Aortic Valve-sparing Operations Research Articles

A nationwide survey of aortic valve surgery in Japan: current status of valve preservation in cases with aortic regurgitation.

Although aortic valve-sparing operations are performed throughout Japan, the indications, specific repair techniques, and outcomes have not been reported in full. Thus, we conducted the first nationwide survey of aortic valve-sparing surgery. We mailed a questionnaire to 508 institutions across Japan to obtain information on elective aortic valve and aortic root surgeries performed in 2014. Included in the mailing was a secondary questionnaire that sought further information from institutions reporting aortic valve-sparing surgeries. Two hundred and fifty (49%) institutions responded and reported a total of 7859 aortic valve operations and 771 aortic root operations. Aortic valve operations performed strictly for aortic regurgitation totaled 2080, 156 (8%) of which were aortic valve repairs. Of the 699 aortic root surgeries performed for aortic regurgitation, 236 (34%) were valve-sparing root replacement surgeries. The valve-sparing root replacement surgeries comprised aortic valve reimplantation (n=173, 73%) and aortic root remodeling (n=63, 27%). Five of 57 (9%) institutions were responsible for 42% (99/233) of the total aortic valve-sparing surgeries performed. Detailed information that was obtained for 233 patients who underwent aortic valve repair or valve-sparing root replacement showed 30-day mortality and reoperation for regurgitation after aortic valve repair (n=97), aortic root remodeling (n=37), and aortic valve reimplantation (n=99) to be 1, 0, and 1% and 3, 3, and 1%, respectively. To date, aortic valve-sparing operations have been performed for limited patients at limited institution in Japan, but the early outcomes have been excellent.

Reparación de prolapso de velo por rotura en válvula aórtica

IntroductionLeaflets prolapse causes a lack of central coaptation and increases tension excessively on them. This fact predisposes to their rupture. This video is presented in which an aortic valve sparing surgery is performed by rebuilding a broken and prolapsing leaflet as an alternative to prosthetic implant. Materials and methodsA 61 year-old patient with tricuspid aortic valve and aortic regurgitation grade iv due to a prolapse and rupture of right-coronary leaflet and dilated ascending aorta. A retrospective analysis was performed on 19 patients with aortic valve sparing surgery and an untreated aortic root (2011-2015). ResultsThe video shows an annuloplasty, broken leaflet reconstruction, prolapse elimination with central plications, supracoronary conduit implantation, and sinotubular junction annuloplasty. Aortic regurgitation was grade i after surgery.The retrospective analysis of the group showed a mean age of 64.3±16.9 years, of which 5 (26.3%) were women. The Logistic EuroSCORE was 9.4±7.6, and the EuroSCORE II was 3.9±3.1. The procedures performed included, supracoronary conduit+aortic plasty in 11 (58%) and an isolated aortic plasty in 8 (42%). Pre-operative aortic regurgitation grade was iii (36.8%) and iv (63.2%). There were 3 (15.8%) conversions to prosthesis. Mean follow-up was 25.4±11.4 months (median 27), with 81% free not requiring re-intervention, and 69% free from aortic regurgitation>ii. ConclusionsAortic valve repair without addressing the root is more complex, due to its dynamic changes, and it is less stable over time.

The role of neo-sinus reconstruction in aortic valve-sparing surgery.

The aim of this study was to evaluate the clinical and echocardiographic results and the predictors of outcomes in patients undergoing valve-sparing operation (VSO) at two aortic centers. In addition, we sought to evaluate the potential effect of recreation of the sinuses of Valsalva (SV) on the outcome of valve-sparing procedures. During a 14-year period, 328 patients underwent aortic valve-sparing root replacement at two institutions. Clinical and echo evaluation was performed 6 months after surgery and every year thereafter or in case of clinical symptoms. Propensity weighting and propensity-weighted risk competing analysis were used. No operative mortality was reported; the most common complication was revision for bleeding, occurring in 15 patients (4.6%). At a mean follow-up of 30.0 ± 33.9 months, two patients died (0.6%). Recurrent aortic insufficiency (AI) >2+ was found in 11 patients (3.3%); five (1.5%) underwent reoperation. Recreation of the SV did not affect clinical outcome and aortic valve status. Need for aortic valve repair was the only independent predictor of recurrent AI, whereas a bicuspid aortic valve was a protective factor. Re-creation of the SV does not affect short-term outcomes following VSO.

Should the annulus be fixed in aortic valve-sparing root replacement with remodeling?

If the aortic root dilates after native aortic valve-sparing root reconstruction with remodeling, aortic regurgitation may recur. However, it has not been demonstrated clearly that the aortic root dilates after remodeling. This study enrolled 15 patients who underwent an aortic valve-sparing operation with remodeling (2002-2014) but without any ventriculo-aortic junction (VAJ) fixation. Technically, special care was taken to pass the sutures through the fibrous annulus. The diameter of the aortic root (VAJ, neosinus of Valsalva, and sinotubular junction), degree of aortic regurgitation, and effective height of the aortic valve were measured in the patients. All patients had postoperative follow-up, and the median follow-up period was 7.3 (IQR: 3.1-8.3)years. The mean preoperative diameters of the VAJ, sinus of Valsalva, and sinotubular junction were 23.5 ± 2.3 (20-27)mm, 51.1 ± 7.2 (43-60)mm, and 42.4 ± 9.4 (29-58)mm, respectively. The postoperative diameters of the VAJ changed from 21.6 ± 2.6 (early) to 21.8 ± 2.9mm (late) (p = 0.75). The diameters of the sinus of Valsalva and sinotubular junction changed from 26.5 ± 3.0 (early) to 28.5 ± 4.2mm (late) (p = 0.0013), and 22.4 ± 3.0 (early) to 24.3 ± 3.3mm (late) (p = 0.0003), respectively. The effective height of the aortic valve changed from 9.7 ± 1.3 (early) to 8.9 ± 2.0mm (late) (p = 0.08). The degree of aortic regurgitation (grade: 0-4) changed from 0.3 ± 0.5 (early) to 1.2 ± 0.8 (late) (p = 01558). Significant VAJ dilation and changes in aortic valve configuration after our remodeling procedure were not observed. Therefore, fixation of the annulus with remodeling may not be needed for cases without preoperative dilation of the annulus.

Invited Commentary

Invited Commentary

Valve-Sparing Root Replacement Compared With Composite Valve Graft Procedures in Patients With Aortic Root Dilation

BackgroundAlthough aortic valve-sparing (AVS) operations are established alternatives to composite valve graft (CVG) procedures for patients with aortic root aneurysms, comparative long-term outcomes are lacking. ObjectivesThis study sought to compare the results of patients undergoing AVS procedures with those undergoing CVG operations. MethodsFrom 1990 to 2010, a total of 616 patients age <70 years and without aortic stenosis underwent elective aortic root surgery (AVS, n = 253; CVG with a bioprosthesis [bio-CVG], n = 180; CVG with a mechanical prosthesis [m-CVG], n = 183). A propensity score was used as a covariate to adjust for unbalanced variables in group comparisons. Mean age was 46 ± 14 years, 83.3% were male, and mean follow-up was 9.8 ± 5.3 years. ResultsPatients undergoing AVS had higher rates of Marfan syndrome and lower rates of bicuspid aortic valve than those undergoing bio-CVG or m-CVG procedures. In-hospital mortality (0.3%) and stroke rate (1.3%) were similar among groups. After adjusting for clinical covariates, both bio-CVG and m-CVG procedures were associated with increased long-term major adverse valve-related events compared with patients undergoing AVS (hazard ratio [HR]: 3.4, p = 0.005; and HR: 5.2, p < 0.001, respectively). They were also associated with increased cardiac mortality (HR: 7.0, p = 0.001; and HR: 6.4, p = 0.003). Furthermore, bio-CVG procedures were associated with increased risk of reoperations (HR: 6.9; p = 0.003), and m-CVG procedures were associated with increased risk of anticoagulant-related hemorrhage (HR: 5.6; p = 0.008) compared with AVS procedures. ConclusionsThis comparative study showed that AVS procedures were associated with reduced cardiac mortality and valve-related complications when compared with bio-CVG and m-CVG. AVS is the treatment of choice for young patients with aortic root aneurysm and normal or near-normal aortic cusps.

Aortic root reimplantation procedure: a new milestone in aortic valve-sparing operations

&lt;p&gt;&lt;strong&gt;Aim:&lt;/strong&gt; Emphasis in this study was placed on clinical and functional assessment of a modified "Florida Sleeve" procedure during surgical correction of ascending aorta aneurysms with concomitant aortic insufficiency.&lt;br /&gt;&lt;strong&gt;Methods:&lt;/strong&gt; 32 patients with an aneurysm of the ascending aorta and aortic insufficiency underwent a modified "Florida Sleeve" procedure. The average follow-up was 17 (0-60) months. The average age of patients was 57±13 (23-73) years 56±13 years.&lt;br /&gt;&lt;strong&gt;Results:&lt;/strong&gt; The expected 4-year cumulative survival rate was 84.3%. Overall freedom from aortic insufficiency in the late period was 88.9%. Median aortic regurgitation was 1+ (1; 2). Long-term follow-up revealed no valve-associated complications.&lt;br /&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt; The aortic root reimplantation procedure enables optimal correction of the existing lesions of the aortic root without performing aortic valve replacement and demonstrates stable clinical and functional outcomes in the long-term period.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Key words:&lt;/strong&gt; aortic aneurysm; aortic valve; valve-sparing operations.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Funding&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;The study had no sponsorship.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conflict of interest&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;The authors declare no conflict of interest.&lt;/p&gt;

Long-term results of external aortic ring annuloplasty for aortic valve repair.

An untreated dilated aortic annulus is a major risk factor for failure of aortic valve-sparing operations or repair of either bicuspid or tricuspid valve. Aortic annuloplasty efficiently reduces the annulus and increases the coaptation height, thus protecting the repair. This study analyses long-term results of 232 consecutive patients operated on with a standardized and physiological approach to aortic valve repair according to each phenotype of the dystrophic ascending aorta. Subvalvular aortic annuloplasty was systematically added using an external aortic ring to reduce annulus diameter when ≥25 mm. Data were collected into the multicentric international AVIATOR registry (AorticValve repair InternATiOnal Registry): 149 patients with root aneurysm underwent remodelling with an external ring; 21 patients with tubular aortic aneurysm underwent supracoronary grafts with an external open ring and 62 patients with isolated aortic insufficiency (AI) underwent double sub- and/or supravalvular external open ring annuloplasty. Preoperative AI ≥ Grade III was present in 58.6% (133), and the valve was bicuspid in 37.9% (88). Cusp repair was performed in 75.4% (175) patients. The 30-day operative mortality rate was 1.4% (3). The mean follow-up was 40.1 ± 37.8 months (0-145.5). The actuarial survival rate at 7 years was 89.9%. The rate of freedom from reoperation at 7 years was similar among each phenotype, being 90.5% for root aneurysms, 100% for tubular aortic aneurysms and 97.5% for isolated AI with no difference between the bicuspid and tricuspid valve. The rates of freedom from AI ≥ Grade 2 and from AI ≥ Grade 3 at 7 years were, respectively, 76.0 and 93.1% for root aneurysms, 92.9 and 100% for tubular aortic aneurysms and 57.3 and 82.2% for isolated AI. Eye balling repair achieved suboptimal valve competency when compared with systematic cusp effective height assessment, which tended to improve the rate freedom from reoperation, respectively, from 85.8 ± 5.5% to 98.9 ± 1.1% and the rate of freedom from AI ≥ Grade 3 from 89.8 ± 4.9% to 100%. For isolated AI, an additional sinotubular junction ring (double sub- and supravalvular annuloplasty) tended to reduce recurrent AI when compared with single subvalvular annuloplasty. External aortic ring annuloplasty provides a reproducible technique for aortic valve repair with satisfactory long-term results for each ascending aorta phenotype with bicuspid or tricuspid valve. Longer follow-up is ongoing with the AVIATOR registry.

Single-centre experience in surgery of acute aortic type A dissection and true aortic arch aneurysm

Surgery of the aortic arch is challenging. To assess the results of aortic arch surgery. Analysis of 172 patients operated on arch dissection (emergency group: 97 patients) or aneurysm (elective group: 75 patients) between 2007 and 2014. Arch surgery was defined as a procedure requiring circumferential anastomosis at the level of the aortic arch or the descending aorta with the use of techniques of brain protection (deep hypothermic circulatory arrest [DHCA] or selective antegrade cerebral perfusion [SACP]) and/or debranching of at least one supra-aortic vessel. Men predominated in both groups (> 70%). Men were younger in the emergency group (55 vs. 66 years; p < 0.008). The operative risk was higher in the emergency group (19.2% vs. 12.5%; p < 0.001). Forty-nine per cent of the patients from the emergency group and 5% from the elective group were operated with antiplatelet therapy (p < 0.001). Extended hemiarch procedure was performed in 79% (n = 77) in the emergency and 76% (n = 57) in the elective group. Total arch replacement was performed in 19 (21%) patients from the emergency and 18 (24%) patients from the elective group. In these patients debranching was performed in 68% of the emergency patients group and in 67% of the elective group. Elephant trunk procedure (classic/frozen) was performed in 53% (n = 10) from the emergency and in 78% (n = 14) of patients from the elective group. Aortic valve sparing surgery was performed in 20% of patients from the emergency and 9% from the elective group (p = 0.063). DHCA was performed in 58% (n = 43) of patients from the elective group and 39% (n = 37) from the emergency group. SACP was performed in 61% (n = 58) of patients from the emergency and 42% (n = 31) from the elective group. Thirty-day mortality in the emergency group reached 33% (n = 32), and in the elective group 15% (n = 11; p = 0.007). In multivariate analysis, predictors of death in the emergency group were: Logistic EuroSCORE above 19.5%, extracorporeal circulation time above 228 min, and postoperative acute renal failure (ARF); and in the elective group: DHCA time above 26 min, rethoracotomy due to bleeding, and ARF. Follow-up was completed in 100% of patients in terms of vital status. The mean follow-up time of the patients from the emergency group was 24.3 ± 27.10 (min 0, max 92) months, and from the elective group 30.3 ± 24.5 (min 0, max 99) months. During the follow-up period all-cause mortality in the emergency group was 43% (n = 42/97), and in the elective group it was 36% (n = 27/75). Early mortality in the emergency group was higher, while long-term mortality did not differ among the groups. Postoperative ARF is a critical predictor of mortality in both groups.

Long Term Survival after Aortic Valve-sparing (David and Yacoub) Operation

Long Term Survival after Aortic Valve-sparing (David and Yacoub) Operation

THE ROSS PROCEDURE IN CHILDREN: A TWENTY-FIVE YEAR FOLLOW-UP STUDY

Ideal aortic valve substitute in children is still to be defined. The Ross procedure offers advantages such as growth potential and low thrombogenicity. Concerns regarding autograft and homograft longevity as well as subsequent reoperations may limit this prosthetic choice in young patients. We reviewed our 25-year experience with the Ross procedure with the aim of defining survival rate and freedom from reintervention. This is a single-center prospective cohort including fifty-eight consecutive children who had the Ross procedure. The first Ross procedure was performed in 1990. Median follow-up duration was 18.9 years and ranged up to 25 years. Complete postoperative clinical and echocardiographic evaluation was obtained and there was no loss to follow-up. Transthoracic echocardiogram was performed when clinically indicated. There were 48 males (82.8%) with a median age at surgery of 11.3 years (0.04 - 17.9). Indications for surgery were stenosis in 32 (55.2%), regurgitation in 13 (22.4%) and mixed aortic valve disease in 13 (22.4%) patients. Survival at 10 and 25 years was 96.2% and 93.9%, respectively. There was one (1.7%) hospital death and two (3.4%) late deaths. Freedom from pulmonary autograft-related reintervention (the aortic root prosthesis) was 93.9% and 69.7% at 10 and 25 years, respectively. Eleven patients underwent reoperations on the autograft at a median follow-up of 16.1 years. Aortic valve-sparing surgery was performed in 6 patients and a Bentall procedure in 4 patients (3 mechanical, 1 homograft). Over the study period, twice as many patients (34.5%) required pulmonary homograft-related (right ventricular outflow tract) reintervention (10 transcatheter, 10 surgical conduit replacement). Freedom from homograft-related reintervention was 73% and 50.4% at 10 and 25 years, respectively. The Ross procedure is associated with excellent long term survival. Late reintervention for the homograft was more common than for the pulmonary autograft in our cohort.

Outcomes of Aortic Valve-Sparing Operations in Marfan Syndrome

BackgroundIn many cardiac units, aortic valve-sparing operations have become the preferred surgical procedure to treat aortic root aneurysm in patients with Marfan syndrome, based on relatively short-term outcomes. ObjectivesThis study examined the long-term outcomes of aortic valve-sparing operations in patients with Marfan syndrome. MethodsAll patients with Marfan syndrome operated on for aortic root aneurysm from 1988 through 2012 were followed prospectively for a median of 10 years. Follow-up was 100% complete. Time-to-event analyses were calculated using the Kaplan-Meier method with log-rank test for comparisons. ResultsA total of 146 patients with Marfan syndrome had aortic valve-sparing operations. Reimplantation of the aortic valve was performed in 121 and remodeling of the aortic root was performed in 25 patients. Mean age was 35.7 ± 11.4 years and two-thirds were men. Nine patients had acute, 2 had chronic type A, and 3 had chronic type B aortic dissections before surgery. There were 1 operative and 6 late deaths, 5 caused by complications of dissections. Mortality rate at 15 years was 6.8 ± 2.9%, higher than the general population matched for age and sex. Five patients required reoperation on the aortic valve: 2 for endocarditis and 3 for aortic insufficiency. Three patients developed severe, 4 moderate, and 3 mild-to-moderate aortic insufficiency. Rate of aortic insufficiency at 15 years was 7.9 ± 3.3%, lower after reimplantation than remodeling. Nine patients developed new distal aortic dissections during follow-up. Rate of dissection at 15 years was 16.5 ± 3.4%. ConclusionsAortic valve-sparing operations in patients with Marfan syndrome were associated with low rates of valve-related complications in long-term follow-up. Residual and new aortic dissections were the leading cause of death.

A Simple Device for Morphofunctional Evaluation During Aortic Valve-Sparing Surgery

Valve-sparing operations for the treatment of aortic root disease with a structurally normal aortic valve are increasingly performed as they avoid prosthesis-related complications. Short- and long-term results are critically dependent on perfect intraoperative restoration of valve anatomy and function. Residual aortic regurgitation is the main cause of early failure, and it is the most common motive for reoperation. However, intraoperative morphofunctional valve assessment requires expertise, and only transesophageal echocardiography can provide reliable information. We describe a simple, economic, reproducible hydrostatic test to intraoperatively evaluate valve competency under direct visualization.

Aortic Valve Sparing Surgery: The Use of the Coroneo Extra-Aortic Annuloplasty Ring

Ideal prosthetic aortic valve should maintain excellent hemodynamic characteristics that are sustainable during varying hemodynamic conditions and demands, have minimal trans-aortic pressure gradients, should be durable in the long term, resist thrombus formation without the need for anticoagulation and be straightforward to implant. Unfortunately, the ideal prosthetic aortic valve does not yet exist. This review critically evaluates available-to-the-surgeon options.Critical evaluation of relevant literature sources available on PubMed with the emphasis on current situation and new trend in the aortic valve sparing procedures. Current prosthetic devices are associated with complications such as valve thrombosis and thromboembolic events, bleeding events associated with anticoagulation use and structural valve deterioration. Therefore native valve disease is replaced by prosthetic valve disease. Aortic valve sparing operations were developed to preserve the native aortic valve during surgery for aortic root aneurysm and ascending aortic aneurysm with associated aortic insufficiency, circumventing complications arising from prosthetic valve implantation by preserving the native aortic valve apparatus. There are two fundamental types of aortic valve sparing procedures: remodelling of the aortic root and reimplantation of the aortic valve. Evidence based medicine shows that reimplantation of the aortic valve is in long term associated with lower risk of developing aortic insufficiency. An alternative standardized approach that combines an external subvalvular aortic prosthetic ring annuloplasty with remodelling technique was presented. Implantation of an external aortic ring provides a reproducible technique for aortic valve repair with great preliminary results.

Cusp repair during aortic valve-sparing operation: technical aspects and impact on results.

Aortic valve-sparing operations are nowadays considered safe and reliable procedures in terms of mid-term and long-term results. Although surgical techniques regarding the modality of grafts' implantation have been properly addressed, the modality of cusp repair, when needed, is still open to debate. We sought to review the literature to try to shed light on when the cusp repair is required and how it should be performed. We searched the PubMed database using the keywords aortic valve-sparing operation, aortic valve-sparing reimplantation, valve-sparing aortic root replacement, aortic valve repair, and aortic cusp repair. Only studies that included and described in detail the technique of cusp repairs in adjunct to aortic valve-sparing operation were considered. Bicuspid aortic valve more often requires correction when compared with tricuspid valve. The range of the techniques varies from the 'simple' free margin plication to the more complex triangular resection with patch repair. Results in the literature seem to be encouraging, showing that, in most of the cases, cusp repair does not affect valve competence in the mid-term and long-term. Correction of the cusp is a delicate balance between undercorrection that could lead to residual prolapse and overcorrection that could lead to cusp restriction. Although complex repair of the aortic valve in addition to root replacement provided satisfactory results, it should be reserved for experienced centers with a large volume of patients.

自己弁温存基部置換術後に Stanford A 型大動脈解離をきたし上行弓部置換術を施行した Loeys-Dietz 症候群の1例

症例は14歳男児．6歳時の心エコーで大動脈弁輪拡大を指摘され，身体所見と併せて遺伝子検索でLoeys-Dietz症候群と診断された．その後の経過観察でバルサルバ洞の急速な拡大と中等度の大動脈弁閉鎖不全を認め，9歳時に手術目的で当院紹介となった．大動脈弁は3尖で器質的変性を認めず，自己弁温存大動脈基部置換術を施行した．術後経過は良好であり，外来で経過観察をしていた．平成26年12月に胸痛とCRP高値にて近医から紹介となり，心エコー，胸部CTでStanford A型急性大動脈解離と診断し緊急手術を行った．前回の人工血管末梢側吻合部のすぐ末梢から弓部大動脈中枢までの巨大なtearを認め，elephant trunkを用いた全弓部置換術を施行した．術後経過は良好であり術後17日目に退院となったが，術後13日目の胸部CTで新たに左鎖骨下動脈の解離，拡大を認めた．大動脈に残存解離腔は存在しなかった．Loeys-Dietz症候群は，大動脈瘤や解離など血管系症状と骨格系所見が特徴的な常染色体優性遺伝の疾患である．Marfan症候群に比べると大動脈径が小さくても解離を発症する危険が高く，大動脈瘤に対しては早期積極的介入が推奨されている．今回自己弁温存基部置換術後5年後にStanford A型大動脈解離を発症し救命し得たLoeys-Dietz症候群の1例を経験した．組織の脆弱性を鑑みるに，厳密な経過観察が必要であると思われる．

A quarter of a century of experience with aortic valve-sparing operations

To examine the late outcomes of aortic valve-sparing operations to treat patients with aortic root aneurysm with and without aortic insufficiency (AI) in a cohort of patients followed up prospectively since 1988. A total of 371 consecutive patients had undergone aortic valve-sparing surgery (mean age, 47 ± 15 years; 78% men) from 1988 through 2010. In addition to the aortic root aneurysm, 47% had moderate or severe AI, 35.5% had Marfan syndrome, 12.1% had type A aortic dissection, 9.2% had bicuspid aortic valve, 8.4% had mitral insufficiency, 16.1% had aortic arch aneurysm, and 10.2% had coronary artery disease. Reimplantation of the aortic valve was used in 296 patients and remodeling of the aortic root in 75. Cusp repair by plication of the free margin along the nodule of Arantius was used in 36.6% of patients, and reinforcement of the free margin with a double layer of fine Gore-Tex suture in 24.2%. The patients were followed up prospectively with images of the aortic root for a median follow-up of 8.9 ± 5.2 years. A total of 4 operative and 39 late deaths occurred. Survival at 18 years was 76.8% ± 4.31%, lower than that for the general population matched for age and gender. Age, type A aortic dissection, impaired ventricular function, and preoperative AI were associated with increased mortality on multivariable analysis. Reoperations on the aortic valve were performed in 8 patients for recurrent AI and in 2 for infective endocarditis. Freedom from reoperation on the aortic valve at 18 years was 94.8% ± 2.0%. No predictors of the need for reoperation were found on multivariable analysis. Eighteen patients developed AI greater than mild. Freedom from AI greater than mild at 18 years was 78.0% ± 4.8%. No predictors of recurrent AI were identified on multivariable analysis. Aortic valve-sparing operations continue to provide excellent clinical outcomes, although a slow but progressive deterioration of aortic valve function seems to occur during the first 2 decades of follow-up. Preoperative AI and cusp repair had no adverse effect on valve function.

Aortic Valve-sparing Operation with Reimplantation Technique

Introduction: The aortic valve-sparing operation offers the unique possibility of preserving the native valve in patients whoneed surgical treatment for aortic root disease. Objective: The aim of this study was to assess the long term outcome of the aortic valve-sparing operation with reimplantation technique at the Hospital Universitario Fundacion Favaloro. Methods: A total of 66 patients underwent aortic valve-sparing operation from June 1998 to December 2011. Fifty threepatients operated on with the aortic valve reimplantation technique were included in the study and 13 patients operatedwith the remodeling technique were excluded. Clinical and echocardiographic follow-up was performed. Aortic insufficiencywas graded as: 0: absent; 1+: mild; 2+: moderate; 3+: moderate-severe, and 4+: severe. Survival and freedom from aorticinsufficiency >2+ and reoperation were analyzed using the Kaplan-Meier method.Results: Mean age was 45±17 years, 79% of patients were men and 36% had Marfan syndrome. In-hospital and late mortalitywas 3.8%. Survival at 8 years was 91% (95% CI: 78-97%). Freedom from aortic insufficiency > 2+ and reoperation at 8 yearswas 84% (95% CI: 66-92%) and 90% (95% CI: 74-96%), respectively. Preoperative aortic insufficiency >2+ was not associatedwith aortic insufficiency >2+ (RR 1.45; p=0.16) or reoperation (RR 1.96; p=0.4) during follow-up. Conclusions: In our experience, the aortic valve-sparing operation with reimplantation technique in patients with aortic rootdisease shows comparable results to other published international series. This surgical technique is a valid option for eligiblepatients duly informed about the different surgical techniques, and should be performed in experienced centers.

Current Readings: Aortic Valve–Sparing Operations

It has been more than 2 decades since aortic valve-sparing operations were introduced to preserve the aortic valve in patients with aortic root aneurysm. Remodeling of the aortic root is physiologically superior to reimplantation of the aortic valve, mostly because it preserves the aortic annulus movement during the cardiac cycle. However, several comparative studies have shown that reimplantation of the aortic valve has provided more stable aortic valve function than remodeling of the aortic root. This difference in outcomes is largely because of patients׳ selection. Remodeling of the aortic root has been associated with high failure rates in patients with aneurysms associated with genetic syndromes and bicuspid aortic valves with dilated aortic annulus, but it has provided excellent long-term results in older patients with aortic root aneurysms secondary to ascending aortic aneurysms and normal aortic annulus. Thus, both techniques are useful in preserving the aortic valve. With either technique, restoration of normal aortic annulus and cusp geometry is the single most important technical aspect of these operations. In addition to having a competent valve with no or trivial aortic insufficiency at the end of the operation, there must be no cusp prolapse and the coaptation level of the cusps has to be well above the level of the nadir of the aortic annulus.

Three-year results from the surgical treatment of diseases of the aortic valve and aortic root

PURPOSE: Pathology of the aortic root and aortic valve is subjected to adult cardiac surgery and includes Stanford A aortic dissection, annuloaortic ectasia or chronic aneurysm of the ascending aorta. In such cases, Bentall-De Bono procedure is usually preferred. Aortic valve reimplantation by using Tirone David's technique presenting with the advantages of valve-sparing surgery can be performed in selected cases. MATERIAL AND METHODS: A retrospective analysis of a three-year experience with the complex surgical treatment of diseases of the aortic valve and root was carried out. During the period from January 1, 2009 to December 31, 2012, fifty-three patients with aortic valve and aortic root pathology were treated in the Division of Cardiac Surgery, St. Marina University Hospital of Varna. Bentall procedure was carried out in 37 patients (Group B). In 19 of them (51%) emergency surgery was done for acute aortic dissection of type Stanford A. The rest 18 patients underwent elective surgery for dilated ascending aorta and aortic valve dysfunction. Aortic valve-sparing surgery by David's technique for aortic aneurysm was accomplished in 16 patients (Group D). This technique was emergently applied in one patient with aortic dissection, too. Baseline data, intraoperative details, early results and complications were compared. RESULTS: Early (30-day) mortality after Bentall-De Bono procedure was 10.5% (0% after elective surgery and 21.1% after dissection repair). All the patients survived after David's procedure that proved the significant advantages of the valve-sparing surgery. CONCLUSION: The aortic valve reimplantation provides long-term results that are comparable to those after the Bentall-De Bono procedure such as high survival rates, low incidence rate of endocarditis, and slightly higher risk of reinterventions. There is no need of life-long anticoagulation that improves patient's quality of life. Scripta Scientifica Medica 2013; 45(4): 50-55.