Aortic Valve-sparing Procedures Research Articles

Standardization of the aortic valve sparing procedure allows introduction of a new surgical technique with good early results: Retrospective analysis.

Standardization of the aortic valve sparing procedure allows introduction of a new surgical technique with good early results: Retrospective analysis.

Successful aortic valve-sparing procedure for an aortic root aneurysm associated with a congenital defect of the right sinus of Valsalva—a case report

Successful aortic valve-sparing procedure for an aortic root aneurysm associated with a congenital defect of the right sinus of Valsalva—a case report

Aortic valve-sparing procedure in the pediatric population.

Aortic valve-sparing procedures have been established as a mainstream treatment option for adult patients with aortic root aneurysms. However, data regarding their use in the pediatric population is limited. This study reports on our experience with aortic valve-sparing procedures in children. A retrospective review was conducted of all patients who underwent an aortic valve-sparing procedure at the Royal Children's Hospital, Melbourne, Australia between April 2006 and April 2016. Clinical and echocardiographic data were analyzed. The study included 17 patients, with a median age of 15.7 years and a majority of patients being male (82.4%). The most common diagnosis was transposition of great arteries after arterial switch operation, followed by Loeys-Dietz syndrome and Marfan syndrome. Preoperative echocardiography showed more than moderate aortic regurgitation in 94.1% of the patients. The David procedure was performed in all 17 patients, with no mortality during follow-up. Reoperation was required in 29.4% of patients, and 23.5% required aortic valve replacement. Freedom from reoperation for aortic valve replacement at 1, 5, and 10 years was 93.8%, 93.8% and 68.2% respectively. Aortic valve-sparing surgery can be successfully performed in the pediatric population. However, it requires a highly skilled surgeon due to the often dysplastic or distorted nature of these valves and the need for additional procedures on the aortic valve leaflets.

A simplified approach to determine the ventriculoaortic junction diameter in the reimplantation procedures.

In aortic valve–sparing procedures, sufficient effective height (EH) is essential for long-term aortic valve durability.1 The plication of the nodule of Arantius (central plication) and the free margin resuspension with polytetrafluoroethylene sutures are performed to obtain sufficient EH, but overcorrection brings the immobility of the cusp and the gap in the central coaptation zone. In the reimplantation procedure, reducing the ventriculoaortic junction (VAJ) diameter with the proximal suture line is another option for increasing the coaptation height2; however, the degree of the reduction must be decided at the beginning of the procedure before the cusp configuration is completed.

Improved Outcomes Following Reimplantation of the Aortic Valve Compared to Remodeling in Marfan Syndrome: A Propensity-matched Study

Objective: We sought to compare perioperative and late outcomes of patients with Marfan syndrome undergoing aortic valve sparing (AVS) root replacement using the reimplantation versus the remodeling technique. Methods: From 1988 to 2018, 194 patients with Marfan syndrome underwent AVS procedures in a single center. Of these, 24 who had remodeling AVS were matched to 44 who had reimplantation (1:2 matching). After matching, baseline characteristics were well balanced including: age, sex, NYHA III/IV, moderate or severe AI, acute aortic dissection, and year of operation. Outcomes included perioperative mortality and complications, as well as late survival, freedom from reoperation on the aortic valve, and probability of developing moderate or severe AI. Results: There was no in-hospital mortality, stroke, sepsis, myocardial infarction, or need for permanent pacemaker. Re-exploration was slightly lower in reimplantation patients (n=1 2% vs n=3 12% p=0.04) ICU length of stay was 2±1 day and similar between groups. Median follow up was 17.5 years (IQR: 11.8 - 20.4). Survival at 20 years was not different following remodeling vs reimplantation (71% vs 80% p=0.36). However, 20-year moderate to severe aortic insufficiency and reoperation were higher in remodeling patients (31% vs 16% p=0.01; and 18% vs 0% p=0.01). Conclusions: AVS operations have excellent long term survival and durability in Marfan syndrome. Reimplantation was associated with less early re-exploration and lower risk of late aortic insufficiency and reintervention at 20 years.

The Skirt and Collar of The Valsalva Graft: One Dress Fits All

In the original pre-formed Valsalva graft, the skirt is the defining feature. It is a self-expanding portion, obtained by 90° rotation of the Dacron fabric corrugation with respect to the rest of the graft. Due to this manufacturing feature, the skirt length is equal to the graft diameter and, once pressurized, it expands by 25-30% (up to 10 mm) from the nominal size. Proximal to this bulged portion, a small collar completes the prosthesis. By virtue of this anatomical design, the Valsalva graft is recommended for most aortic root surgeries including valve-sparing and Bentall procedures. The skirt, by recreating the pseudo-sinuses, represents the key feature of the graft when used for aortic valve-sparing procedures (remodeling and reimplantation). However, in the Bentall procedure, the graft collar is an important feature because it is useful to attach the Valsalva graft to the valve prosthesis sewing ring when making a valved conduit. Moreover, once the graft is pressurized, the whole volume of the skirt better accommodates the struts and the leaflets of biological and mechanical prostheses. Furthermore, the expanded skirt reduces the distance and the tension on the coronary button anastomosis, increasing safety and possibly reducing complication rates. This review demonstrates the versatility of the Valsalva graft in various scenarios of aortic root surgery, with special emphasis on different uses of the skirt and the collar.

The importance of collagen composition and biomechanics for the porcine aortic root

A thorough understanding of the aortic root structure and biomechanics is necessary when performing aortic valve-sparing procedures in patients with aortic root aneurysms. This study aimed to evaluate the amount of collagen and biomechanics at different levels and segments of the aortic root. Ten aortic roots from healthy pigs were excised including the aortic annulus, the sinuses of Valsalva, and the sinotubular junction (STJ). Specimens were further divided into three circumferential segments; left coronary (LC)-, right coronary (RC)-, and non-coronary (NC) sinus. Collagen was determined using hydroxyproline analysis and specimens were tested biomechanically for stress–strain relations. The annulus showed significantly larger average maximum stiffness (9.6 ± 4.5 N/mm) compared with the sinus (4.5 ± 2.0 N/mm) and STJ (4.8 ± 1.8 N/mm). The average collagen content was likewise higher in the annulus (4.0 ± 1.0 mg/ml) compared with the sinus (2.4 ± 0.6 mg/ml) and STJ (2.2 ± 0.5 mg/ml) for all three segments. The NC sinus segment exhibited a significantly larger maximum stiffness and stress under static conditions compared with the RC. These results suggest that the aortic root is heterogeneous in both structure and biomechanical properties and that it varies both in levels and segments of the aortic root. Future surgical approaches should consider enhanced strength parameters for specific areas of the aortic root to achieve the best results when performing aortic valve-sparing techniques. From this study, we conclude that the aortic annulus needs special attention to imitate normal physiologic properties during aortic valve-sparing surgery due to its higher maximum stiffness, stress, and load. Modified future surgical procedures could potentially prevent recurrent aneurysmal formation.

Aortic valve-sparing procedure\u2014a durable choice in liver transplantation recipient

A 44-year old man with aortic regurgitation and aneurysm of the ascending aorta underwent an aortic valve-sparing procedure as a durable treatment before liver transplantation. Since patients with chronic liver failure are at high risk of hemorrhagic complications at time of major surgery, while management of warfarin administration may still represent a concern, the choice of a cardiac procedure which avoids any anticoagulant treatment appeared justified.

Long-term outcomes of aortic valve repair in over 500 consecutive patients: a single-center experience.

Over the last years, aortic valve repair has evolved from being a random and irreproducible procedure to a standardized technique yielding durable long‑term results. The aim of the study was to assess long‑term outcomes of aortic valve repair and aortic valve sparing procedures. We analyzed the outcomes of all consecutive patients who underwent aortic valve repair and/ or aortic valve sparing root replacement till the end of 2019. We assessed mortality, freedom from reoperation, and freedom from at least moderate aortic valve regurgitation. A total of 504 patients underwent aortic valve repair and/or aortic valve sparing root replacement over 17 years, including 452 (89.7%) elective and 52 (10.3%) emergency surgeries for acute type A aortic dissections. Median (interquartile range) age was 59 (35-66) years, 72.4% were male. Median follow‑up time was 35 months. Estimated 5‑year survival was 83%, and 10‑year survival was 73%. In 452 patients after elective surgery, the estimated actuarial 5‑year and 10‑year survival was 86% and 75%, respectively. In patients after emergency surgery for acute type A aortic dissection, actuarial 5‑year survival was 62%, and 10‑year survival was 62%. Estimated 5- and 10‑year freedom from reoperation was 96% and 87%, respectively. The comparison of both subgroups did not reveal differences (P = 0.42). Freedom from at least moderate aortic valve regurgitation was confirmed in 86.6% of patients. Aortic valve repair is a durable and effective surgical procedure associated with low early and late mortality. Aortic valve reconstruction in patients with acute type A aortic dissection yields good long‑term results.

Aortic valve-sparing procedures in patients with aortic valve insufficiency: a single‑center experience.

Aortic valve-sparing procedures in patients with aortic valve insufficiency: a single‑center experience.

Aortic valve sparing techniques: pearls and pitfalls

Aortic valve sparing procedures became more popular in the last decades due to the better understanding of aortic root physiology. Searching for an optimal root reconstruction several modifications have been proposed to the original reimplantation (David) and to the remodeling (Yacoub) technique. Currently, the most adopted technique worldwide is the reimplantation because of its peculiar characteristics of annular stabilization, support of the aortic wall, and better hemostatic efficacy. The remodeling technique aims for optimal root restoration, but does not prevent annular dilatation and may be associated with a higher risk of bleeding. The main theoretical issue with the classic reimplantation operation is the elimination of Valsalva’s sinuses which play a fundamental role in regulating leaflet dynamics. On the other hand, data on long-term aortic valve performance in classic reimplantation procedures without sinuses appears to hold well the test of time. However, over the time this technique has been often modified attempting to re-create sinuses, it is therefore difficult to draw definite conclusions. In the last decade, the use of “anatomic” Dacron graft designed specifically for root reconstruction or specific modifications to the straight Dacron graft, led to a standardization of the technique and consequently to a stable improvement of the results and to the diffusion of the reimplantation. However, long-term durability of the spared valve assessed by the incidence of residual aortic valve insufficiency and/or the need for reoperation during the follow-up is still to be clarified. Overall, the results are satisfactory especially in consideration of the relatively “young age” of this technique. A spared aortic valve with moderate valve regurgitation and/or eccentric aortic jet soon after the procedure, will invariably lead to a later need for reoperation. Therefore, a good coaptation height inside a repaired root warrant long-lasting results.

Ascending aorta and aortic root replacement (with or without valve sparing) in early childhood: surgical strategies and long-term outcomes.

Aortic root and ascending aorta replacements (AARs) are rarely required in the paediatric population. We report here a series of AAR performed in young children using different surgical techniques. Between 1995 and 2017, 32 children under the age of 10 years (median age 5.4 years) underwent AAR procedures at our institution. Twenty-two (69%) had a connective tissue disease (infantile Marfan syndrome or Loeys-Dietz syndrome). We performed 11 AAR using a composite graft with a mechanical prosthesis and 21 valve-sparing procedures (10 Yacoub operations and 11 David operations). Median follow-up for operative survivors was 7.7 years (interquartile range 4.2-12.8 years). The cardiac-related early mortality rate was 6%. Patient survival was 91% at both 1 and 10 years. Eleven survivors (38%), all with a status of post-valve-sparing procedure, required an aortic root reintervention with an aortic valve replacement after a median interval of 4.2 years. Interestingly, only patients with infantile Marfan syndrome tended to be associated with risk of reoperation. Aortic root and AARs are safe in young children whatever the surgical procedure. Aortic valve-sparing procedures show good long-term results except in children with infantile Marfan syndrome whose ineluctable aortic annulus dilatation or aortic valve regurgitation requires reintervention after a short period.

Aortic Valve Sparing Procedure - Is There a Learning Curve?

Aortic Valve Sparing Procedure - Is There a Learning Curve?

Updates in Aortic Valve Sparing Surgery

For more than 90 years ago Aortic valve-sparing operations had been performed, but only recently surgeons have been able to match the aortic root disorder to the operative procedure correctly The development of aortic valve-sparing operations (re-implantation of the aortic valve and remodeling of the aortic root) expanded the surgical issues for treating patients with aortic root dilation caused by a variety of disorders. Young adults with aortic root aneurysms associated with genetic syndromes are ideal candidates for re-implantation of the aortic valve, and the long-term results have been excellent. Incompetent bicuspid aortic valves with dilated aortic annuli are also satisfactorily treated with the same type of operation. Older patients with ascending aortic aneurysm and aortic insufficiency secondary to dilated sino-tubular junction and a normal aortic annulus can be treated with remodeling of the aortic root or with re-implantation of the aortic valve. Annular dilation is often present in patients with incompetent BAV, correction of annular dilation is important, and re-implantation of the aortic valve may be the best option. There is a variety of techniques for Cusp Repair, considered as one of the valve-sparing techniques. Aortic valve-sparing surgery is performed to prevent hazards of Prosthetic valve implantation which is the most widely used therapeutic option for aortic regurgitation (AR), but complications associated with prosthetic valves, with an incidence of 3–5% patient/year, and the need for anticoagulation in mechanical valves, force us to consider aortic valve repair as an alternative to the prosthetic implant, especially in young people with many potential years of life for these complications. Aim of the work: This paper aims to have a description of surgical and dynamic anatomy of the aortic root, pathological changes that may affect it and important investigation for proper diagnosis and surgical planning. Highlights for aortic valve-sparing operations and their modification Review of Literature: Aortic valve-sparing (AVS) operations have become established alternatives to composite valve graft (CVG) procedures for patients with aortic root aneurysms and favorable aortic cusp morphology. The theoretical benefits of AVS procedures include avoiding the complications associated with prosthetic valves, specifically the risks of systemic thromboembolism and lifelong anticoagulation associated with mechanical valves. Summary: The development of aortic valve-sparing operations (re-implantation of the aortic valve and remodeling of the aortic root) expanded the surgical issues for treating patients with aortic root dilation caused by a variety of disorders.

Aortic valve repair in adult congenital heart disease.

Aortic valve repair in adult congenital heart disease (ACHD) went through a major development during the last two decades to become an increasingly established treatment option in experienced heart valve repair centers. This mini-review addresses valve-sparing treatment strategies in the two most common clinical entities of patients with adult congenital aortic valve disease, namely those presenting with bicuspid (BAV) and unicuspid (UAV) aortic valve disease. Both diseases are integral components of the continuum of congenital aortic valve diseases and represent one of the most common reasons of cardiovascular morbidity in young and otherwise healthy adult patients. The review will highlight the most important advantages of aortic valve sparing procedures as compared to the conventional valve replacement strategy. New treatment aspects will be reviewed including minimally-invasive surgical approaches for aortic valve repair as well as modern protocols of enhanced perioperative recovery which will potentially improve the perioperative recovery and quality of life of the patients undergoing valve-sparing surgical procedures in the future.

Chirurgická léčba aneuryzmatu aortálního kořene: srovnání Bentallovy operace a reimplantace aortální chlopně podle Davida

The aortic root aneurysm is associated with a more frequent occurrence of aortic dissection and development of aortic regurgitation. The aim of this study was to compare outcomes of composite graft replacement and valve sparing root replacement in treating aortic root aneurysms.From January 2006 to December 2015 a total of 137 patients (mean age 46.3 ± 14.5, range 16-65) underwent elective surgery for aortic root aneurysm without valvular structural defects. Replacement by mechanical composite graft (Bentall procedure) has been performed in 46 patients while 91 patients underwent valve sparing root replacement (David procedure). The mean length of follow-up has been 77 months.There was no operative death. Overall 9 patients died during follow-up. Five patients were after Bentall procedure and 4 were after reimplantation of aortic valve. Thromboembolic and bleeding complications were observed in 7 patients, 5 of them were after Bentall surgery and 2 after reimplantation of the aortic valve. Five patients after reimplantation of aortic valve underwent reoperation. Four of these patients had aortic valve replacement and in 1 case aortic homograft was implanted.Bentall procedure used to be the standard treatment for patients with aortic root aneurysms. During the past two decades, aortic valve sparing procedure has gained widespread use to reduce thromboembolic and bleeding complications.Key words: aortic root aneurysm - composite graft replacement - valve-sparing root replacement.

Valve preserving surgery in patients with bicuspid aortic valve

Bicuspid aortic valve can be associated with clinically important aortic regurgitation and dilatation of ascending aorta. Aortic valve repair seems to be optimal therapeutic option how to avoid valve-related and anticoagulation-related complications. We have analyzed midterm outcomes of patients after bicuspid aortic valve repair. MethodsBetween January 2008 and December 2015, 91 patients (mean age 40.9±12.2) with bicuspid aortic valve (type 0 or 1) underwent valve-sparing surgery for aortic valve insufficiency or aortic aneurysm. Urgent procedures and patients of age more than 65 were not included. The cohort of patients was retrospectively divided into two groups. Forty-nine patients underwent aortic valve-sparing procedure with root replacement (group 1). Forty-two patients underwent aortic valve repair without root replacement (group 2). The mean length of follow-up was 57.5 months. ResultsThere was no death in connection with aortic valve repair during follow up. Three patients from group 2 required in-hospital reoperation for early repair failure. Another seven patients (4 from group 1 and 3 from group 2) were reoperated for recurrent aortic insufficiency during follow-up period. Freedom from aortic valve reoperation at 5 years was 90% in group 1 and 87% in group 2. Freedom from recurrent aortic insufficiency (>2°) at 5 years was 85% in group 1 and 78% in group 2. ConclusionBicuspid aortic valve repair is a safe procedure, which can be performed with acceptable midterm results. Risk of repair failure depends on preoperative valve morphology and choice of repair technique. Repair technique needs to be tailored to the specific anatomy of the valve.

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.

Late echocardiographic study of aortic valve and aortic root after surgery for type a acute aortic dissection

Objective:In case of concomitant aortic regurgitation (AR) valve, sparing operation is considered the first choice in selected patients. The aim of this retrospective clinical and echocardiographic study was to evaluate the long-term survival results of conservative approach and the determinants of recurrent AR.Methods:From 2000 to 2011, fifty patients (median: 63 years and interquartile range: 53–72) underwent an aortic valve-sparing procedure for acute aortic dissection, and discharged alive. The long-term clinical and echocardiographic outcome was analyzed.Results:Late all-causes mortality was 18% (nine patients) at a median follow-up of 55.8 months. Ten patients (20%) underwent re-operations, five of them for aortic valve/root recurrent disease; freedom from proximal re-operation was 90%. Two-third of the patients had a preoperative AR grade <3; a non-negligible number of patients with acute significant AR (23% with grade ≥3) at the time of surgery underwent conservative aortic valve surgery. At a median echocardiographic follow-up of 50.5 months, we found no significant correlation between late recurrent AR and AR grade at the time of surgery and the aortic root diameter. Late recurrent AR grade was significantly higher in patients who underwent aortic commissures and cusps resuspension than those who underwent lone ascending aorta replacement (2.29 ± 1.05 vs. 1.58 ± 1.03, P = 0.028).Conclusions:Preoperative AR and late aortic root diameter were not the predictors of late AR. Late AR is higher in patients who underwent aortic commissures and cusps resuspension compared to the only replacement of the ascending aorta.

Long-term outcomes of aortic root operations for Marfan syndrome: A comparison of Bentall versus aortic valve-sparing procedures

ObjectivesProphylactic aortic root replacement improves survival in patients with Marfan syndrome with aortic root aneurysms, but the optimal procedure remains undefined. MethodsAdult patients with Marfan syndrome who had Bentall or aortic valve-sparing root replacement (VSRR) procedures between 1997 and 2013 were identified. Comprehensive follow-up information was obtained from hospital charts and telephone contact. ResultsOne hundred sixty-five adult patients with Marfan syndrome (aged > 20 years) had either VSRR (n = 98; 69 reimplantation, 29 remodeling) or Bentall (n = 67) procedures. Patients undergoing Bentall procedure were older (median, 37 vs 36 years; P = .03), had larger median preoperative sinus diameter (5.5 cm vs 5.0 cm; P = .003), more aortic dissections (25.4% vs 4.1%; P < .001), higher incidence of moderate or severe aortic insufficiency (49.3% vs 14.4%; P < .001) and more urgent or emergent operations (24.6% vs 3.3%; P < .001). There were no hospital deaths and 9 late deaths in more than 17 years of follow-up (median, 7.8 deaths). Ten-year survival was 90.5% in patients undergoing Bentall procedure and 96.3% in patients undergoing VSRR (P = .10). Multivariable analysis revealed that VSRR was associated with fewer thromboembolic or hemorrhagic events (hazard ratio, 0.16; 95% confidence interval, 0.03-0.85; P = .03). There was no independent difference in long-term survival, freedom from reoperation, or freedom from endocarditis between the 2 procedures. ConclusionsAfter prophylactic root replacement in patients with Marfan syndrome, patients undergoing Bentall and valve-sparing procedures have similar late survival, freedom from root reoperation, and freedom from endocarditis. However, valve-sparing procedures result in significantly fewer thromboembolic and hemorrhagic events.