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Notenboom ML, de Keijzer AR, Veen KM, Gökalp A, Bogers AJJC, Heijmen RH, van Kimmenade RRJ, Geuzebroek GSC, Mokhles MM, Bekkers JA, Roos-Hesselink JW, Takkenberg JJM. Sex-related differences in the clinical course of aortic root and ascending aortic aneurysms: the DisSEXion Study. Eur Heart J 2024:ehae525. [PMID: 39185705 DOI: 10.1093/eurheartj/ehae525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 06/13/2024] [Accepted: 07/31/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND AND AIMS To explore male-female differences in aneurysm growth and clinical outcomes in a two-centre retrospective Dutch cohort study of adult patients with ascending aortic aneurysm (AscAA). METHODS Adult patients in whom imaging of an AscAA (root and/or ascending: ≥40 mm) was performed between 2007 and 2022 were included. Aneurysm growth was analysed using repeated measurements at the sinuses of Valsalva (SoV) and tubular ascending aorta. Male-female differences were explored in presentation, aneurysm characteristics, treatment strategy, survival, and clinical outcomes. RESULTS One thousand eight hundred and fifty-eight patients were included (31.6% female). Median age at diagnosis was 65.4 years (interquartile range: 53.4-71.7) for females and 59.0 years (interquartile range: 49.3-68.0) for males (P < .001). At diagnosis, females more often had tubular ascending aortic involvement (75.5% vs. 70.2%; P = .030) while males more often had SoV involvement (42.8% vs. 21.6%; P < .001). Maximum absolute aortic diameter, at any location, at diagnosis did not differ between females (45.0 mm) and males (46.5 mm; P = .388). In females, tubular ascending growth was faster (P < .001), whereas in males, SoV growth was faster (P = .005), corrected for covariates. Unadjusted 10-year survival was 72.5% [95% confidence interval (CI) 67.8%-77.6%] for females and 78.3% (95% CI 75.3%-81.3%) for males (P = .010). Twenty-three type A dissections occurred, with an incidence rate of 8.2/1000 patient-years (95% CI 4.4-14.1) in females and 2.4/1000 patient-years (95% CI 1.2-4.5) in males [incidence rate ratio females/males: 3.4 (95% CI 1.5-8.0; P = .004)]. CONCLUSIONS In patients having entered a diagnostic programme, involvement of aortic segments and age- and segment-related growth patterns differ between women and men with AscAA, particularly at an older age. Unravelling of these intertwined observations will provide a deeper understanding of AscAA progression and outcome in women and men and can be used as an evidence base for patient-tailored clinical guideline development.
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Affiliation(s)
- Maximiliaan L Notenboom
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Room Rg-633, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Adine R de Keijzer
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Room Rg-633, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Kevin M Veen
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Room Rg-633, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Arjen Gökalp
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Room Rg-633, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Room Rg-633, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Robin H Heijmen
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Guillaume S C Geuzebroek
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M Mostafa Mokhles
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jos A Bekkers
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Room Rg-633, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | | | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Room Rg-633, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
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Carpenter A, Connaire S, Chandra Mohan N, Curtis SL, Stoica SC, Caputo M, Strange JW. Coronary Stenosis and Cardiogenic Shock Secondary to Aortitis Following Aortic Root Support Procedure. JACC Case Rep 2024; 29:102313. [PMID: 38559390 PMCID: PMC10981095 DOI: 10.1016/j.jaccas.2024.102313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/20/2024] [Accepted: 02/23/2024] [Indexed: 04/04/2024]
Abstract
A woman with recent personalized external aortic root support implant presented in cardiogenic shock with bilateral coronary ostial occlusion and aortic inflammation requiring emergency coronary angioplasty. Subsequent computed tomography with positron emission tomography scanning demonstrated aortitis with extensive inflammation adjacent to the personalized external aortic root support mesh, the first report of this important complication.
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Redondo A, Austin C. Our 7-year experience supporting the Ross autograft with the novel technique of Personalized External Aortic Root Support. JTCVS Tech 2024; 24:121-127. [PMID: 38835595 PMCID: PMC11145418 DOI: 10.1016/j.xjtc.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 01/08/2024] [Accepted: 02/02/2024] [Indexed: 06/06/2024] Open
Abstract
Objective The Ross operation is a widely accepted option for aortic valve replacement in children, and evidence shows its excellent results in terms of hemodynamics and durability. However, indications are still limited due to the fact that it is a technically demanding procedure, only performed by specialized surgeons. On top of that, and despite numerous techniques being applied, autograft dilatation remains a key disadvantage, which can lead to graft failure. In recent years, the ExoVasc Personalized External Aortic Root Support (PEARS) has proven to be a safe and effective option to prevent aortic root dilatation in various aortopathies and is a technique that lends itself to support the pulmonary autograft in the Ross operation. Methods During the past 7 years, we have used the ExoVasc PEARS graft, manufactured from the patients' pulmonary artery measurements from computed tomography scan data, to support the pulmonary autograft in the Ross operation. This graft (manufactured by Exstent Ltd, UK) is implanted at the same time as the autograft. We have reviewed all the patients who underwent this surgery, including demographic data, aorta measurements, operative data, and follow-up assessment consisting of periodic echocardiograms and magnetic resonance imaging scans. Results Fifty patients were included in the study. Mean age at the time of the operation was 29.84 years, the youngest patient was 9 years-old. Nineteen patients (38%) had previous sternotomies; 11 of them having had a previous aortic valve replacement. Seventy-two percent of patients had initially a bicuspid aortic valve. Mean diameter of the ascending aorta was 3.83 cm. Forty-four percent of patients required a concomitant reduction aortoplasty due to mismatch sizes between the ascending aorta and the autograft. Mean bypass and crossclamp times were 200.66 and 151.14 minutes, respectively. Median length of stay was 6 days. Mean follow-up was 16.88 months. Two patients required subsequent aortic valve replacement (1 had rheumatic valve disease and the other had iatrogenic damage in his autograft valve leaflet). Ascending aorta dimensions remain stable when compared with immediate postoperative studies. There were no deaths. Conclusions The ExoVasc PEARS graft has proven to be an excellent support in the Ross operation to prevent the autograft failure related to autograft dilatation that can offer several advantages compared with other existing techniques. With this type of support, we believe the Ross indications can be expanded to multiple clinical scenarios, given the good long-term results this operation offers in terms of durability, life expectancy, and hemodynamics.
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Affiliation(s)
- Ana Redondo
- Congenital Cardiac Surgery Department, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Conal Austin
- Congenital Cardiac Surgery Department, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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Vervenne T, Maes L, Van Hoof L, Rega F, Famaey N. Drivers of vascular growth and remodeling: A computational framework to promote benign adaptation in the Ross procedure. J Mech Behav Biomed Mater 2023; 148:106170. [PMID: 37852088 DOI: 10.1016/j.jmbbm.2023.106170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/04/2023] [Accepted: 10/09/2023] [Indexed: 10/20/2023]
Abstract
In the sixties, Dr Donald Ross designed a surgical solution for young patients with aortic valve disease by using the patients' own pulmonary valve. The Ross procedure is the only aortic valve replacement technique that can restore long-term survival and preserve quality of life. The main failure mode of the Ross procedure is wall dilatation, potentially leading to valve regurgitation and leakage. Dilatation occurs due to the inability of the pulmonary autograft to adapt to the sudden increase in loading when exposing to aortic pressures. Previous experimental data has shown that a permanent external support wrapped around the artery can prevent the acute dilatation of the arterial wall. However, the textile support leads to stress-shielding phenomena due to the loss of mechanical wall compliance. We present a pragmatic and modular computational framework of arterial growth and remodeling predicting the long-term outcomes of cardiovascular tissue adaptation, with and without textile wrapping. The model integrates mean, systolic and diastolic pressures and assumes the resulting wall stresses to drive the biological remodeling rules. Rather than a single mean pressure or stress deviation from the homeostatic state, we demonstrate that only pulsatile stresses can predict available experimental results. Therefore, we suggest that a biodegradable external support could induce benign remodeling in the Ross procedure. Indeed, a biodegradable textile wrapped around the autograft fulfills the trade-off between prevention of acute dilatation on the one hand and recovery of arterial wall compliance on the other hand. After further validation, the computational framework can set the basis for the development of an actual biodegradable external support for the Ross procedure with optimized polymer mechanical properties and degradation behavior.
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Affiliation(s)
- Thibault Vervenne
- Biomechanics Section, Mechanical Engineering Department, KU Leuven, Celestijnenlaan 300, Leuven, 3001, Belgium.
| | - Lauranne Maes
- Biomechanics Section, Mechanical Engineering Department, KU Leuven, Celestijnenlaan 300, Leuven, 3001, Belgium
| | - Lucas Van Hoof
- Cardiac Surgery, Department of Cardiovascular Sciences, KU Leuven, UZ Herestraat 49, Leuven, 3000, Belgium
| | - Filip Rega
- Cardiac Surgery, Department of Cardiovascular Sciences, KU Leuven, UZ Herestraat 49, Leuven, 3000, Belgium
| | - Nele Famaey
- Biomechanics Section, Mechanical Engineering Department, KU Leuven, Celestijnenlaan 300, Leuven, 3001, Belgium
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Zhu Y, Woo J. Response to: Correspondence on "Has personalised surgery made another advancement in aortic root surgery?" by Zhu and Woo. Heart 2023; 109:887. [PMID: 37080763 DOI: 10.1136/heartjnl-2023-322704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Affiliation(s)
- Yuanjia Zhu
- Cardiothoracic Surgery, Stanford University, Stanford, California, USA
- Bioengineering, Stanford University, Stanford, California, USA
| | - Joseph Woo
- Cardiothoracic Surgery, Stanford University, Stanford, California, USA
- Bioengineering, Stanford University, Stanford, California, USA
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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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Van Hoof L, Lamberigts M, Noé D, El-Hamamsy I, Lansac E, Kluin J, de Kerchove L, Pepper J, Treasure T, Meuris B, Rega F, Verbrugghe P. Matched comparison between external aortic root support and valve-sparing root replacement. Heart 2023; 109:832-838. [PMID: 36650042 DOI: 10.1136/heartjnl-2022-321840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/26/2022] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Differences in indication and technique make a randomised comparison between valve-sparing root replacement (VSRR) and personalised external aortic root support (PEARS) challenging. We performed a propensity score (PS)-matched comparison of PEARS and VSRR for syndromic root aneurysm. METHODS Patients in the PEARS 200 Database and Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (undergoing VSRR) with connective tissue disease operated electively for root aneurysm <60 mm with aortic regurgitation (AR) <1/4 were included. Using a PS analysis, 80 patients in each cohort were matched. Survival, freedom from reintervention and from AR ≥2/4 were estimated using a Kaplan-Meier analysis. RESULTS Median follow-up was 25 and 55 months for 159 PEARS and 142 VSRR patients. Seven (4.4%) patients undergoing PEARS required an intervention for coronary injury or impingement, resulting in one death (0.6%). After VSRR, there were no early deaths, 10 (7%) reinterventions for bleeding and 1 coronary intervention. Survival for matched cohorts at 5 years was similar (PEARS 98% vs VSRR 99%, p=0.99). There was no difference in freedom from valve or ascending aortic/arch reintervention between matched groups. Freedom from AR ≥2/4 at 5 years in the matched cohorts was 97% for PEARS vs 92% for VSRR (p=0.55). There were no type A dissections. CONCLUSIONS VSRR and PEARS offer favourable mid-term survival, freedom from reintervention and preservation of valve function. Both treatments deserve their place in the surgical repertoire, depending on a patient's disease stage. This study is limited by its retrospective nature and different follow-ups in both cohorts.
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Affiliation(s)
- Lucas Van Hoof
- Cardiac Surgery, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Marie Lamberigts
- Cardiac Surgery, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Dries Noé
- Cardiac Surgery, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Ismail El-Hamamsy
- Cardiovascular Surgery, Mount Sinai Hospital, New York, New York, USA
| | - Emmanuel Lansac
- Cardiothoracic Surgery, University Hospital Pitié Salpêtrière, Paris, France
| | - Jolanda Kluin
- Cardiothoracic Surgery, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Laurent de Kerchove
- Cardiovascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - John Pepper
- Cardiac Surgery, Royal Brompton and Harefield NHS Trust, London, UK.,Cardiovascular Biomedical Research Unit (BRU), NIHR Imperial Biomedical Research Centre, London, UK
| | - Tom Treasure
- Clinical Operational Research Unit, University College London, London, UK
| | - Bart Meuris
- Cardiac Surgery, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Filip Rega
- Cardiac Surgery, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Cardiac Surgery, KU Leuven University Hospitals Leuven, Leuven, Belgium
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(Outcomes of personalised external aortic root support implantation in 100 patients in the Czech Republic). COR ET VASA 2022. [DOI: 10.33678/cor.2022.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Personalized external aortic root support in aneurysm disease. Curr Opin Cardiol 2022; 37:454-458. [PMID: 36094493 DOI: 10.1097/hco.0000000000000990] [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] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To bring together and annotate publications about personalised external aortic root support reported in the 18 months preceding submission. RECENT FINDINGS The total number of personalised external aortic root support (PEARS) operations is now approaching 700 in 30 centres in Australia, Belgium, Brazil, Czech Republic, Great Britain, Greece, Ireland, Malaysia, Netherlands, New Zealand, Poland and Slovakia. There are continued reports of stability of aortic dimensions and aortic valve function with the only exceptions known being where the surgeon has deviated from the instructions for use of the device. The median root diameter of Marfan patients having PEARS was 47 mm suggesting that the existing criterion of 50 mm is due for reconsideration. The peri-operative mortality currently estimated to be less than 0.3%. The first recipient remains alive and well after 18 years. The use of PEARS as an adjunct to the Ross operation to support the pulmonary autograft is being explored in several centres. SUMMARY The operation requires proctoring and adherence to a strict operative protocol and with those precautions excellent results are attained. The evidence and opinions provided in the cited publications indicate that PEARS is a proven and successful prophylactic operation for aortic root aneurysm.
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Notenboom ML, Bekkers JA, Takkenberg JJM. A left-shift in the diameter for prophylactic aneurysmectomy: The right decision for all? J Thorac Cardiovasc Surg 2022:S0022-5223(22)00934-5. [PMID: 36184318 DOI: 10.1016/j.jtcvs.2022.08.034] [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: 08/26/2022] [Accepted: 08/31/2022] [Indexed: 10/14/2022]
Affiliation(s)
- Maximiliaan L Notenboom
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jos A Bekkers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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Schoenhoff FS, Zimmer E. One ring* to rule them all. *lat. anulus. Eur J Cardiothorac Surg 2022; 62:6650623. [PMID: 35894653 DOI: 10.1093/ejcts/ezac402] [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: 07/14/2022] [Accepted: 07/25/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Florian S Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, University of Bern, Switzerland
| | - Emmanuel Zimmer
- Department of Cardiac Surgery, University Hospital Bern, University of Bern, Switzerland
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Kallenbach K, Remes A, Müller OJ, Arif R, Zaradzki M, Wagner AH. Translational Medicine: Towards Gene Therapy of Marfan Syndrome. J Clin Med 2022; 11:jcm11143934. [PMID: 35887698 PMCID: PMC9319421 DOI: 10.3390/jcm11143934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/28/2022] [Accepted: 07/01/2022] [Indexed: 12/12/2022] Open
Abstract
Marfan syndrome (MFS) is one of the most common inherited disorders of connective tissue caused by mutations of the fibrillin-1 gene (FBN1). Vascular abnormalities, such as the enlargement of the aorta with the risk of life-threatening rupture are frequently observed. However, current treatment is limited and therapeutic options focus solely on symptomatic therapy. Gene therapy focuses on genetically modifying cells to produce a therapeutic effect and may be a promising treatment option for MFS. Here, we first provide an overview of the historical background and characterization of MFS. Subsequently, we summarise current gene therapy options and possible translational concepts for this inherited disorder that affects connective tissue.
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Affiliation(s)
- Klaus Kallenbach
- Institute for Cardiac Surgery and Interventional Cardiology (INCCI), Department of Cardiac Surgery, 1210 Luxembourg, Luxembourg;
- VASCERN HTAD European Reference Center, 1210 Luxembourg, Luxembourg
| | - Anca Remes
- Department of Internal Medicine III, University of Kiel and University Hospital Schleswig-Holstein, 24105 Kiel, Germany; (A.R.); (O.J.M.)
- German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, 20251 Hamburg, Germany
| | - Oliver J. Müller
- Department of Internal Medicine III, University of Kiel and University Hospital Schleswig-Holstein, 24105 Kiel, Germany; (A.R.); (O.J.M.)
- German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, 20251 Hamburg, Germany
| | - Rawa Arif
- Department of Cardiac Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany; (R.A.); (M.Z.)
| | - Marcin Zaradzki
- Department of Cardiac Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany; (R.A.); (M.Z.)
| | - Andreas H. Wagner
- Department of Cardiovascular Physiology, Heidelberg University, Im Neuenheimer Feld 326, 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-6221-544062; Fax: +49-6221-544038
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Anderson RH. Correspondence on 'The personalized external aortic root support procedure: interesting niche or ready for prime time?' by Burke et al. Heart 2022; 108:744. [PMID: 35264418 DOI: 10.1136/heartjnl-2021-320555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Van Hoof L, Verbrugghe P, Jones EAV, Humphrey JD, Janssens S, Famaey N, Rega F. Understanding Pulmonary Autograft Remodeling After the Ross Procedure: Stick to the Facts. Front Cardiovasc Med 2022; 9:829120. [PMID: 35224059 PMCID: PMC8865563 DOI: 10.3389/fcvm.2022.829120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/17/2022] [Indexed: 12/12/2022] Open
Abstract
The Ross, or pulmonary autograft, procedure presents a fascinating mechanobiological scenario. Due to the common embryological origin of the aortic and pulmonary root, the conotruncus, several authors have hypothesized that a pulmonary autograft has the innate potential to remodel into an aortic phenotype once exposed to systemic conditions. Most of our understanding of pulmonary autograft mechanobiology stems from the remodeling observed in the arterial wall, rather than the valve, simply because there have been many opportunities to study the walls of dilated autografts explanted at reoperation. While previous histological studies provided important clues on autograft adaptation, a comprehensive understanding of its determinants and underlying mechanisms is needed so that the Ross procedure can become a widely accepted aortic valve substitute in select patients. It is clear that protecting the autograft during the early adaptation phase is crucial to avoid initiating a sequence of pathological remodeling. External support in the freestanding Ross procedure should aim to prevent dilatation while simultaneously promoting remodeling, rather than preventing dilatation at the cost of vascular atrophy. To define the optimal mechanical properties and geometry for external support, the ideal conditions for autograft remodeling and the timeline of mechanical adaptation must be determined. We aimed to rigorously review pulmonary autograft remodeling after the Ross procedure. Starting from the developmental, microstructural and biomechanical differences between the pulmonary artery and aorta, we review autograft mechanobiology in relation to distinct clinical failure mechanisms while aiming to identify unmet clinical needs, gaps in current knowledge and areas for further research. By correlating clinical and experimental observations of autograft remodeling with established principles in cardiovascular mechanobiology, we aim to present an up-to-date overview of all factors involved in extracellular matrix remodeling, their interactions and potential underlying molecular mechanisms.
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Affiliation(s)
- Lucas Van Hoof
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Jay D. Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, CT, United States
| | - Stefan Janssens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Nele Famaey
- Biomechanics Section, KU Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
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Otto CM. Heartbeat: ECG approaches to early detection of atrial fibrillation. Heart 2021; 107:1765-1767. [PMID: 34706889 DOI: 10.1136/heartjnl-2021-320418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Catherine M Otto
- Division of Cardiology, University of Washington, Seattle, Washington, USA
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Burke CR, Bavaria J. The personalized external aortic root support procedure: interesting niche or ready for prime time? Heart 2021; 107:1768-1769. [PMID: 34452906 DOI: 10.1136/heartjnl-2021-319790] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - Joseph Bavaria
- Division of CV Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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