Which technique of cusp repair is durable in reimplantation procedure?

Valve-Sparing Aortic Root Replacement State-of-the-Art Review, Part II: Surgical Techniques

Aortic valve disease is common, and valve-preserving operations are preferred whenever possible. Valve-sparing aortic root replacement (VSRR) has become an important tool for managing aortic root pathology in children and adults. The learning curve for this operation is challenging, but with increasing experience and technical modifications, early and late outcomes continue to improve. Durable long term results vary based on underlying anatomy, pathology, and patient selection, as well as surgeon expertise. Part II of this VSRR State-of-the-Art Review article provides technical pearls related to VSRR.

AVNeo improves early haemodynamics in regurgitant bicuspid aortic valves compared to aortic valve repair

OBJECTIVES

Calcified or fibrotic cusps in patients with bicuspid aortic valves and aortic regurgitation complicate successful aortic valve (AV)-repair. Aortic valve neocuspidization (AVNeo) with autologous pericardium offers an alternative treatment to prosthetic valve replacement. We compared patients with regurgitant bicuspid valves undergoing AV-repair or AVNeo.

METHODS

We retrospectively analysed patients with regurgitant bicuspid valves undergoing AV-repair or AVNeo. We focused on residual regurgitation, pressure gradients and effective orifice area, determined preoperatively and at discharge.

RESULTS

AV-repair was performed in 61 patients (mean age: 43.2 ± 11.3 years) and AVNeo in 22 (45.7 ± 14.1). Prior to the operation patients of the AV-repair group showed severe regurgitation in 38 cases (62.3%) and moderate in 23 (37.6%); in the AVNeo group, all patients exhibited severe regurgitation. Postoperatively, 57 patients (93.4%) patients had no or mild regurgitation after AV-repair and 21 (95.4%) after AVNeo. In AVNeo-patients, peak (10.6 ± 3.1 mmHg vs 22.7 ± 11 mmHg, P< 0.001) and mean pressure gradients (5.9 ± 2 mmHg vs 13.8 ± 7.3 mmHg, P < 0.001) were significantly lower and the orifice area significantly larger (2.9 ± 0.8 cm2 vs 1.9 ± 0.7 cm2, P < 0.001) compared to repair.

CONCLUSIONS

Compared to AV-repair, patients AVNeo showed lower mean pressure gradients and larger orifice areas at discharge. The functional result was not different.

Valve-sparing aortic root replacement and aortic valve repair for a 2-year-old girl with Loeys-Dietz syndrome

We report the case of a 2-year-old girl with Loeys–Dietz syndrome complicated by aortic root dilatation and aortic regurgitation. We performed valve-sparing aortic root replacement with reimplantation technique and aortic valve repair using central plication and free-margin reinforcement simultaneously. The postoperative course was uneventful and the latest echocardiography, 5 years after procedure, revealed trivial aortic insufficiency.

Two decades of valve-sparing root reimplantation in tricuspid aortic valve: impact of aortic regurgitation and cusp repair

OBJECTIVES

Our goal was to analyse the influence of preoperative aortic regurgitation (AR) on the necessity of cusp repair during valve-sparing reimplantation (VSR). We focused on patients with tricuspid aortic valves (TAV) and evaluated the impact of AR and cusp repair on long-term outcomes.

METHODS

From March 1998 to December 2018, a total of 512 consecutive patients underwent VSR at our institution; of these, 303 had a TAV. The mean age was 53 ± 15 years, and the median follow-up was 6.12 years. The rate and type of cusp repair were analysed based on preoperative AR. Time-to-event analysis was performed, as well as risk of death, reoperation and AR recurrence.

RESULTS

Cusp repair was necessary in 168 (55.4%) patients; the rate rose significantly as AR grade increased (P < 0.001). In-hospital mortality was 1% (n = 3). At 5 and 10 years, overall survival was 92 ± 2% and 75 ± 5%, respectively. Freedom from valve reoperation was 95 ± 2% and 90 ± 3%. Freedom from AR >2+ and AR >1+ at 10 years was 88 ± 4% and 70.4 ± 4.6%, respectively. Independent predictors of death included age, New York Heart Association functional class and type-A aortic dissection. Predictors of AR greater than mild included previous cardiac surgery and severe preoperative AR.

CONCLUSION

In patients with TAV receiving VSR, the necessity of cusp repair increased with the degree of preoperative AR. Preoperative AR and cusp repair do not impact long-term survival and aortic valve reoperation, but severe preoperative AR and multiple cusp repair increase the risk of recurrent moderate-to-severe AR. Overall, cusp repair seems to attenuate the negative impact of preoperative AR for at least 1 decade in a majority of patients.

Comparison of outcomes following isolated repair of tricuspid versus bicuspid aortic valves

Background

Aortic valve repair (AV-repair) is an alternative treatment option for patients with aortic regurgitation (AR), but durability is still reason for concern, especially for bicuspid aortic valves (BAV). We retrospectively evaluated mid-term results after AV-repair in patients with BAV or tricuspid aortic valves (TAV), including reoperation rates, recurrence of regurgitation, and survival.

Methods

Patients undergoing AV-repair between November 2004 and March 2016 without procedures involving the aortic root were included. Echocardiographic examinations were performed before and after the operation and at follow-up. Repair techniques were recorded and evaluated.

Results

Of 150 patients, 89 (59.3%) had TAV and 61 (40.7%) BAV. AR ≥ moderate was found in 66 patients with TAV (74.2%) and 49 with BAV (80.3%). At discharge, 74 TAV-patients had ≤ mild AR (84.4%), 11 (12.4%) moderate. 57 patients (93.4%) with BAV had ≤ mild AR, 1 (1.6%) moderate and 2 (3.3%) severe. Mean follow-up was 4.4±2.7 years with ≤ mild AR in 56 TAV patients (73.7%) and moderate in 18 (20.2%). In patients with BAV, 43 (76.8%) had ≤ mild AR and 4 (6.6%) moderate. Survival in patients with TAV was significantly decreased compared to BAV (P=0.033), but reoperation-rates did not differ significantly (P=0.651).

Conclusions

AV-repair is a safe and feasible option in patients with AR and can achieve similar results in patients with TAV and BAV. The complexity of the repair technique predicts repair failure.

Reimplantation for annular stabilization in bicuspid aortic valve repair

OBJECTIVES

To review the outcomes of bicuspid aortic valve repair with the reimplantation technique.

PATIENTS AND METHODS

From 2006 to 2018, 46 patients with bicuspid aortic valve underwent the reimplantation procedure for aortic valve repair. Those patients were included in this study. The mean age was 45 ± 15 years and 44 were male. Preoperative echocardiography showed a mean ventriculoaortic junction diameter of 28 ± 3 mm. The mean diameter at the sinus of Valsalva was 41 ± 9 mm. The minimum cusp height was 19 ± 3 mm. Regarding cusp repair technique, central plication was used in 45 patients, free margin reinforcement in 10 patients, and patch repair in 4 patients. Follow-up was performed by annual echocardiography.

RESULTS

There were no hospital deaths. All patients were found with either no/trivial or mild AR on postoperative transesophageal echocardiography. The postoperative ventriculoaortic junction diameter was 23 ± 2 mm and 83 ± 17% preoperatively. Freedom from moderate AR was 85 ± 6% at 5 years, and freedom from reoperation was 93 ± 4% at 5 years.

CONCLUSIONS

Reimplantation for bicuspid aortic valve repair showed acceptable mid-term outcomes.

A Novel Aortic Regurgitation Model from Cusp Prolapse with Hemodynamic Validation Using an Ex Vivo Left Heart Simulator

Although ex vivo simulation is a valuable tool for surgical optimization, a disease model that mimics human aortic regurgitation (AR) from cusp prolapse is needed to accurately examine valve biomechanics. To simulate AR, four porcine aortic valves were explanted, and the commissure between the two largest leaflets was detached and re-implanted 5 mm lower to induce cusp prolapse. Four additional valves were tested in their native state as controls. All valves were tested in a heart simulator while hemodynamics, high-speed videography, and echocardiography data were collected. Our AR model successfully reproduced cusp prolapse with significant increase in regurgitant volume compared with that of the controls (23.2 ± 8.9 versus 2.8 ± 1.6 ml, p = 0.017). Hemodynamics data confirmed the simulation of physiologic disease conditions. Echocardiography and color flow mapping demonstrated the presence of mild to moderate eccentric regurgitation in our AR model. This novel AR model has enormous potential in the evaluation of valve biomechanics and surgical repair techniques. Graphical Abstract.

Valve-sparing aortic root replacement combined with bicuspidization for a quadricuspid aortic valve

Quadricuspid aortic valves are rare congenital malformations. Although aortic valve replacement is the first-choice treatment in most cases, aortic valve repair using a tricuspidization procedure has been reported. Herein, we report the case of a patient with a quadricuspid aortic valve associated with aortic insufficiency that we successfully repaired with aortic valve-sparing root replacement and bicuspidization.

Modified sizing technique with newly designed tools to facilitate the valve sparing aortic root replacement "David" procedure with mid-term results

BACKGROUND

Valve sparing root replacement differs in specific points. The main target remains to achieve a perfect intraoperative result and long-term stability. We aimed in this study to present our modified sizing technique for valve-sparing "David" procedure and its mid-term results.

METHODS

We present a retrospective single-center study. A newly designed sizing ring in addition to triple-armed forceps (Trifeet®) was used to measure the proper size of the Valsalva® prosthesis for patients undergoing David-procedure. Primary endpoints are intraoperative aortic regurgitation (AR) and early postoperative outcomes. Secondary endpoints included freedom from aortic regurgitation or reoperation and overall mortality.

RESULTS

A total of 63 consecutive patients who underwent David procedure between 09/2012 and 12/2016 were evaluated. Mean age was 52±15 years and 76.2% were male. Moderate to severe aortic regurgitation was reported in 60 (95.2%) patients. Four (6.3%) patients presented with type-A aortic dissection, 20 (31.7%) patients had bicuspid and 3 (4.8%) had a unicuspid aortic valve, 2 (3.2%) patients had a prior aortic valve repair. Intraoperative echocardiography revealed no 34 (54%), trace 26 (41.2%) or moderate 3 (4.8%) AR. Stroke, myocardial infarction, and 30-day mortality occurred in 1 patient (1.6%). During follow-up 5 (7.9%) patients needed reoperation due to recurrent AR within a mean of 35±18 months. One could be re-repaired, and the other four underwent aortic valve replacement. A second patient died in the late follow-up.

CONCLUSIONS

Our modified sizing technique simplifies the "David-procedure" and allows to achieve a good intraoperative and mid-term results. However, these results have to be confirmed in a larger cohort with a long-term follow-up.

Cardiac surgery 2017 reviewed

For the year 2017, more than 21,000 published references can be found in PubMed when entering the search term "cardiac surgery". This review focusses on conventional cardiac surgery, considering the new interventional techniques only if they were directly compared to classic techniques but also entails aspects of perioperative intensive care management. The publications last year provided a plethora of new and interesting information that helped to quantify classic surgical treatment effects and provided new guidelines for the management of structural heart disease, which made comparisons to interventional techniques easier. The field of coronary bypass surgery was primarily filled with confirmatory evidence for the beneficial role of coronary artery bypass grafting for complex coronary disease and equal outcomes for percutaneous coronary intervention for less complex disease including main stem lesions. For aortic valve treatment, the new guidelines provide an equal recommendation for surgical and transcatheter aortic valve replacement for high and intermediate risk giving specific check lists to individualize decision-making by the heart team. For low-risk aortic stenosis, surgical valve replacement remains the primary indication. For the mitral valve, the importance of surgical experience of the individual surgeon on short- and long-term outcome was presented and the prognostic impact of mitral repair for primary mitral regurgitation was emphasized. In addition, there were many relevant and interesting other contributions from the purely operative arena in the fields of tricuspid disease as well as terminal heart failure (i.e., transplantation and ventricular assist devices). While this article attempts to summarize the most pertinent publications, it does not have the expectation of being complete and cannot be free of individual interpretation. As in recent years, it provides a condensed summary that is intended to give the reader "solid ground" for up-to-date decision-making in cardiac surgery.