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Stephens EH, Dearani JA, Pochettino A, Vricella LA, Sundt TM, David TE, Bavaria JE, Cameron DE. Valve-Sparing Aortic Root Replacement State-of-the-Art Review, Part II: Surgical Techniques. Ann Thorac Surg 2024; 118:736-746. [PMID: 38360342 DOI: 10.1016/j.athoracsur.2023.12.019] [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: 06/20/2023] [Revised: 12/03/2023] [Accepted: 12/19/2023] [Indexed: 02/17/2024]
Abstract
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.
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Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | | | - Luca A Vricella
- Division of Pediatric Cardiovascular Surgery, Department of Surgery, Advocate Children's Heart Institute, Chicago, Illinois
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Tirone E David
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Duke E Cameron
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Claus I, Giebels C, Ehrlich T, Schäfers HJ. Aortic Root Remodeling in the Tricuspid Aortic Valve. Ann Thorac Surg 2024:S0003-4975(24)00579-4. [PMID: 39053693 DOI: 10.1016/j.athoracsur.2024.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 06/14/2024] [Accepted: 07/15/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Aortic root remodeling is one of the principal forms of valve-preserving root replacement. Its value has been questioned by some, whereas others have achieved excellent valve durability. The purpose of this review is to summarize the existing information to determine which factors may have contributed both to failures and to successes. METHODS Publications on root remodeling for aneurysm or dissection with tricuspid aortic valves with >15 patients were reviewed for specific details of preoperative and intraoperative management. RESULTS The series were very heterogeneous. Most operations were performed for root aneurysm, and 10 publications included type A dissection. Connective tissue disease was present in 22% of patients. Mean patient age was 52 years, and 5-year survival varied between 58% and 100%. Most series did not include an annuloplasty. Importantly, no details on quantitative assessment of valve configuration were specified in most series, especially those with suboptimal valve function and durability. The introduction of the effective height concept to control valve configuration was associated with improved results and more frequent correction of cusp prolapse. Late freedom from aortic regurgitation and freedom from reoperation are good in the larger series. CONCLUSIONS Root remodeling can lead to excellent valve durability if quantitative intraoperative measurement of valve configuration is performed. The addition of an annuloplasty seems to improve aortic valve competence further, even though its effect on durability is not unequivocally proven. The long-term results of root remodeling are good, also in the second postoperative decade, and it is a valid form of valve-preserving root replacement.
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Affiliation(s)
- Isabelle Claus
- Department Cardiac Surgery, Ghent University Hospital, Ghent, Belgium.
| | - Christian Giebels
- 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, Westpfalz-Klinikum, Kaiserslautern, Germany; Faculty of Medicine, Saarland University, Homburg/Saar, Germany
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Danial P, Moiroux-Sahraoui A, Nelly A, Pontailler M, Gaudin R, Lansac E, Pavy C, Bonnet D, Vouhé P, Raisky O. Outcomes of aortic valve repair in children stratified by complexity: Which outcome for which lesion? J Thorac Cardiovasc Surg 2024; 167:1533-1542.e6. [PMID: 38008207 DOI: 10.1016/j.jtcvs.2023.11.031] [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: 08/12/2023] [Revised: 10/18/2023] [Accepted: 11/15/2023] [Indexed: 11/28/2023]
Abstract
OBJECTIVE Aortic valvuloplasty frequency has significantly increased over the past 15 years. Surgical repair varies in complexity depending on valvular lesions. Our aim is to report results on the whole spectrum of aortic valvuloplasty techniques. METHODS All children who consecutively underwent aortic valvuloplasty for aortic stenosis and/or aortic insufficiency between January 2006 and December 2020 at Necker Sick Children's Hospital (Paris, France) were included in a retrospective cohort study. Aortic valvuloplasty techniques were classified into 3 difficulty levels: (1) simple repair, corresponding to commissurotomy and/or shaving in aortic stenosis (AS) in neonates (group 1) and children >1 month (group 2); (2) intermediate-complexity repair, corresponding to commissuroplasty, leaflet resuspension, and fenestration closure in aortic insufficiency (leaflet prolapse in connective tissue disease, isolated leaflet prolapse and Laubry-Pezzi groups); and (3) complex repair requiring a pericardial patch to restore a functional aortic valve in mixed aortic valve disease (bicuspidization with neocommissure and cusp extension groups). RESULTS During the study period, 324 children underwent aortic valvuloplasty. Survival and freedom from aortic valve reintervention at 10 years were, respectively, 86.1% and 50.9% in neonates with AS, 95.2% and 71.7% in children >1 month with AS, 93.8% and 79.5% in leaflet prolapse in connective tissue disease, 97.7% and 91.9% in isolated leaflet prolapse, 100% and 88% in those with Laubry-Pezzi syndrome, 97.4% and 84.8% in bicuspidization with neocommissure, and 100% and 54.2% in the cusp extension. CONCLUSIONS Durability of aortic valvuloplasty techniques is satisfactory and offers the possibility to delay the Ross procedure, regardless of the lesion's complexity.
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Affiliation(s)
- Pichoy Danial
- Department of Cardiovascular and Thoracic Surgery, Institute of Cardiology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, Paris, France; INI-CRCT, F-CRIN, Nancy, France
| | - Alexander Moiroux-Sahraoui
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
| | - Asma Nelly
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
| | - Margaux Pontailler
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
| | - Régis Gaudin
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
| | - Emmanuel Lansac
- Department of Cardiovascular and Thoracic Surgery, Institute of Cardiology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, Paris, France
| | - Carine Pavy
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
| | - Damien Bonnet
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
| | - Pascal Vouhé
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
| | - Olivier Raisky
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France.
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Ehrlich T, Abeln KB, Froede L, Burgard C, Giebels C, Schäfers HJ. Valve-sparing aortic root replacement-for all patients? J Thorac Cardiovasc Surg 2023:S0022-5223(23)00781-X. [PMID: 37696427 DOI: 10.1016/j.jtcvs.2023.08.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/22/2023] [Accepted: 08/26/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Valve-sparing root replacement (VSRR) has been associated with good survival and low rates of valve-related complications (VRCs). Whether these advantages are present irrespective of patient comorbidity or age is unclear. The aim of this study was to analyze survival and frequency of VRCs in relation to patient comorbidity and age. METHODS Between October 1995 and December 2021, 1156 patients with a bicuspid or tricuspid aortic valve were treated by root remodeling. The mean patient age was 53.3 ± 14 years, and 973 (84%) were male. The mean duration of follow-up was 6.7 ± 5.5 years (median, 5.9 years), and follow-up was 95% complete (7746 patient-years). We analyzed the population according to comorbidity and age at surgery. A discriminating cutoff for the effect of age was determined using receiver operating characteristic curve (ROC) analysis. RESULTS Mean survival at 15 years was 74.7 ± 2.5%. Deceased patients were older (mean, 65.3 ± 12 years vs 51.6 ± 14.1 years; P < .001) at the time of surgery and had more comorbidities (coronary artery disease [CAD], 28.4% vs 9.8%; P < .001). The sole significant adjusted predictor was age (P < .001). By ROC analysis (area under the curve, 0.780), the optimal cutoff for age was 61 years. Survival was 87.1 ± 2.8% at 15 years in patients age <61 years, compared to 55.3 ± 4.3% in patients age >61 years (P < .0001). Using competing risk analysis, VRC-free survival at 15 years was 66.8% at 15 years, including 76.7% in patients age <61 years and 52.4% in those age >61 years (P < .0001). CONCLUSIONS VSRR is associated with a low incidence of VRC and excellent durability. Survival is decreased in the presence of comorbidities, mainly CAD, and patient age >61 years. Despite lower survival, freedom from VRC is good.
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Affiliation(s)
- Tristan Ehrlich
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Karen B Abeln
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Lennart Froede
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Christian Burgard
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Christian Giebels
- 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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