A simple modified Bentall technique for surgical reconstruction of the aortic root - short and long term outcomes

The Sutureless Biological Bentall Procedure: A New Technique to Create a Modular Valve-Conduit Construct

The Perceval sutureless valve (Corcym, Saluggia, Italy) has been effectively adopted by surgeons for the treatment of degenerative aortic valve stenosis. Its simplified true sutureless implantation technique has proven useful for minimally invasive cases, but the use of Perceval as part of more complex root replacement has not previously been described. We present a novel technical modification to the manufactured biologic Bentall, called the sutureless biological Bentall. This technique allows for a true modular valve-conduit construction that will simplify future reintervention.

Assessment of valve implantation in the descending aorta as an alternative for aortic regurgitation patients not treatable with conventional procedures

BACKGROUND

Aortic Regurgitation (AR) produces the entrance of an abnormal amount of blood in the left ventricle. This disease is responsible for high morbidity and mortality worldwide and may be caused by an aortic valve dysfunction. Surgical and transcatheter aortic valve replacement (TAVR) are the current options for treating AR. They have replaced older procedures such as Hufnagel's one. However, some physicians have reconsidered this procedure as a less aggressive alternative for patients not eligible for surgical or TAVR. Although Hufnagel suggested a 75% regurgitation reduction when a valve is placed in the descending aorta, a quantification of this value has not been reported.

METHODS

In this paper, CFD/FSI numerical simulation is conducted on an idealized geometry. We quantify the effect of placing a bileaflet mechanical heart valve in the descending aorta on a moderate-severe AR case. A three-element Windkessel model is employed to prescribe pressure outlet boundary conditions. We calculate the resulting flow rates and pressures at the aorta and first-generation vessels. Moreover, we evaluate several indices to assess the improvement due to the valve introduction.

RESULTS AND CONCLUSIONS

Regurgitation fraction (RF) is reduced from 37.5% (without valve) to 18.0% (with valve) in a single cardiac cycle. This reduction clearly shows the remarkable efficacy of the rescued technique. It will further ameliorate the left ventricle function in the long-term. Moreover, the calculations show that the implantation in that location introduces fewer incompatibilities' risks than a conventional one. The proposed methodology can be extended to any particular conditions (pressure waveforms/geometry) and is designed to assess usual clinical parameters employed by physicians.

Application of retrograde cerebral perfusion in aortic root replacement combined with right half aortic arch replacement

OBJECTIVES

After cardiac surgery involving the aortic arch, the incidence of neurological complications remains high, therefore it is very important to take measures to protect brain. This study is to investigate the safety and effectiveness of deep hypothermic circulatory arrest and retrograde cerebral perfusion for aortic root combined with right half aortic arch replacement.

METHODS

Clinical data of 31 patients, who underwent aortic root and right half aortic arch replacement with deep hypothermic circulatory arrest and retrograde cerebral perfusion in Xiangya Hospital, Central South University, were retrospectively analyzed. This cohort included 23 aortic aneurysms and 8 aortic dissections. Aortic root replacement was conducted in 26 patients by Bentall procedures, and 5 patients by David procedures. Time of deep hypothermic circulatory arrest and retrograde cerebral perfusion in surgery was (21.9±5.2) min. The in-hospital mortality, postoperative neurological dysfunction and other major adverse complications were observed and recorded.

RESULTS

No in-hospital death and permanent neurological dysfunction occurred. Two patients had transient neurological dysfunction and 2 patients with aortic dissection requiring long-time ventilation due to hypoxemia, 1 patient underwent resternotomy. During 6-36 months of follow-up, all patients recovered satisfactorily.

CONCLUSIONS

Deep hypothermic circulatory arrest and retrograde cerebral perfusion can be safely and effectively applied in aortic root and right half aortic arch replacement, and which can simplify the surgical procedures and be worth of clinical promotion.

Dynamic kinking of right coronary artery after the button Bentall procedure

Postoperative coronary artery complications after Bentall procedures are well recognised but are rare and potentially fatal. There have been only five cases documenting percutaneous coronary intervention (PCI) for right coronary artery (RCA) involvements after button Bentall procedures. We describe a case of postoperative silent myocardial ischaemia in a 72-year-old man who underwent the button Bentall procedure for a right sinus of Valsalva aneurysm. On postoperative day 15, an RCA complication was incidentally detected by follow-up multidetector CT. Coronary angiography showed proximal RCA kinking, which was not an anastomosis but a native coronary artery. The patient underwent a successful PCI with drug-eluting stent implantation. We reviewed six cases consisting of this case and five previous cases treated with PCI. These cases enhance the recognition of potential RCA complications after the button Bentall procedure.

An Alternative Approach to Build a "Biologic Bentall" From a Pericardial Tube and a Sutureless Valve

This report describes a technique to create a biologic Bentall from a pericardial tube and a rapid deployment valve. This technique facilitates reimplantation of the coronary arteries because the proximal anastomosis is sewn before valve implantation and allows suturing of the coronary ostia from inside and outside, given that there is no interference with the implanted valve. Indications for this technique include complex redo cases and patients with contraindications to a conventional Bentall procedure. This technique has been used in 2 patients with good results.

Biomechanical characterization and comparison of different aortic root surgical techniques

OBJECTIVES

Understanding the biomechanical impact of aortic valve-sparing techniques is important in an era in which surgical techniques are developing and are increasingly being used based on biomechanical understanding that is essential in the refining of existing techniques. The objective of this study was to describe how the valve-sparing remodelling (Yacoub) and reimplantation (David Type-1) techniques affect the biomechanics of the native aortic root in terms of force distribution and geometrical changes.

METHODS

Two force transducers were implanted into 22 pigs, randomized to 1 of 3 groups (David = 7, native = 7 and Yacoub = 8) along with 11 sonomicrometry crystals and 2 pressure catheters. Force and geometry data were combined to obtain the local structural stiffness in different segments of the aortic root.

RESULTS

The radial structural stiffness was not different between groups (P = 0.064) at the annular level; however, the David technique seemed to stabilize the aortic annulus more than the Yacoub technique. In the sinotubular junction, the native group was more compliant (P = 0.036) with the right-left coronary segment than the intervention groups. Overall, the native aortic root appeared to be more dynamic at both the annular level and the sinotubular junction than both intervention groups.

CONCLUSIONS

In conclusion, the David procedure may stabilize the aortic annulus more than the Yacoub procedure, whereas the leaflet opening area was larger in the latter (P = 0.030). No difference (P = 0.309) was found in valve-opening delay between groups. The 2 interventions show similar characteristics at the sinotubular junction, whereas the David technique seemed more restrictive at the annular level than the Yacoub technique.

Current Trends in Aortic Root Surgery: The Mini-Bentall Approach

OBJECTIVE

The mini-sternotomy approach is becoming a widespread technique for aortic valve surgery. However, its safety for aortic root replacement has yet to be established. The aim of the present study was to compare the operative outcomes of patients who underwent aortic root replacement via upper mini-sternotomy (mini-Bentall) to patients who underwent Bentall procedure via median sternotomy (full-sternotomy Bentall).

METHODS

Between November 1998 and November 2016, 91 consecutive patients underwent full-sternotomy Bentall procedure and 26 patients underwent mini-Bentall procedure. The mini-Bentall procedure was performed via an upper hemisternotomy incision extending to the right fourth intercostal space. Patients with concomitant procedures and those who underwent deep hypothermic circulatory arrest were excluded from the analysis. Outcome variables were operative mortality and major surgical complications, including prolonged length of hospital stay, transfusion rates, reoperation for bleeding, and prolonged ventilatory support.

RESULTS

No significant differences were observed on the preoperative, operative, and postoperative characteristics between the two treatment groups. The median cardiopulmonary bypass and aortic cross-clamp times were 169 minutes (interquartile range = 156.0-188.5) and 148 minutes (interquartile range = 131.3-160.3) in the mini-Bentall group, respectively. The median duration of hospitalization in the mini-Bentall group was 6.5 days (interquartile range = 5.0-11.0 days). In-hospital mortality and new renal insufficiency occurred at a frequency of 1.1% and reoperation for bleeding at 6.6% in the group of patients who underwent the conventional Bentall procedure compared with 0% for all these measures in the mini-Bentall group (P > 0.33). There was no significant difference in intraoperative red blood cell transfusion and other major postoperative complications. No strokes were observed in either group, and there were no conversions to median sternotomy in the mini-Bentall group.

CONCLUSIONS

An upper hemisternotomy is a feasible technique in patients undergoing elective aortic root replacement surgery. However, future prospective studies are required before these procedures become the standard of care.

Aortic Root Reconstruction with a New Dacron Graft Featuring Prefabricated Coronary Side Branches: Lessons Learned from the Cabrol Procedure

BACKGROUND

Coronary button reimplantation can represent a technical challenge of aortic root reconstruction that can be associated with significant morbidity and mortality. With the goal of simplifying coronary reimplantation and reducing the incidence of related complications, we designed a new Dacron graft with prefabricated coronary branches to minimize coronary artery mobilization and prevent the potential mechanical complications of reattachment to the body of the graft.

METHODS

Between June 2010 and May 2012, we implanted the graft in eight patients (six males, two females) ranging in age from 42-68 years (mean, 54 years). Six procedures were modified Bentall reconstructions, and two procedures were valve-sparing root replacements using the reimplantation technique.

RESULTS

There were no complications and no morbidity or mortality related to coronary reattachment. All patients were alive and doing well at a mean follow-up of 26 months (range, 17-38 months). At an extended mean follow-up of 42 months (range, 25-56 months), one patient died of stroke-related complications. No radiologic or clinical evidence of impairment of coronary perfusion was identified in any patient.

CONCLUSIONS

The use of this new graft model may simplify the technique of root reconstruction and potentially lower the incidence of mechanical complications related to coronary button reimplantation.

Selective serotonin reuptake inhibitors and cardiovascular events: A systematic review

BACKGROUND

Given the importance of the role of depression in predicting the outcome of cardiovascular disorders, current medications for treating depression, particularly selective serotonin reuptake inhibitors (SSRIs), are taken into consideration. This study aimed to systematically review the published findings in the use of SSRIs and the risk for cardiac events.

MATERIALS AND METHODS

An independent review of the Web of Science, PubMed, Scopus, Cochrane, CINAHL, index Copernicus, and Google Scholar, up to 2014, was performed. We identified studies evaluating the effect of SSRIs, on cardiovascular events. Articles in English with full text availability, review articles, and experimental studies were included in the study. Among 150 studies reviewed based on the included keywords, 17 met the study criteria and were finally reviewed.

RESULTS

The use of some types of SSRIs may prevent platelet adhesion and aggregation; control the cardiovascular risk profile including hypertension, insulin resistance, and body weight; and also inhibit inflammatory processes. The appearance of adverse cardiac events, including cardiac arrhythmias (torsade de pointes and QT prolongation), syncope, increased systolic and diastolic right ventricular volume, and the production of pro-inflammatory cytokines leading atherosclerosis development, has also been expected with the chronic use of some types of SSRIs.

CONCLUSION

According to our systematic review, both beneficial and adverse cardiovascular events can be established following the chronic use of various types of SSRIs. Therefore, when taking SSRIs, the cardiovascular effect of each SSRI has to be carefully considered, based on patients' cardiovascular risk profiles.

A Modified Wrapping-internal Shunt Method for Hemostasis in Bentall Procedure

Introduction:

Blindly punching between aorta and right atrium is dangerous. In that case, there is concerned about leakage between the two referred isolate parts. Besides, as the routine imaging techniques (echocardiography or computer tomography) are incompetent to detect this particular anatomic structure preoperatively, the intraoperative inspection appears necessary. Our method is useful for identifying this innate fusion plane.

Case report:

The thrombosis surrounding prosthesis was detected in the first ultrasound examination after the operation, which was considered to be an indication of successful hemostasis. As the innate fusion between aorta and right atrium appears no rare, the selective creation of left-to-right internal shunt is a valuable maneuver for controlling bleeding in appropriate cases.