Success in Valve-Sparing Aortic Root Replacement: Judgment and Skill

Abstract

In this issue of The Annals of Thoracic Surgery, Deas and associates1Deas D.S. Lou X. Leshnower B.G. et al.Fifteen years of aortic valve-sparing root replacement and impact of eccentric jets on late outcomes.Ann Thorac Surg. 2021; 112: 1901-1908Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar identified 111 patients (from a total of 346) who underwent valve-sparing aortic root replacement (VSARR) with at least moderate preoperative aortic insufficiency (AI) (>2+) and divided them into 2 groups based on valve type (65 tricuspid vs 46 bicuspid). In their analysis, the authors demonstrated no difference in redo-aortic valve replacement or mortality at 10 years between tricuspid vs bicuspid valves. Examining the type of preoperative AI jet, bicuspid valve patients were predominantly with eccentric AI jets (93%), as one would expect, but the tricuspid valve patients were evenly distributed between eccentric (43%) and concentric jets (45%). Regardless of the type of AI jet, no differences were observed regarding cumulative risk for AI>1+, risk of redo-AVR, or mortality in follow-up.1Deas D.S. Lou X. Leshnower B.G. et al.Fifteen years of aortic valve-sparing root replacement and impact of eccentric jets on late outcomes.Ann Thorac Surg. 2021; 112: 1901-1908Abstract Full Text Full Text PDF PubMed Scopus (1) Google ScholarThe group from Emory is to be congratulated for the multiple prior reports that have broadened our understanding of the VSARR and the current report, which examined the significance of preoperative insufficiency jet type and its significance. It should be recognized that the commendable results achieved here (0% mortality in bicuspid aortic valve [BAV] and 11% mortality in tricuspid aortic valve [TAV], with 22 and 65 acute type A aortic dissection, respectively) are a credit to the experience gained by the 2 senior authors (EPC, BGL) over the 15-year period. Notable was the authors’ aggressive stance on leaflet repairs, with at least 90% of BAV and 64% of TAV leaflets undergoing some type of leaflet repair (Table 4 of the paper). This likely underscores the importance of performing the best repair at the index procedure with no tolerance for any AI at completion.It remains unclear, however, if one can conclude that type of valve (BAV or TAV) and degree and type of insufficiency jet (eccentric or concentric) have no impact on late outcomes after VSARR. Although the inclusion criteria were appropriate, leading to a very select cohort to analyze, the series was still small, subject to type 2 error. Differing conclusions may have been derived, as only a few events were required to alter the outcome. This was noted in the TAV group, in which 8 of 65 (12%) patients did not have qualifying follow-up echocardiograms. With only 5 events of AI>1+, the potential for a differing conclusion could have occurred. In addition, most won’t argue the long-term durability of VSARR for TAV, as this has been demonstrated by others, but some have reported less durability for VSARR in the setting of BAV.2David T.E. David C.M. Feindel C.M. Manlhiot C. Reimplantation of the aortic valve at 20 years.J Thorac Cardiovasc Surg. 2017; 153: 232-238Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar,3Klotz S. Stock S. Sievers H.H. et al.Survival and reoperation pattern after 20 years of experience with aortic valve-sparing root replacement in patients with tricuspid and bicuspid valves.J Thorac Cardiovasc Surg. 2018; 155: 1403-1411.e1Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar In this report, the BAV group was younger (mean age, 38 years) and, although the survival and freedom from reoperation were no different compared to the TAV group, the follow-up period reported in Figures 2 and 3 were only 4 years. Beyond 4 years, the numbers at risk were not reported and, thus, it was likely that only a few cases were observed at risk beyond 8 years. It will be important for the authors to continue to follow the entire cohort, especially the BAV and eccentric groups with regard to freedom from AI>1+.Tantamount for successful repair during VSARR is the surgeon’s judgment and technical skill, allowing execution of the learned principles. The authors have clearly demonstrated their technical skill with VSARR, although how decisions were made (ie, judgment) was not clearly defined. This “variable” is difficult to present—as it is subjective and rarely (if ever) reported. The authors stated that VSARR was not performed “in the presence of any visible degeneration of the valve cusps which would be felt to preclude a successful result.” And such degenerative changes “included excessive stress fenestrations, cusp sclerosis, perforation,” and so on. But what was “visible degeneration?” How much fenestration is “excessive?” These are questions that can only be answered by experience and judgment.In the end, the authors provide insight that in properly selected patients with good leaflet tissue, VSARR may be performed with acceptable intermediate results, regardless of whether the aortic valve is tricuspid or bicuspid or the AI>2+ is central or eccentric.Dr Estrera discloses a financial relationship with WL Gore. In this issue of The Annals of Thoracic Surgery, Deas and associates1Deas D.S. Lou X. Leshnower B.G. et al.Fifteen years of aortic valve-sparing root replacement and impact of eccentric jets on late outcomes.Ann Thorac Surg. 2021; 112: 1901-1908Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar identified 111 patients (from a total of 346) who underwent valve-sparing aortic root replacement (VSARR) with at least moderate preoperative aortic insufficiency (AI) (>2+) and divided them into 2 groups based on valve type (65 tricuspid vs 46 bicuspid). In their analysis, the authors demonstrated no difference in redo-aortic valve replacement or mortality at 10 years between tricuspid vs bicuspid valves. Examining the type of preoperative AI jet, bicuspid valve patients were predominantly with eccentric AI jets (93%), as one would expect, but the tricuspid valve patients were evenly distributed between eccentric (43%) and concentric jets (45%). Regardless of the type of AI jet, no differences were observed regarding cumulative risk for AI>1+, risk of redo-AVR, or mortality in follow-up.1Deas D.S. Lou X. Leshnower B.G. et al.Fifteen years of aortic valve-sparing root replacement and impact of eccentric jets on late outcomes.Ann Thorac Surg. 2021; 112: 1901-1908Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar The group from Emory is to be congratulated for the multiple prior reports that have broadened our understanding of the VSARR and the current report, which examined the significance of preoperative insufficiency jet type and its significance. It should be recognized that the commendable results achieved here (0% mortality in bicuspid aortic valve [BAV] and 11% mortality in tricuspid aortic valve [TAV], with 22 and 65 acute type A aortic dissection, respectively) are a credit to the experience gained by the 2 senior authors (EPC, BGL) over the 15-year period. Notable was the authors’ aggressive stance on leaflet repairs, with at least 90% of BAV and 64% of TAV leaflets undergoing some type of leaflet repair (Table 4 of the paper). This likely underscores the importance of performing the best repair at the index procedure with no tolerance for any AI at completion. It remains unclear, however, if one can conclude that type of valve (BAV or TAV) and degree and type of insufficiency jet (eccentric or concentric) have no impact on late outcomes after VSARR. Although the inclusion criteria were appropriate, leading to a very select cohort to analyze, the series was still small, subject to type 2 error. Differing conclusions may have been derived, as only a few events were required to alter the outcome. This was noted in the TAV group, in which 8 of 65 (12%) patients did not have qualifying follow-up echocardiograms. With only 5 events of AI>1+, the potential for a differing conclusion could have occurred. In addition, most won’t argue the long-term durability of VSARR for TAV, as this has been demonstrated by others, but some have reported less durability for VSARR in the setting of BAV.2David T.E. David C.M. Feindel C.M. Manlhiot C. Reimplantation of the aortic valve at 20 years.J Thorac Cardiovasc Surg. 2017; 153: 232-238Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar,3Klotz S. Stock S. Sievers H.H. et al.Survival and reoperation pattern after 20 years of experience with aortic valve-sparing root replacement in patients with tricuspid and bicuspid valves.J Thorac Cardiovasc Surg. 2018; 155: 1403-1411.e1Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar In this report, the BAV group was younger (mean age, 38 years) and, although the survival and freedom from reoperation were no different compared to the TAV group, the follow-up period reported in Figures 2 and 3 were only 4 years. Beyond 4 years, the numbers at risk were not reported and, thus, it was likely that only a few cases were observed at risk beyond 8 years. It will be important for the authors to continue to follow the entire cohort, especially the BAV and eccentric groups with regard to freedom from AI>1+. Tantamount for successful repair during VSARR is the surgeon’s judgment and technical skill, allowing execution of the learned principles. The authors have clearly demonstrated their technical skill with VSARR, although how decisions were made (ie, judgment) was not clearly defined. This “variable” is difficult to present—as it is subjective and rarely (if ever) reported. The authors stated that VSARR was not performed “in the presence of any visible degeneration of the valve cusps which would be felt to preclude a successful result.” And such degenerative changes “included excessive stress fenestrations, cusp sclerosis, perforation,” and so on. But what was “visible degeneration?” How much fenestration is “excessive?” These are questions that can only be answered by experience and judgment. In the end, the authors provide insight that in properly selected patients with good leaflet tissue, VSARR may be performed with acceptable intermediate results, regardless of whether the aortic valve is tricuspid or bicuspid or the AI>2+ is central or eccentric. Dr Estrera discloses a financial relationship with WL Gore. Dr Estrera discloses a financial relationship with WL Gore. Dr Estrera discloses a financial relationship with WL Gore. Fifteen Years of Aortic Valve-sparing Root Replacement and Impact of Eccentric Jets on Late OutcomesThe Annals of Thoracic SurgeryVol. 112Issue 6PreviewValve-sparing root replacement is more challenging with eccentric aortic insufficiency due to cusp and root asymmetry, which may impact valve durability and survival. This study analyzed the effect of jet eccentricity on long-term outcomes in tricuspid aortic valves (TAVs) and bicuspid aortic valves (BAVs). Full-Text PDF