Aortic Root Replacement Research Articles

True redo-aortic root replacement versus root replacement after any previous surgery

ObjectiveThe impact of previous aortic root replacement (True-Redo) versus any previous operation (Any-Redo) on outcomes after reoperative aortic root replacement (redo-ROOT) is largely unknown. In this first multi-institutional study, the clinical impact True-Redo versus Any-Redo in the setting of redo-ROOT was reviewed. MethodsFrom 2004 to 2021, 822 patients underwent redo-ROOT at 2 major academic centers: 638 Any-Redo and 184 True-Redo. Matching based on preoperative demographics and concomitant operations resulted in 174 matched pairs. An independent risk factor analysis was performed to determine risk factors for early and late mortality. ResultsPatients in the True-Redo group were younger, at 49.9 ± 15.1 versus 55.3 ± 14.7 years, P < .001. Concomitant operations were largely similar between the 2 groups, P > .05. Median cardiopulmonary bypass time (P < .001) and aortic crossclamp time (P = .03) were longer for True-Redo group. In-hospital mortality was 13% (109) and was without significant difference between groups, P = .41. Ten-year survival was 78% versus 76% for True-Redo versus Any-Redo groups respectively, P = .7. Landmark survival analysis at 4 years' postoperatively on the matched groups found that patients in the True-Redo group had improved survival outcomes (P = .046). Risk factors of in-hospital mortality consisted of older age (P < .0001), lower ejection fraction (P = .02), and male patient (P = .0003). ConclusionsClinical outcomes following redo-ROOT are excellent. Performance of a True-Redo-ROOT does not result in worse in-hospital morbidity or mortality and has improved survival benefit at midterm follow-up when compared with patients in the Any-Redo group. The decision to perform a redo-ROOT must be taken seriously and must be individualized in a patient-specific manner for optimal outcomes.

Surgical treatment of aortic root abscess: 10-year single center experience

The issue of optimal surgical scope in patients with aortic root abscess due to infective endocarditis remains open, since there are different strategies and interventional methods. In addition, the guidelines do not give preference to any particular type of surgical intervention and recommend an individual approach to each situation. The study included 25 patients with aortic root abscess due to aortic valve infective endocarditis. The most frequently performed surgical intervention in patients was the Ross procedure (n=12, 48%). Eight (32%) patients of the center underwent aortic homograft root replacement. Combined surgery was performed in 7 (28%) patients as follows: 3 (12%) patients — interventions on the mitral valve (all patients underwent mitral valve repair due to mitral valve involvement in abscess), 3 (12%) — coronary artery bypass grafting, 1 (4%) — ascending aortic replacement due to dilatation. Five- and ten-year survival after surgical treatment of patients with aortic root abscess was 86,9% and 78,6%, respectively. There was no reintervention and recurrence of infective endocarditis in the long-term period.

Surgical treatment of aortic root abscess: 10-year single center experience

The issue of optimal surgical scope in patients with aortic root abscess due to infective endocarditis remains open, since there are different strategies and interventional methods. In addition, the guidelines do not give preference to any particular type of surgical intervention and recommend an individual approach to each situation. The study included 25 patients with aortic root abscess due to aortic valve infective endocarditis. The most frequently performed surgical intervention in patients was the Ross procedure (n=12, 48%). Eight (32%) patients of the center underwent aortic homograft root replacement. Combined surgery was performed in 7 (28%) patients as follows: 3 (12%) patients — interventions on the mitral valve (all patients underwent mitral valve repair due to mitral valve involvement in abscess), 3 (12%) — coronary artery bypass grafting, 1 (4%) — ascending aortic replacement due to dilatation. Five- and ten-year survival after surgical treatment of patients with aortic root abscess was 86,9% and 78,6%, respectively. There was no reintervention and recurrence of infective endocarditis in the long-term period.

Long-Term Outcomes of Patients Undergoing Aortic Root Replacement WithMechanical Versus Bioprosthetic Valves: Meta-Analysis of Reconstructed Time-to-Event Data.

Background An aspect not so clear in the scenario of aortic surgery is how patients fare after composite aortic valve graft replacement (CAVGR) depending on the type of valve (bioprosthetic versus mechanical). We performed a study to evaluate the long-term outcomes of both strategies comparatively. Methods and Results Pooled meta-analysis of Kaplan-Meier-derived time-to-event data from studies with follow-up for overall survival (all-cause death), event-free survival (composite end point of cardiac death, valve-related complications, stroke, bleeding, embolic events, and/or endocarditis), and freedom from reintervention. Twenty-three studies met our eligibility criteria, including 11 428 patients (3786 patients with mechanical valves and 7642 patients with bioprosthetic valve). The overall population was mostly composed of men (mean age, 45.5-75.6 years). In comparison with patients who underwent CAVGR with bioprosthetic valves, patients undergoing CAVGR with mechanical valves presented no statistically significant difference in the risk of all-cause death in the first 30 days after the procedure (hazard ratio [HR], 1.24 [95% CI, 0.95-1.60]; P=0.109), but they had a significantly lower risk of all-cause mortality after the 30-day time point (HR, 0.89 [95% CI, 0.81-0.99]; P=0.039) and lower risk of reintervention (HR, 0.33 [95% CI, 0.24-0.45]; P<0.001). Despite its increased risk for the composite end point in the first 6 years of follow-up (HR, 1.41 [95% CI, 1.09-1.82]; P=0.009), CAVGR with mechanical valves is associated with a lower risk for the composite end point after the 6-year time point (HR, 0.46 [95% CI, 0.31-0.67]; P<0.001). Conclusions CAVGR with mechanical valves is associated with better long-term outcomes in comparison with CAVGR with bioprosthetic valves.

High-speed videography of an exemplary porcine aortic valve after the valve-sparing aortic root replacement using the anticommissural plication configuration.

High-speed videography of an exemplary porcine aortic valve after the valve-sparing aortic root replacement using the anticommissural plication configuration.

High-speed videography of an exemplary porcine aortic valve after the valve-sparing aortic root replacement using the straight graft configuration.

High-speed videography of an exemplary porcine aortic valve after the valve-sparing aortic root replacement using the straight graft configuration.

Retrograde Cerebral Perfusion May Decrease Stroke Risk During Elective Aortic Arch Surgery.

Controversy remains regarding the optimal neuroprotection strategy for elective hemiarch replacement (HEMI). This study sought to compare outcomes in patients who underwent HEMI utilizing the 2 most common contemporary methods of cerebral protection. The ARCH international aortic database was queried, and 782 patients undergoing elective HEMI with circulatory arrest from 2007 to 2012 were identified. There were 418 patients who underwent HEMI using moderate hypothermia (nasopharyngeal temperature 20.1 to 28.0 °C) and antegrade cerebral perfusion (MHCA/ACP). There were 364 patients who underwent HEMI using deep hypothermia (nasopharyngeal temperature 14.1 to 20 °C) and retrograde cerebral perfusion (DHCA/RCP). Adverse outcomes were compared between the groups using both univariable and multivariable analyses. Patients who underwent MHCA/ACP were older (64 vs 61 years, P = 0.01) and more frequently had peripheral vascular disease than DHCA/RCP patients (28.5% vs 7.1%, P < 0.001). Patients in the DHCA/RCP group had a greater incidence of full aortic root replacement (55.8% vs 26.4%, P < 0.001) and more frequently had a central cannulation strategy (83% vs 55.7%, P < 0.001). Cardiopulmonary bypass (170 vs 157 min, P = 0.002) and aortic cross-clamp (134 vs 92 min, P < 0.001) times were significantly longer in the DHCA/RCP group. On univariable analysis, overall mortality was statistically similar between groups (MHCA/ACP 3.4% vs DHCA/RCP 2.3%, P = 0.47), but permanent neurologic deficits were significantly lower in the DHCA/RCP cohort (MHCA/ACP 3.9% vs DHCA/RCP 1.0%, P = 0.02). Multivariable analysis showed no difference in mortality nor perioperative stroke between perfusion cohorts. Both MHCA/ACP and DHCA/RCP are excellent neuroprotective strategies that produce low mortality in patients undergoing elective HEMI. DHCA/RCP may demonstrate theoretically improved neurologic outcomes compared with MHCA/ACP, but this topic warrants further study.

High-speed videography of an exemplary porcine aortic valve after the valve-sparing aortic root replacement using the Valsalva graft configuration.

High-speed videography of an exemplary porcine aortic valve after the valve-sparing aortic root replacement using the Valsalva graft configuration.

Cardiovascular Events After Aortic Root Repair in Patients With Marfan Syndrome

BackgroundThe usefulness of aortic valve sparing operations to treat aortic root aneurysm in patients with Marfan syndrome (MS) remains controversial. ObjectivesThe purpose of this study was to evaluate the occurrence of cardiovascular events in patients with MS who have undergone valve-preserving aortic root replacement. MethodsPatients with MS who had aortic valve sparing operations (reimplantation of the aortic valve or remodeling of the aortic root) from 1988 through 2019 were followed prospectively for a median of 14 years. Pertinent data from clinical, echocardiographic, computed tomography, and magnetic resonance images of the aorta were collected and analyzed. ResultsThere were 189 patients whose mean age was 36 years, and 67% were men. Ten patients presented with acute type A dissection and 29 had mitral regurgitation. There were 52 patients at risk at 20 years. Mortality rate at 20 years was 21.5% (95% CI: 14.7%-30.8%); advancing age and preoperative aortic dissections were associated with increased risk of death by multivariable analysis. At 20 years, the cumulative incidence of moderate or severe aortic insufficiency was 14.5% (95% CI: 9.5%-22.0%), reoperation on the aortic valve was 7.5% (95% CI: 3.9%-14.7%), and new distal aortic dissections was 19.9% (95% CI: 13.9%-28.5%). Remodeling of aortic root was associated with greater risk of developing aortic insufficiency and aortic valve reoperation than reimplantation of the aortic valve. ConclusionsAortic valve sparing operations provide stable aortic valve function and low rates of valve-related complications during the first 2 decades of follow-up but aortic dissections remain problematic in patients with MS.

High-speed videography of an exemplary porcine aortic valve after the valve-sparing aortic root replacement using the Stanford modification configuration.

High-speed videography of an exemplary porcine aortic valve after the valve-sparing aortic root replacement using the Stanford modification configuration.

David V procedure and hemiarch replacement in a patient with Loeys-Dietz-Syndrome and beta thalassemia minor: a case report

We report the case of a 36-year-old European female patient presenting with a sinus valsalva aneurysm of 47 mm with moderate aortic regurgitation. Additionally, an aneurysm of the brachiocephalic trunk and multiple aneurysms of the right internal mammary artery were identified. Previous medical history included Loeys-Dietz syndrome (LDS) Type RII due to a TGF-beta receptor mutation, and beta thalassemia minor with a baseline hemoglobin of 9,3 g/dL on admission.Reconstruction of the aortic root and hemiarch replacement was performed in circulatory arrest under moderate hypothermia. During surgery, hypothermia was required as part of the cerebral protection strategy. We aim to highlight special considerations and discuss the effects of cooling, rewarming and the use of cardiopulmonary bypass (CPB) during extensive surgery in a patient with LDS and beta thalassemia minor.

Discussion to: The impact of reoperative surgery on aortic root replacement in the United States

Discussion to: The impact of reoperative surgery on aortic root replacement in the United States

Mitral annular disjunction on cardiac MRI: Prevalence and association with disease severity in Loeys-Dietz syndrome

BackgroundThe purpose of this study was to evaluate mitral annular disjunction (MAD) on cardiac magnetic resonance imaging (MRI) in Loeys-Dietz Syndrome (LDS) and to explore its association with adverse outcomes. MethodsIn this retrospective cohort study, adult patients with LDS who underwent cardiac MRI were evaluated for MAD, aortic dimensions, and ventricular volumetry. Aortic events were defined as aortic surgery and/or dissection and severe arrhythmic events as cardiac arrest or sustained ventricular tachycardia (VT). ResultsAmong 46 LDS patients (52% female, 37.2 ± 14.3 years), 17 had MAD (37%). MAD and no MAD groups were similar in age, sex, aortic dimensions and left ventricular parameters. After a clinical follow-up of 4.3 years (IQR 1.5–8.4), 3 in MAD and 4 in no MAD groups required aortic valve sparing root replacement (VSRR) and 1 in MAD developed type A dissection. Over a similar imaging follow-up period [4.1 years (IQR 2.7–9.1) vs. 3.2 years (IQR 1.0–9.0), p = 0.65], compared to baseline, increase in native aortic root size was significant only in MAD (39.4 ± 4.6 mm vs. 38.1 ± 5.3 mm, p = 0.02, 19.3 ± 2.4 mm/m2 vs. 18.7 ± 2.4 mm/m2, p = 0.01) compared to those without MAD. Patients with MAD were younger at first aortic event compared to those without (26.7 ± 11.5 years vs. 45.0 ± 14.9 years, p = 0.03). MAD distance correlated with need for VSRR, r = 0.57, p = 0.02. Two patients in the MAD group developed sustained VT. No cardiac arrest or death was observed. ConclusionMAD is highly prevalent in LDS, associated with progressive aortic dilatation, and aortic events at younger age. MAD may be a marker of disease severity necessitating close surveillance.

Outcomes of aortic valve-sparing root replacement with cusp repair in connective tissue disease

BackgroundAlthough, valve sparing is commonly performed in patients with Marfan syndrome, feasibility and results of cusp repair for aortic insufficiency have not been studied. AimTo report on the outcomes and durability of aortic cusp repair in valve sparing in patients with Marfan syndrome. MethodsAll consecutive adult patients with Marfan syndrome who underwent remodelling and annuloplasty with aortic valve repair for aortic insufficiency between May 2005 and December 2020 were included. Patients with Marfan syndrome treated for aortic aneurysm, but without aortic insufficiency, were excluded. Data were collected prospectively and reviewed retrospectively from the Aorticvalve repair International Registry (AVIATOR). ResultsDuring the study period, 71 patients with Marfan syndrome were referred to surgery. Fifty-five patients with connective tissue disease and aortic insufficiency with aorta aneurysm were treated: 46 underwent aortic valve repair and nine underwent aortic valve replacement (five mechanical aortic valve replacements and four biological aortic valve replacements). The mean age was 42.9±15.4 years, and the mean EuroScore II was 2.5±2.2. No patient died, and no patient had significant aortic insufficiency (grade≥II) at discharge. The 5-year survival rate estimate was 94.4%, which seems statistically similar to that of the age- and sex-matched general population. At 5 years, freedom from reoperation was 94.6%, and the incidence of infective endocarditis was 2.6%. No valve thrombosis, aortic dissection, major bleeding events, thromboembolic events (stroke) or myocardial infarctions were noted during follow-up. ConclusionRemodelling and aortic valve repair showed excellent durability at 5 years, even in connective tissue disorders.

Discussion to: Reintervention after valve-sparing aortic root replacement: A comprehensive analysis of 781 David V procedures

Discussion to: Reintervention after valve-sparing aortic root replacement: A comprehensive analysis of 781 David V procedures

Aortic Valve Reimplantation or Aortic Root Replacement With a Valved Conduit?

Aortic Valve Reimplantation or Aortic Root Replacement With a Valved Conduit?

Three Decades of Experience with Aortic Prosthetic Valve Endocarditis.

The objective of this study was to evaluate early and long-term outcomes of patients with aortic prosthetic valve endocarditis (a-PVE) treated with a prosthetic aortic valve (PAV), prosthetic valved conduit (PVC), or cryopreserved aortic homograft (CAH). A total of 144 patients, 115 male and 29 female, aged 67 ± 12 years, underwent surgery for a-PVE at our institution between 1994 and 2021. Median time from the original cardiac surgery was 1.9 [0.6-5.6] years, and 47 (33%) patients developed an early a-PVE. Of these patients, 73 (51%) underwent aortic valve replacement (AVR) with a biological or mechanical PAV, 12 (8%) underwent aortic root replacement (ARR) with a biological or mechanical PVC, and 59 (42%) underwent AVR or ARR with a CAH. Patients treated with a CAH had significantly more circumferential annular abscess multiple valve involvement, longer CPB and aortic cross-clamping times, and needed more postoperative pacemaker implantation than patients treated with a PAV. No difference was observed in survival, reoperation rates, or recurrence of IE between patients treated with a PAV, a PVC, or a CAH. CAHs are technically more demanding and more often used in patients who have extensive annular abscess and multiple valve involvement. However, the use of CAH is safe in patients with complex a-PVE, and it shows excellent early and long-term outcomes.

Valve Sparing vs Composite Valve Graft Root Replacement: Propensity Score–Matched Analysis

BackgroundBoth valve-sparing root replacement and composite valve graft (CVG) are acceptable options in aortic root replacement. We compare outcomes of these 2 approaches and durability of the aortic valve. MethodsA consecutive 1635 patients without acute dissection underwent primary aortic root replacement from 1997 to 2022; 473 (29%) underwent valve-sparing root replacement, and 1162 (71%) received CVG. Propensity score matching was used to reduce baseline differences. ResultsThe CVG group was older (59 ± 14 years vs 49 ± 14 years; P < .001) with more comorbidities, such as hypertension (88.4% vs 66.4%; P < .001), diabetes (7% vs 1.7%; P < .001), ischemic heart disease (5.1% vs 1.3%; P = .001), pulmonary disease (6.6% vs 1.3%; P < .001), renal impairment (8.6% vs 1.3%; P < .001), class III-IV heart failure (35% vs 9.2%; P < .001), bicuspid aortic valves (44.8% vs 24.1%; P < .001), and severe aortic insufficiency (50.2% vs 13.2%; P < .001). Operative mortality was 0.4% (0% in valve sparing); incidence of major postoperative complications was 2.9% (3.6% vs 1.1%; P = .009). Ten-year survival was 93.1% (91.2% vs 97.7%; hazard ratio [HR], 1.7; 95% CI, 0.9-3.3; P = .120). Mean follow-up was 65 ± 60 months; aortic valve reoperations were similar (5.8% vs 5.7%; HR, 0.8; 95% CI, 0.4-1.4; P = .401). Recurrent moderate-severe aortic insufficiency was less prevalent in CVG (6.1% vs 11.1%; HR, 0.14; 95% CI, 0.07-0.27; P < .001). Propensity score matching identified 225 pairs. There was no difference in 10-year survival or reoperations. Recurrent moderate-severe aortic insufficiency was higher with valve sparing. ConclusionsBoth valve-sparing operations and CVG provide excellent early and late outcomes out to 10 years. Valve sparing is associated with a higher risk for development of aortic insufficiency but no difference in reoperations.

Long-term Results of Valve-Sparing Aortic Root Replacement and Aortic Cusp Repair

BackgroundLong-term results of valve-sparing aortic root replacement (VSRR) and aortic cusp repair for aortic regurgitation are unclear. MethodsVSRR by reimplantation was performed in 363 patients. Tricuspid aortic valve (TAV) and bicuspid aortic valve were found in 285 and 71 patients, respectively. ResultsAortic cusp repair was performed in 268 patients. Of patients with TAV 129 had central plication of the Arantius node, 36 had free margin resuspension, and 71 had reinforcement. Mean follow-up was 71.4 months. Among TAV patients freedom from aortic valve reoperation at 10 and 15 years was 85.1% and 78.3%, respectively. Freedom from aortic valve reoperation at 10 years was lower in patients with cusp prolapse than without (77.4% vs 93.2%, P = .007). The overall freedom from more than mild aortic regurgitation at 10 and 15 years was 72.4% and 64.0%, respectively. It was also significantly greater in patients without cusp prolapse (78.4% vs 67.7%, P = .02). As for the cusp repair technique the freedom from aortic valve reoperation at 10 years was significantly better in patients who underwent only resuspension or reinforcement techniques compared with patients who underwent only central plication technique (100% vs 72.8%, P = .008). ConclusionsLong-term results of VSRR with aortic cusp repair were satisfactory. The resuspension technique appears to be useful for repairing aortic cusp prolapse in patients with TAV.

Transthoracic echocardiogram color Doppler of the aortic root in long axis obtained six-months following valve-sparing aortic root replacement in the patient described in Figure 6 demonstrates good valve funct on with no stenosis or regurgitation.

Transthoracic echocardiogram color Doppler of the aortic root in long axis obtained six-months following valve-sparing aortic root replacement in the patient described in Figure 6 demonstrates good valve funct on with no stenosis or regurgitation.