa. When HV is 14.5 mm, the valve is well adapted to the dilatation of the aortic root to enhance repair durability. Therefore, more attention should be paid to HV in surgical planning.
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Affiliation(s)
- Qianwen Hou
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China.,Intelligent Physiological Measurement and Clinical Translation, Beijing International Base for Scientific and Technological Cooperation, Beijing, China
| | - Guimei Liu
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China.,Intelligent Physiological Measurement and Clinical Translation, Beijing International Base for Scientific and Technological Cooperation, Beijing, China
| | - Ning Liu
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China.,Intelligent Physiological Measurement and Clinical Translation, Beijing International Base for Scientific and Technological Cooperation, Beijing, China
| | - Honghui Zhang
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China.,Intelligent Physiological Measurement and Clinical Translation, Beijing International Base for Scientific and Technological Cooperation, Beijing, China
| | - Zhuoran Qu
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China.,Intelligent Physiological Measurement and Clinical Translation, Beijing International Base for Scientific and Technological Cooperation, Beijing, China
| | - Hanbing Zhang
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China.,Intelligent Physiological Measurement and Clinical Translation, Beijing International Base for Scientific and Technological Cooperation, Beijing, China
| | - Hui Li
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China.,Intelligent Physiological Measurement and Clinical Translation, Beijing International Base for Scientific and Technological Cooperation, Beijing, China
| | - Youlian Pan
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China.,Intelligent Physiological Measurement and Clinical Translation, Beijing International Base for Scientific and Technological Cooperation, Beijing, China
| | - Aike Qiao
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China.,Intelligent Physiological Measurement and Clinical Translation, Beijing International Base for Scientific and Technological Cooperation, Beijing, China
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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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15
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Mazine A, El-Hamamsy I. The Ross procedure is an excellent operation in non-repairable aortic regurgitation: insights and techniques. Ann Cardiothorac Surg 2021; 10:463-475. [PMID: 34422558 DOI: 10.21037/acs-2021-rp-25] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 06/10/2021] [Indexed: 11/06/2022]
Abstract
The Ross procedure is the best operation to treat aortic stenosis (AS) in young and middle-aged adults. However, its role in non-repairable aortic regurgitation (AR) remains debated since many historical series have reported an increased risk of pulmonary autograft dilatation and subsequent need for reintervention in these patients. Some have attributed these findings to an unrecognized and poorly characterized inherited genetic defect that prevents adaptive remodelling of the pulmonary autograft. Herein, we review the contemporary evidence surrounding the use of the Ross procedure in young adults with AR and put forth the argument that with proper technical refinements, the Ross procedure may still be the best operation to treat these patients. We believe that by tailoring the operation to the patient's anatomy and ensuring strict postoperative blood pressure control, one can achieve excellent results with the Ross procedure, including in this challenging patient population.
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Affiliation(s)
- Amine Mazine
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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16
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Abstract
Purpose of Review Preservation or repair of the aortic valve has evolved dynamically in the past 20 years. It leads to a high freedom from valve-related complications if an adequate valve durability can be achieved; it may possibly also improve survival. To date, little structured information is available about which valves can be repaired and which should better be replaced. Recent Findings For surgical decision-making, the size of the aortic root is important and the anatomy of the aortic valve must be considered. In the presence of root aneurysm, most tricuspid and bicuspid aortic valves can be preserved. In aortic regurgitation and normal aortic dimensions, the majority of tricuspid and bicuspid aortic valves can be repaired with good long-term durability. In bicuspid aortic valves, the morphologic characteristics must be taken into consideration. Unicuspid and quadricuspid aortic valves can be repaired in selected cases. Generally, cusp calcification is a sign of a poor substrate for repair; the same is true for cusp retraction and cusp destruction due to active endocarditis. They are associated with limited valve durability. Summary Using current concepts, many non-calcified aortic valves can be repaired. Modern imaging, in particular three-dimensional transesophageal echocardiography (TEE), should be able to define repairable aortic valves with a high probability.
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17
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Chirichilli I, Irace FG, Salica A, D'Aleo S, Guerrieri Wolf L, Garufi L, De Paulis R. Root Reimplantation and Aortic Annuloplasty With External Ring in Bicuspid Aortic Valve: An Anatomical Comparison. Semin Thorac Cardiovasc Surg 2021; 34:844-851. [PMID: 34216751 DOI: 10.1053/j.semtcvs.2021.06.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 01/16/2023]
Abstract
Aortic annuloplasty has demonstrated to be a protective factor in valve-sparing root replacement and aortic valve repair. Both reimplantation for aortic root aneurysms and external ring annuloplasty for isolated aortic regurgitation have demonstrated good long-term results. The aim of this anatomical study is to compare aortic reimplantation with Valsalva graft with aortic external ring annuloplasty in bicuspid aortic valves, analyzing their morphological features with CT scan. We selected 56 patients with bicuspid aortic valve who underwent reimplantation procedure with Valsalva graft or external ring annuloplasty; after propensity-matching, 2 homogeneous groups of 10 patients each were obtained. Through multiplanar ECG-gated CT-Scan reconstructions, pre- and postoperative, aortic annular, and valve geometrical characteristics were compared (diameters, perimeter, area and ellipticity index for the annulus; effective height, coaptation length and commissural height for the valve). Aortic root volume was also analyzed. Postoperative comparison of the two groups showed similar geometric features of the aortic annulus in terms of major and minor diameters, perimeter, area and ellipticity index. Analysis of valve's parameters showed similar results in terms of effective height and coaptation length (respectively 10.9 ± 2.1 mm and 7.5 ± 1.9 mm in External Ring group and 10.1 ± 2.0 mm and 7.6 ± 1.6 mm in the Reimplantation group). Both techniques achieve an efficient annuloplasty with similar anatomical results on bicuspid the aortic valves. The stability of these results needs to be confirmed by long-term clinical and echocardiographic follow-up.
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Affiliation(s)
- Ilaria Chirichilli
- Department of Cardiac Surgery, European Hospital, Rome, Italy; Department of Cardiac Surgery and Heart Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Francesco Giosuè Irace
- Department of Cardiac Surgery, European Hospital, Rome, Italy; Department of General and Specialized Surgery "Paride Stefanini", Sapienza University, Rome, Italy
| | - Andrea Salica
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | | | | | - Luigi Garufi
- Department of Cardiac Surgery, European Hospital, Rome, Italy; Department of Cardio-Thoracic and Vascular Sciences, University of Padua, Italy
| | - Ruggero De Paulis
- Department of Cardiac Surgery, European Hospital, Rome, Italy; Chair of Cardiac Surgery, UniCamillus, International University of Health Sciences, Rome, Italy.
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18
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Zakkar M, Bruno VD, Zacek P, Di Centa I, Acar C, Khelil N, Debauchez M, Lansac E. Isolated aortic insufficiency valve repair with external ring annuloplasty: a standardized approach. Eur J Cardiothorac Surg 2021; 57:308-316. [PMID: 31292613 DOI: 10.1093/ejcts/ezz193] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/02/2019] [Accepted: 05/05/2019] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES Aortic valve (AV) insufficiency with normal root and ascending aorta is most frequently treated by valve replacement with significant prosthetic-related complications and reduced life expectancy. We compared the outcomes of a new standardized isolated AV repair approach using an external aortic annuloplasty ring at the subvalvular level (single ring annuloplasty) and the role of an additional supravalvular ring at the sinotubular junction (double ring annuloplasty). METHODS Single centre data were collected from the Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (AVIATOR) between 2003 and 2017. A total of 93 patients (56 single ring and 37 double ring) underwent isolated AV repair. RESULTS The overall 30-day mortality rate and the need for a permanent pacemaker were 1% and 2%, respectively. The overall survival rate at 6 years was similar for sex- and age-matched members of the general population (89% vs 95%; P = 0.1) and did not differ between the double and single ring groups (82% vs 93%; P = 0.4) at 6 years. There were no thromboembolic or bleeding events in the entire cohort. However, at 6 years, the cumulative incidence of valve-related reintervention was 26% in the single ring annuloplasty group compared to 3% in the double ring annuloplasty (P = 0.02) group. Similarly, at 6 years, the cumulative incidence of moderate-to-severe (>2) aortic insufficiency was 30% in the single ring annuloplasty group compared to 0% in the double ring annuloplasty group (P = 0.007). CONCLUSIONS Standardized AV repair with external ring annuloplasty has a survival rate similar to that of the general population. The additional stabilization of the sinotubular junction with a second supravalvular ring (double ring annuloplasty) is associated with better outcomes compared to single subvalvular annuloplasty. It can be considered as a first line intervention for patients with isolated aortic insufficiency and pliable leaflets.
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Affiliation(s)
- Mustafa Zakkar
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France.,Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield Hospital, Leicester, UK
| | - Vito D Bruno
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, UK
| | - Pavel Zacek
- Department of Cardiac Surgery, Charles University Hospital in Prague, Faculty of Medicine, Hradec Kralove, Czech Republic
| | | | - Christophe Acar
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Nizar Khelil
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Mathieu Debauchez
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Emmanuel Lansac
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
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19
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Federspiel JM, Ehrlich T, Abeln K, Schäfers HJ. Aortic annuloplasty: Subcommissural, intra-annular suture techniques, external and internal rings. JTCVS Tech 2021; 7:98-102. [PMID: 34318215 PMCID: PMC8311589 DOI: 10.1016/j.xjtc.2020.12.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 12/14/2020] [Indexed: 11/28/2022] Open
Abstract
Aortic valve repair and valve-preserving root replacement have evolved into increasingly practiced procedures. With increasing experience, the need for an annuloplasty has become more evident, at least for pathologies that involve annular dilatation. To understand the effect of an aortic annuloplasty, it is necessary to know the details of aortic valve and root anatomy. Geometrically, the functional annulus is best defined as the virtual basal ring, ie, plane of the cusp nadirs. The sinotubular diameter also influences the aortic valve form, at least in tricuspid valves. Different annuloplasty concepts have been developed for isolated valve repair or in combination with root remodeling, such as subcommissural sutures, suture annuloplasty, external, and internal rings. Subcommissural sutures do not consistently provide durable annular stabilization. More positive results have been published for circular approaches, ie, suture annuloplasty, external, or internal rings. The results of different techniques are difficult to judge because most outcome data have not been analyzed with control of confounding predictors of repair failure. The evidence that annuloplasty improves aortic valve function and repair durability is best documented for isolated bicuspid aortic valve repair. In summary, the addition of annuloplasty to aortic valve reconstruction is probably a useful tool to improve valve competence and stabilize the repair. This is best documented for isolated bicuspid valve repair and circular approaches. The relative benefit of individual concepts is difficult to judge because of lack of both control groups and control of confounding factors.
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Affiliation(s)
- Jan M Federspiel
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Tristan Ehrlich
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Karen Abeln
- 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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20
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Jasinski MJ, Miszalski-Jamka K, Kosiorowska K, Gocol R, Wenzel-Jasinska I, Bielicki G, Berezowski M, Lukaszewski M, Kansy A, Deja MA. The evaluation of annuloplasty in bicuspid aortic valve repair using cardiac magnetic resonance. BMC Cardiovasc Disord 2021; 21:13. [PMID: 33407164 PMCID: PMC7789766 DOI: 10.1186/s12872-020-01831-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 12/20/2020] [Indexed: 01/09/2023] Open
Abstract
Background The incompetent bicuspid aortic valve (BAV) can be replaced or repaired using various surgical techniques. This study sought to assess the efficacy of external annuloplasty and postoperative reverse remodelling using cardiac magnetic resonance (CMR) and compare the results of external and subcommissural annuloplasty. Methods Out of a total of 200 BAV repair performed between 2004 and 2018, 21 consecutive patients (median age 54 years) with regurgitation requiring valve repair with annuloplasty without concomitant aortic root surgery were prospectively referred for CMR and transthoracic echocardiography (TTE) one year after the operation. Two aortic annulus stabilization techniques were used: external, circumferential annuloplasty (EA), and subcommissural annuloplasty (SCA). Results 11 patients received EA and 10 patients were treated using SCA. There was no in-hospital mortality and all patients survived the follow-up period (median: 12.6 months (first quartile: 6.6; third quartile: 14.1). CMR showed strong correlation between postoperative aortic recurrent regurgitant fraction and left ventricular end-diastolic volume (r = 0.62; p = 0.003) as well as left ventricular ejection fraction (r = -0.53; p = 0.01). Patients treated with EA as compared with SCA had larger anatomic aortic valve area measured by CMR (3.5 (2.5; 4.0) vs. 2.5 cm2 (2.0; 3.4); p = 0.04). In both EA and SCA group, aortic valve area below 3.5 cm2 correlated with no regurgitation recurrency. EA (vs. SCA) was associated with lower peak transvalvular aortic gradients (10 (6; 17) vs. 21 mmHg (15; 27); p = 0.04). Conclusions The repair of the bicuspid aortic valve provides significant postoperative reverse remodelling, provided no recurrent regurgitation and durable reduction annuloplasty can be achieved. EA is associated with lower transvalvular gradients and higher aortic valve area assessed by CMR, compared to SCA.
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Affiliation(s)
- Marek J Jasinski
- Department of Cardiac Surgery, University Hospital in Wroclaw, 50-556, Wrocław, Poland.,Department of Cardiac Surgery, Children's Memorial Paediatric Health Institute, Warsaw, Poland
| | - Karol Miszalski-Jamka
- Division of Magnetic Resonance Imaging, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Kinga Kosiorowska
- Department of Cardiac Surgery, University Hospital in Wroclaw, 50-556, Wrocław, Poland.
| | - Radoslaw Gocol
- Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland
| | | | - Grzegorz Bielicki
- Department of Cardiac Surgery, University Hospital in Wroclaw, 50-556, Wrocław, Poland
| | - Mikolaj Berezowski
- Department of Cardiac Surgery, University Hospital in Wroclaw, 50-556, Wrocław, Poland
| | - Marceli Lukaszewski
- Department of Cardiac Surgery, University Hospital in Wroclaw, 50-556, Wrocław, Poland
| | - Andrzej Kansy
- Department of Cardiac Surgery, Children's Memorial Paediatric Health Institute, Warsaw, Poland
| | - Marek A Deja
- Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland
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21
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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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22
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Youssefi P, Lansac E. Aortic annulus and the importance of annuloplasty. Indian J Thorac Cardiovasc Surg 2020; 36:88-96. [PMID: 33061189 DOI: 10.1007/s12055-019-00852-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Dystrophic aortic insufficiency accounts for the majority of Western cases of aortic insufficiency and can be divided into the three phenotypes of isolated aortic insufficiency, dilated aortic root, and dilated ascending aorta. Each of these phenotypes is associated with a dilated annulus and/or sinotubular junction. Recent international guidelines recommend reimplantation or remodeling with aortic annuloplasty for valve-sparing root replacement, as well as consideration of aortic valve repair in cases of aortic insufficiency. A dilated aortic annulus is a major risk factor for failure of aortic valve repair procedures, indicating the need to address the annulus at the time of aortic valve or root repair. Calibrated annuloplasty should be performed at sub- and supravalular levels in order to restore the ratio of the sinotubular junction and annulus and be adapted according to the phenotype of the root and ascending aorta. Standardization of aortic valve repair techniques with use of a calibrated annuloplasty will improve dissemination of techniques and rate of aortic valve repair. Current medical evidence shows that aortic valve repair is safe, produces better quality of life, and reduces valve-related mortality compared to prosthetic valve replacement.
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Affiliation(s)
- Pouya Youssefi
- Department of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Emmanuel Lansac
- Department of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France
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23
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Patlolla SH, Schaff HV, Stulak JM, Michelena HI, Saran N, King KS, Dearani JA. Bicuspid Aortic Valve Repair: Causes of Valve Failure and Long-Term Outcomes. Ann Thorac Surg 2020; 111:1225-1232. [PMID: 32599047 DOI: 10.1016/j.athoracsur.2020.04.146] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 03/30/2020] [Accepted: 04/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Repair of bicuspid aortic valves (BAVs) for aortic regurgitation (AR) has favorable outcomes, but the impact of natural disease progression on durability of repair is uncertain. We evaluated causes of reoperation and compared outcomes of BAV repair to those of patients undergoing aortic valve replacement (AVR). METHODS Between January 1993 and December 2016, 113 patients had BAV repair at our institution for significant AR. Operative notes and pathology reports were studied to identify late causes of repair failure. For comparison with AVR, we utilized propensity score weighting with the score derived from preoperative and operative characteristics using gradient boosting machine model. RESULTS A total of 26 patients had late AVR after initial repair. Causes of late valve dysfunction included calcification or fibrosis of the cusps (68%), concomitant replacement addressing moderate degree of aortic valve disease to avoid future operation (20%), and cusp prolapse (12%). Pathological evaluation of these excised valves reported calcification and fibrosis in 88% of the valves. Ten-year survival of patients undergoing BAV repair was 91% compared with 90% for patients undergoing AVR with a mechanical valve and 79% for AVR with a bioprosthesis (P = .6). Incidence of reoperation after AVR with a bioprosthesis was similar to risk after repair whereas AVR with mechanical valve showed significant advantage. CONCLUSIONS Disease progression with calcification or fibrosis is the most common cause of valve failure after initial repair of BAV. Clinical outcomes of BAV repair for severe AR appear superior to AVR with bioprosthesis.
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Affiliation(s)
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Katherine S King
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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24
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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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25
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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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26
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Tasca G, Trinca F, Riva B, Lobiati E, Nasatti A, Faccioli P, Gamba A. Sleeve valve-sparing procedure in bicuspid aortic valve: early and midterm clinical results. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:250-255. [DOI: 10.23736/s0021-9509.20.11051-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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27
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Guo MH, Boodhwani M. Aortic Valve Repair: From Concept to Future Targets. Semin Thorac Cardiovasc Surg 2019; 31:650-655. [PMID: 31220531 DOI: 10.1053/j.semtcvs.2019.05.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/02/2019] [Indexed: 11/11/2022]
Abstract
Aortic valve repair has become an important treatment alternative to patients with aortic insufficiency. In this paper, we review refinements and advances in the understanding of core concepts of aortic valve anatomy and pathophysiology which have enhanced our approach to aortic valve preservation and repair. With these improvements in understanding and techniques, the outcome for aortic valve repair continues to improve. We also review current challenges in the field and explore potential areas of innovation and future study including timing of surgical intervention for aortic insufficiency, comparisons between aortic valve repair and replacement in randomized trials, and development of personalized surgical management plan based on patient-specific pathologies. These advances will further establish the role of aortic valve repair in the management of aortic valve and aortic disease.
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Affiliation(s)
- Ming Hao Guo
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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Zakkar M, Youssefi P, Acar C, Khelil N, Debauchez M, Lansac E. Bicuspid aortic valve repair adapted to aortic phenotype. Ann Cardiothorac Surg 2019; 8:401-410. [PMID: 31240187 DOI: 10.21037/acs.2019.04.13] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The bicuspid aortic valve (BAV) is the most common congenital cardiovascular anomaly and may present with differing phenotypes including almost constant annular dilation. We have developed a standardized approach to BAV repair with a systematic adjunct of aortic annuloplasty according to the three phenotypes of the proximal aorta, which include a dilated aortic root, dilated ascending aorta and normal root and ascending aorta. In our cohort of 191 patients, freedom from AV-related re-intervention was 98% for remodeling with annuloplasty (n=100) and 100% for tubular aortic replacement with annuloplasty (n=31) at 8 years. In an isolated aortic insufficiency (AI) group, freedom from AV-related re-intervention varied from 72.4% with a single subvalvular annuloplasty ring (n=31) compared to 100% at 6 years when a double sub- and supra-valvular (STJ) annuloplasty ring was performed (n=29). Restoration of the annulus: sinotubular junction (STJ) ratio is a key factor to ensure longevity of the bicuspid valve repair and freedom from re-intervention.
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Affiliation(s)
- Mustafa Zakkar
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France.,Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Pouya Youssefi
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Christophe Acar
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Nizar Khelil
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Mathieu Debauchez
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Emmanuel Lansac
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
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29
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Zakkar M, Youssefi P, Di Centa I, Khelil N, Debauchez M, Lansac E. Isolated aortic valve repair-how to do it and long-term results: external ring annuloplasty. Ann Cardiothorac Surg 2019; 8:418-421. [PMID: 31240190 DOI: 10.21037/acs.2019.04.14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Mustafa Zakkar
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France.,Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Pouya Youssefi
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | | | - Nizar Khelil
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Mathieu Debauchez
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Emmanuel Lansac
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
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30
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Youssefi P, El-Hamamsy I, Lansac E. Rationale for aortic annuloplasty to standardise aortic valve repair. Ann Cardiothorac Surg 2019; 8:322-330. [PMID: 31240176 DOI: 10.21037/acs.2019.05.13] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Available evidence shows that aortic valve repair reduces valve-related mortality and improves quality of life compared to prosthetic aortic valve replacement. One of the most important predictors of bicuspid and tricuspid aortic valve repair failure is the absence of treating a dilated aortic annulus greater than 25-28 mm. Competency of the aortic valve depends on multiple factors including the diameter of the annulus, sinotubular junction, valve cusps and commissures. Dystrophic aortic insufficiency (AI) is the commonest cause of AI in the Western world and is characterised by dilatation of the aortic annulus (≥25 mm), sinuses and/or sinotubular junction (≥30 mm). Depending on whether the sinuses of Valsalva and/or tubular ascending aorta are dilated, three phenotypes can be identified: dilated aortic root, dilated ascending aorta and isolated AI. All three phenotypes are associated with a dilated aortic annulus. Aortic annuloplasty reduces the dilated aortic annulus and improves the surface of coaptation, as in the case of mitral valve repair. In treating AI, it is also important to restore the physiological sinotubular junction/annulus ratio, which can be carried out with remodeling root repair + subvalvular annuloplasty (for dilated aortic root), tubular ascending aorta replacement + subvalvular annuloplasty (for dilated ascending aorta) and double sub- and supra-valvular annuloplasty (for isolated AI). Aortic annuloplasty is now considered an essential component of aortic valve repair and valve-sparing root surgery.
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Affiliation(s)
- Pouya Youssefi
- Department of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Ismail El-Hamamsy
- Division of Cardiac Surgery, Montreal Heart Institute, Universite de Montreal, Montreal, Quebec, Canada
| | - Emmanuel Lansac
- Department of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France
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31
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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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32
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Liu T, Xie M, Lv Q, Li Y, Fang L, Zhang L, Deng W, Wang J. Bicuspid Aortic Valve: An Update in Morphology, Genetics, Biomarker, Complications, Imaging Diagnosis and Treatment. Front Physiol 2019; 9:1921. [PMID: 30761020 PMCID: PMC6363677 DOI: 10.3389/fphys.2018.01921] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/20/2018] [Indexed: 12/19/2022] Open
Abstract
The bicuspid aortic valve, a kind of heart disease that comes from parents, has been paid attention around the world. Although most bicuspid aortic valve (BAV) patients will suffer from some complications including aortic stenosis, aortic regurgitation, endocarditis, and heart dysfunction in the late stage of the disease, there is none symptom in the childhood, which restrains us to diagnose and treatment in the onset phase of BAV. Hemodynamic abnormalities induced by the malformations of the valves in BAV patients for a long time will cause BAV-associated aortopathy: including progress aortic dilation, aneurysm, dissection and rupture, cardiac cyst and even sudden death. At present, preventive surgical intervention is the only effective method used in this situation and the diameter of the aorta is the primary reference criterion for surgery. And the treatment effects are always not satisfactory for patients and clinicians. Therefore, we need more methods to evaluate the progression of BAV and the surgery value and the appropriate intervention time by combining basic research with clinical treatment. In this review, advances in morphology, genetic, biomarkers, diagnosis and treatments are summarized, which expects to provide an update about BAV. It is our supreme expectations to provide some evidences for BAV early screening and diagnosis, and in our opinion, personalized surgical strategy is the trend of future BAV treatment.
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Affiliation(s)
- Tianshu Liu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Mingxing Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Qing Lv
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yuman Li
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Lingyun Fang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Li Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Wenhui Deng
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Jing Wang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
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33
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Ko H, Bavaria JE, Habertheuer A, Augoustides JG, Siki MA, Freas M, Komlo C, Milewski K, Desai ND, Szeto WY, Vallabhajosyula P. Functional Outcomes of Type I Bicuspid Aortic Valve Repair With Annular Stabilization: Subcommissural Annuloplasty Versus External Subannular Aortic Ring. Ann Thorac Surg 2019; 107:68-75. [DOI: 10.1016/j.athoracsur.2018.06.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 06/11/2018] [Accepted: 06/18/2018] [Indexed: 10/28/2022]
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34
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Habertheuer A, Milewski RK, Bavaria JE, Siki M, Freas M, Desai N, Szeto W, Ram C, Hu R, Vallabhajosyula P. Predictors of Recurrent Aortic Insufficiency in Type I Bicuspid Aortic Valve Repair. Ann Thorac Surg 2018; 106:1316-1324. [DOI: 10.1016/j.athoracsur.2018.06.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 06/05/2018] [Accepted: 06/06/2018] [Indexed: 11/16/2022]
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35
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Kunihara T. Aortic valve repair for aortic regurgitation and preoperative echocardiographic assessment. J Med Ultrason (2001) 2018; 46:51-62. [PMID: 30232651 DOI: 10.1007/s10396-018-0903-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 08/01/2018] [Indexed: 12/26/2022]
Abstract
Aortic valvuloplasty (AVP) has been performed less frequently than mitral valvuloplasty. The survival benefit of AVP over replacement has been demonstrated. Therefore, standardization of AVP is crucial for its widespread adoption. The hemodynamic advantage of AVP of preserving the native aortic valve may be one reason for the survival benefit. Recent guidelines still recommend AVP in selected cases compared with the less restricted recommendation for mitral valvuloplasty, although recent studies have proposed earlier indication for surgical intervention. Indication for aortic root replacement is also still conservative, especially in Japan. However, more liberal root replacement should be recommended for better repair when AVP is indicated. Theoretically, all aortic regurgitation lesions can be repaired with acceptable durability. However, restricted cusp should be extended by a pericardial patch, which itself has emerged as a risk of recurrence. Therefore, indications for aortic regurgitation for type III lesions should be determined carefully. Special consideration is crucial for bicuspid aortic valve repair; prevention of postoperative stenosis is especially important. Arrangement of the commissure position is the most important consideration for this purpose, although it remains controversial. Therefore, detailed diagnosis is important in planning AVP, and echocardiography plays a key role in this process.
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Affiliation(s)
- Takashi Kunihara
- Department of Cardiac Surgery, Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan.
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36
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Nawaytou O, Mastrobuoni S, de Kerchove L, Baert J, Boodhwani M, El Khoury G. Deep circumferential annuloplasty as an adjunct to repair regurgitant bicuspid aortic valves with a dilated annulus. J Thorac Cardiovasc Surg 2018; 156:590-597. [DOI: 10.1016/j.jtcvs.2018.03.110] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 02/17/2018] [Accepted: 03/02/2018] [Indexed: 12/30/2022]
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37
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Al-Atassi T, Boodhwani M. Aortic valve insufficiency in aortic root aneurysms: consider every valve for repair. J Vis Surg 2018; 4:60. [PMID: 29682470 DOI: 10.21037/jovs.2018.01.13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 01/08/2018] [Indexed: 01/24/2023]
Abstract
Aortic valve (AV) preservation and repair is emerging as an attractive alternative to AV replacement in younger patients with aortic insufficiency (AI) and aortic root aneurysms. AV repair mitigates some of the risks associated with prosthetic valves. More centers are reporting the safety of AV preservation and repair and favorable short- and long-term outcomes. However, further work is needed to improve long-term repair durability and dissemination of knowledge and technique to make AV repair the gold standard in this patient population.
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Affiliation(s)
- Talal Al-Atassi
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Canada
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38
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Ničovský J, Ondrášek J, Fila P, Štěrba J, Vetešková L, Šebo M, Němec P. Valve preserving surgery in patients with bicuspid aortic valve. COR ET VASA 2018. [DOI: 10.1016/j.crvasa.2017.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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39
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Valve-sparing aortic root surgery. CON: remodeling. Gen Thorac Cardiovasc Surg 2017; 67:82-92. [DOI: 10.1007/s11748-017-0833-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 09/06/2017] [Indexed: 01/05/2023]
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40
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Fattouch K, Moscarelli M, Castrovinci S, Murana G, Dioguardi P, Guccione F, Nasso G, Speziale G, Lancellotti P. Mid-term results of bicuspid aortic valve repair guided by morphology and function assessment. Interact Cardiovasc Thorac Surg 2017; 25:83-88. [DOI: 10.1093/icvts/ivx027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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41
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Anatomy of the aortic root: implications for aortic root reconstruction. Gen Thorac Cardiovasc Surg 2017; 65:488-499. [PMID: 28656518 DOI: 10.1007/s11748-017-0792-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 06/07/2017] [Indexed: 10/19/2022]
Abstract
Since the introduction of valve-preserving root replacement and aortic annuloplasty, precise understanding of the aortic root anatomy has emerged as a key to successful aortic valve-preservation surgery. Fundamentally, surgeons need to know the precise anatomical definition and structure of the aortic root, including its normal dimensions, know the anatomy of the coronary arteries, and understand the cardiac conduction system. Surgeons must be able to clearly distinguish normal and abnormal structures, and recognize the effects of aortic valve regurgitation or root expansion on dimensions and geometric relationships within the aortic root. Possessing a detailed understanding of the aortic root, surgeons can select appropriately sized grafts and achieve optimum annular fixation. This review covers the essentials of aortic root anatomy and provides tips for correct and safe performance of aortic valve-preservation surgery with a view toward durable late outcomes.
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42
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Remodeling root repair with an external aortic ring annuloplasty. J Thorac Cardiovasc Surg 2017; 153:1033-1042. [DOI: 10.1016/j.jtcvs.2016.12.031] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 11/25/2016] [Accepted: 12/09/2016] [Indexed: 12/20/2022]
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44
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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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45
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Bicuspid Aortic Insufficiency With Aortic Root Aneurysm: Root Reimplantation Versus Bentall Root Replacement. Ann Thorac Surg 2016; 102:1221-8. [DOI: 10.1016/j.athoracsur.2016.03.087] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 03/15/2016] [Accepted: 03/22/2016] [Indexed: 11/21/2022]
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46
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Holubec T, Higashigaito K, Belobradek Z, Dergel M, Harrer J, Alkadhi H, Zacek P, Vojacek J. An Expansible Aortic Ring in Aortic Root Remodeling: Exact Position, Pulsatility, Effectiveness, and Stability in Three-Dimensional CT Study. Ann Thorac Surg 2016; 103:83-90. [PMID: 27457826 DOI: 10.1016/j.athoracsur.2016.05.098] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 04/21/2016] [Accepted: 05/23/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to assess effectiveness, stability, position, and expansibility of an expansible aortic annuloplasty ring with computed tomography (CT). METHODS Ten men (median age 51 years) scheduled for aortic root remodeling with implantation of external annuloplasty ring underwent contrast-enhanced CT of the aortic root preoperatively, postoperatively, and at a median of 21 months after operation. A reconstructed transverse double oblique view of the aortic base (AB) and of the new defined annuloplasty ring base (ARB; plane of the lower edge of the ring) in systole and diastole were obtained. The diameters, perimeter, and area were measured. In addition, the distances between AB and ARB in the nadir of each sinus were measured. RESULTS We found 12% reduction of the postoperative AB and 19% of ARB perimeter in both systole (p = 0.004, p < 0.001, respectively) and diastole (p = 0.001, p < 0.001, respectively) compared with preoperative. There was 22% reduction of the postoperative AB area in systole and 24% in diastole (p = 0.002, p = 0.001, respectively) and 33% reduction of the ARB area in systole and 32% in diastole (p < 0.001 for both) compared with the preoperative period. Nearly all measured variables in the follow-up period showed a slight increase compared with the postoperative period; however, they did not reach statistical significance. The postoperative systolic-diastolic differences in the three measured variables at the level of AB and ARB were statistically significant and were maintained throughout the follow-up period. The base of the ring was implanted 2 ± 2 mm at the right, 0 ± 1 mm at the left above the AB, and 2 (-3 to 2) mm at the noncoronary nadir below the AB. CONCLUSIONS This study demonstrates imaging evidence of the effectiveness, stability, and pulsatility of the annuloplasty ring in aortic root remodeling in follow-up and describes the exact position of the ring at the base of the aortic root.
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Affiliation(s)
- Tomas Holubec
- Division of Cardiovascular Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Cardiac Surgery, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
| | - Kai Higashigaito
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Zdenek Belobradek
- Department of Radiology, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Martin Dergel
- Department of Cardiac Surgery, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jan Harrer
- Department of Cardiac Surgery, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Hatem Alkadhi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Pavel Zacek
- Department of Cardiac Surgery, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jan Vojacek
- Department of Cardiac Surgery, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
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Lansac E, Di Centa I, Sleilaty G, Lejeune S, Khelil N, Berrebi A, Diakov C, Mankoubi L, Malergue MC, Noghin M, Zannis K, Salvi S, Dervanian P, Debauchez M. Long-term results of external aortic ring annuloplasty for aortic valve repair. Eur J Cardiothorac Surg 2016; 50:350-60. [DOI: 10.1093/ejcts/ezw070] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 01/25/2016] [Indexed: 01/18/2023] Open
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Ridley CH, Vallabhajosyula P, Bavaria JE, Patel PA, Gutsche JT, Shah R, Feinman JW, Weiss SJ, Augoustides JG. The Sievers Classification of the Bicuspid Aortic Valve for the Perioperative Echocardiographer: The Importance of Valve Phenotype for Aortic Valve Repair in the Era of the Functional Aortic Annulus. J Cardiothorac Vasc Anesth 2016; 30:1142-51. [PMID: 27241768 DOI: 10.1053/j.jvca.2016.02.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Indexed: 12/13/2022]
Affiliation(s)
- Clare H Ridley
- Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, School of Medicine, Washington University, St. Louis, MO
| | | | | | - Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ronak Shah
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jared W Feinman
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stuart J Weiss
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Kunihara T. Annular management during aortic valve repair: a systematic review. Gen Thorac Cardiovasc Surg 2015; 64:63-71. [DOI: 10.1007/s11748-015-0602-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Indexed: 10/22/2022]
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50
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Khelil N, Sleilaty G, Palladino M, Fouda M, Escande R, Debauchez M, Di Centa I, Lansac E. Surgical Anatomy of the Aortic Annulus: Landmarks for External Annuloplasty in Aortic Valve Repair. Ann Thorac Surg 2015; 99:1220-6. [DOI: 10.1016/j.athoracsur.2014.12.034] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 12/02/2014] [Accepted: 12/05/2014] [Indexed: 10/23/2022]
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