Reoperative Aortic Valve Replacement After Bio-Bentall using a Double Sewing Ring Technique

We report an 89-year-old hemodialysis patient with a structural valve deterioration following a Bentall-de Bono operation with a tissue valve using the double sewing ring technique. The bioprosthesis was extracted easily, and the aortic valve replacement was performed without any complications in a high-risk patient. This procedure may be feasible given the prospects of reoperation.

Degenerated BioBentall graft with failing stentless bioprosthesis and dissection of the aortic conduit treated with a bail-out valve in valve procedure: a case report

Background

The Bentall procedure is commonly performed to treat combined aortic valve and ascending aorta disease requiring surgical correction. Although the technique has been shown to provide favourable long-term outcomes, both the valvular prosthesis and the aortic conduit can go through structural degeneration. Increasing use of the biological prosthesis opened to percutaneous treatment of valvular deterioration according to a valve-in-valve (ViV) technique. On the contrary, damages of the tube graft are normally referred to repeated surgical operation.

Case summary

In the present case, a patient with a biological Bentall graft was diagnosed with severely deteriorated stentless aortic prosthesis and dissection of the conduit arising from a tube wall tear closely located to the valvular plane. The attempted redo surgery was technically unfeasible because of severe mediastinal adhesions; therefore, a ViV procedure with a balloon expandable transcatheter heart valve was performed in order to contemporarily treat the valve prothesis dysfunction and the aortic tube dissection. No procedure-related complications occurred and subsequent aortic computed tomography angiography showed the sealing of the graft wall false lumen.

Discussion

Surgical reintervention remains the treatment of choice for degeneration of a previous Bentall surgery, especially when damages of the aortic conduit exist. Nevertheless, when surgery has to be discarded, ViV can be a reliable option as a bail-out strategy to deal with combined aortic valve dysfunction and tube dissection.

Bicuspid-Associated Aortic Root Aneurysm: Mid to Long-Term Outcomes of David V Versus the Bio-Bentall Procedure

David V valve-sparing root replacement (VSRR) and bio-Bentall (BB) are increasingly performed for aortic root aneurysms associated with a bicuspid aortic valve (BAV). However, durability remains a concern in both procedures. We compared the 10-year outcomes of VSRR vs BB for BAV-associated root aneurysms. A retrospective review identified 134 patients with a BAV-associated root aneurysm who underwent VSRR (n = 65) or BB (n = 69) from 2005 to 2019. Patients with aortic stenosis, endocarditis, previous aortic valve replacement, and emergent cases were excluded. Propensity-score matching was performed, resulting in 2 risk-adjusted groups (n = 40 per group). Median follow-up was 6.21 (1.43-8.28) years. The VSRR cohort was younger (46.0 years vs 56.0 years, P < 0.001) and had a lower incidence of at least moderate aortic insufficiency (AI) (78.5% vs 92.8%, P = 0.02). The incidence of Marfan syndrome, aortic root diameter, and ascending aortic diameter were similar. In-hospital mortality was 1.5% (n = 1) and 1.4% (n = 1) for VSRR and BB, respectively. There was no difference between VSRR and BB in 10-year survival (98.3% [95% confidence interval (CI): 88.6-99.8%] vs 96.2% [95% CI: 85.5-99.0%], P = 0.567) and aortic valve reintervention at 10 years (16.1% [95% CI: 6.3-29.8%] vs 12.9% [95% CI: 3.7-28.0%], P = 0.309). The most common reason for valve reintervention in both groups was AI. Survival and valve reintervention at 10 years were similar in the matched cohort. David V VSRR yields similar mid to long-term outcomes to BB for select patients with a BAV-associated aortic root aneurysm in regards to survival and reintervention rates. Further studies comparing longer term outcomes between root replacement techniques and native valve durability are needed.

Early results of a modified biological valved conduit for the Bentall procedure

INTRODUCTION

Few bioprosthetic valved conduits for aortic root surgery are commercially available. Long-term Warfarin therapy (mechanical), potential root calcification (xeno- or homograft valves), and the need for additional ascending aorta grafts are concerns associated with currently used valved conduits. A simplified, self-assembled bioroot conduit comprising currently available materials that facilitates future intervention and exhibits advantages of a bioprosthesis was used.

METHODS

From November 2015 to January 2017, 17 consecutive patients underwent urgent or elective aortic root surgery. A bioroot conduit, constructed using 28 or 30 mm of sinus of Valsalva Gelweave tube graft and a 3 to 5 mm smaller bioprosthetic Trifecta valve sewn into the sinus of Valsalva base, was preconstructed in the operating room before sternotomy. The size of the valved conduit was based on the distal ascending aorta or proximal arch and not aortic annular dimension. The bioroot was sutured to the native aortic annulus at the level of the bottom skirt of the Valsalva graft without contacting the sewing cuff of the bioprosthetic valve.

RESULTS

All patients survived the operation and were discharged home without long-term anticoagulation therapy. The mean age was 65 ± 12 years, and 13 patients were male. The cardiopulmonary bypass duration was 169 ± 84 minutes, and the cross-clamp (XC) duration was 110 ± 32 minutes. The operation was elective in 12 patients, urgent/emergent in five, and redo in three.

CONCLUSION

A simplified self-assembled bioroot Bentall conduit is appropriate for aortic root reconstruction. Use of a patient-tailored valved conduit will not prolong the cardiac ischemic time and will facilitate future valve replacement.

Impact of sinuses of Valsalva on prosthesis durability in patients undergoing ascending aorta and aortic valve replacement with Carpentier-Edwards bioprosthesis: a propensity score-based study

OBJECTIVES

The effect of sinuses of Valsalva on aortic bioprosthesis durability has not been investigated so far. The aim of this study was to compare durability of the Carpentier-Edwards aortic bioprosthesis in patients undergoing aortic valve and ascending aorta replacement as a composite bioconduit (Group A, case group) versus patients undergoing separate replacement of the aortic valve and ascending aorta, with preservation of the aortic root (Group B, control group), between January 2000 and January 2014.

METHODS

Records of Group A (n = 133) and Group B (n = 162) patients were retrospectively reviewed. End-points were evaluated among groups in three ways: before and after propensity score 1:1 matching (Group A, n = 94; Group B, n = 94 patients) and after patient stratification through quintiles of propensity scores.

RESULTS

There was no difference among groups regarding mean and maximal trans-prosthetic pressure gradients at discharge (P = 0.07 and 0.45, respectively). Maximal trans-prosthetic gradients were lower in Group A patients at last control (P = 0.03). Structural valve deterioration (SVD) was due to prosthesis regurgitation (Group A, n = 5; Group B, n = 1), stenosis (Group A, n = 2; Group B, n = 5) or combined (Group A, n = 4; Group B, n = 2). After a mean follow-up of 68 ± 42 months, there was no difference among groups, at 5 and 12 years, regarding mortality, freedom from SVD, from redo aortic valve replacement for SVD and cardiac redo of any type, before and after matching and after stratification according to quintiles of propensity scores.

CONCLUSIONS

Within the 12-year follow-up, the absence of the sinuses of Valsalva seems to have no influence on durability of Carpentier Edwards aortic bioprosthesis. Longer follow-up may be warranted.

Long-term results of the valve reimplantation technique using a graft with sinuses

OBJECTIVE

Aortic valve reimplantation is the most commonly used technique to spare the aortic valve. Long-term results data are scarce and available only with the use of standard straight graft. We examined the long-term results of reimplantation of the aortic valve using a graft incorporating sinuses of Valsalva.

METHODS

From May 2000 to December 2014, 124 patients had an aortic valve reimplanted into a graft with sinuses of Valsalva. The mean age was 53 ± 13 years and the majority were men (87%). Marfan syndrome was present in 21 patients (17%) and 12% had a bicuspid valve. Patients were prospectively followed by means of transthoracic echocardiography. The mean follow-up was 63 ± 52 months.

RESULTS

Overall survival at 5, 10, and 13 years was 94.4% ± 2.2%, 90.5% ± 4.4%, and 81.4% ± 7.3%, respectively. Six patients required reoperation within a time frame of 6 to 96 months. None of the patients died at reoperation. Freedom from reoperation was 95.4% ± 2.3% at 5 years and 90.1% ± 4.3% at 10 and 13 years. All patients who needed reoperation had surgery during the first 5 years. Three patients had residual aortic insufficiency >2. Considering also all patients who underwent reoperation because of aortic insufficiency, freedom from moderate to severe residual aortic insufficiency was 94.1% ± 2.6% at 5 years, and 87.1% ± 4.7% at 10 and 13 years.

CONCLUSIONS

The majority of patients who had their valve reimplanted in a graft with sinuses continue to perform well after 10 years.