Aortic Valve-sparing Procedures Research Articles

Valve sparing: aortic root replacement with the reimplantation technique.

Aortic valve-sparing procedures are alternative options to aortic valve replacement in patients with aortic root aneurysm and/or severe aortic regurgitation reducing the risk of prosthesis-related complications, such as thromboembolism, and have no need for long-term oral anticoagulation. However, these techniques are technically demanding and long-term results are highly dependent on perfect intraoperative restoration of valve function. We describe a systematic approach to aortic valve-sparing aortic root replacement with the reimplantation technique the way it is currently performed in our institution.

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.

Early and Medium Term Results of the Sleeve Valve-Sparing Procedure for Aortic Root Ectasia

The aim of this retrospective study was to evaluate our experience of using a simplified aortic valve sleeve procedure to treat aortic root ectasia and aneurysms with or without aortic regurgitation. In experienced hands, 2 aortic valve-sparing procedures, ie, Yacoub and David, have yielded excellent long-term results in the treatment of aortic root aneurysms, with or without aortic regurgitation. However, these techniques are demanding and not widely used. Recently, a new and simplified valve-sparing technique, named "sleeve procedure," has been proposed, and has yielded encouraging early results. Ninety consecutive patients with aortic root aneurysms underwent sleeve procedures from October 2006 to October 2012. Follow-up data (clinical 100% complete and echocardiographic 93% complete) were acquired from our outpatient clinic or from the referring cardiologist. The mean age of the patients was 61.5 ± 12.5 years, 79% were male, 16 (18%) had a bicuspid valve, 3had Marfan syndrome, and 2 had aortic dissection. Over a mean clinical follow-up of 34 ± 19 months, 2 patients died from noncardiac causes and 1 was reoperated on for the recurrence of aortic regurgitation. On follow-up echocardiography after a mean of 18 ± 9 months, aortic regurgitation was absent/negligible, mild or moderate in 62%, 37%, and 1% of patients, respectively, and the diameters of the annulus, Valsalva sinuses, and sinotubular junction were 27.3+ 2.2, 37.0+ 3.4, and 30.6+3.1 mm, respectively. Our encouraging early and medium term results suggest that the sleeve procedure is a safe and effective aortic valve-sparing technique for the treatment of aortic root ectasia and aneurysm. However, longer follow-up is needed in order to draw definitive conclusions.

Aortic root surgery in the United States: A report from the Society of Thoracic Surgeons database

The purpose of the present study was to evaluate the early clinical outcomes of aortic root surgery in the United States. The Society of Thoracic Surgeons database was queried to identify all patients who had undergone aortic root replacement from 2004 to early 2010 (n=13,743). The median age was 58 years (range, 18-96); 3961were women (29%) and 12,059 were white (88%). The different procedures included placement of a mechanical valve conduit (n=4718, 34%), stented pericardial (n=879, 6.4%) or porcine (n=478, 3.5%) bioprosthesis, stentless root (n=4309, 31%), homograft (n=498, 3.6%), and valve sparing root replacement (n=1918, 14%). The median number of aortic root surgeries per site was 2, and only 5% of sites performed >16 aortic root surgeries annually. An increased trend to use biostented (porcine or pericardial) valves during the study period (7% in 2004 vs 14% in 2009). The operative (raw) mortality was greater among the patients with aortic stenosis (6.2%) who had undergone aortic root replacement, independent of age. Mortality was greater in patients who had undergone concomitant valve or coronary artery bypass grafting or valve surgery (21%). The lowest operative mortality was observed in patients who had undergone aortic valve sparing procedures (1.9%). Most cardiac centers performed aortic root surgery in small volumes. The unadjusted operative mortality was greater for patients >80 years old and those with aortic stenosis, regardless of age. Valve sparing root surgery was associated with the lowest mortality. A trend was seen toward an increased use of stented tissue valves from 2004 to 2009.

Invited Commentary

Aortic valve repair and aortic valve-sparing procedures are associated with very low morbidity and mortality rates, favorable durability, and a high quality of life [1–3]. Despite these advantages, however, relatively few cardiac surgery centers perform these procedures on a routine basis.

Aortic Valve Repair: A Systematic Review and Meta-analysis of Published Literature.

Background : It is widely accepted that aortic valve disease is surgically managed with aortic valve replacement (AVR) using different available prostheses. The long-term survival, durability of the valve, and freedom from reoperation after AVR are well established in published literature. Over the past two decades, aortic valve repair (AVr) has evolved into an accepted surgical option for patients with aortic valve disease. We review and analyze the published literature on AVr. Methods : A systematic review of the current literature was performed through three electronic databases from inception to August 2013 to identify all relevant studies relating to aortic valve repair. Articles selected were chosen by two reviewers. Articles were excluded if they contained a pediatric population or if the patient number was less than 50. Twenty-four studies conformed to the inclusion criteria for inclusion in the systematic review. In total, 4986 patients underwent aortic valve repair. 7 studies represented bicuspid aortic valve (BAV) repair, 5 studies represented cusp prolapse, and 3 studies represented valve repair with root dilation or aneurysm. Overall weighted in-hospital mortality for all studies was low (1.46% ± 1.21). Preoperative aortic insufficiency (AI) ≥ 2+ did not correlate to reoperation for valve failure (Pearson's Rs 0.2705, P = 0.2585). AI at discharge was reported in 9 studies with a mean AI ≥ 2+ in 6.1% of patients. Weighted average percentage for valve reoperation following BAV repair was 10.23% ± 3.2. Weighted average reoperation following cusp prolapse repair was 3.83 ± 1.96. Weighted average reoperation in aortic valve sparing procedures with root replacement was 4.25% ± 2.46. Although there are limitations and complications of prosthetic valves, especially for younger individuals, there is ample published literature that confers strong evidence for AVR. On the contrary, aortic valve repair may be a useful option for selected patients, but there is lack of uniformity in data and absence of compelling supporting evidence. An international multi-center study comparing and assessing the results between AVR & AVr is the next step required. Currently, higher levels of evidence do not exist for aortic valve repair.

To Spare or Not to Spare…? The Aortic Valve in Scleroderma and Aortic Root Aneurysm

Acute valve-sparing procedures are effective in the treatment of aortic root dilation when there is no valve pathology. In this review, we discuss the role of aortic valve-sparing procedures in the presence of connective tissue disorders such as scleroderma.

Mitral Valve Disease in Patients with Marfan Syndrome Undergoing Aortic Root Replacement

Cardiac manifestations of Marfan syndrome include aortic root dilation and mitral valve prolapse (MVP). Only scant data exist describing MVP in patients with Marfan syndrome undergoing aortic root replacement. We retrospectively analyzed data from 166 MFS patients with MVP who were enrolled in a prospective multicenter registry of patients who underwent aortic root aneurysm repair. Of these 166 patients, 9% had mitral regurgitation (MR) grade >2, and 10% had MR grade 2. The severity of MVP and MR was evaluated by echocardiography preoperatively and ≤ 3 years postoperatively. Forty-one patients (25%) underwent composite graft aortic valve replacement, and 125 patients (75%) underwent aortic valve-sparing procedures; both groups had similar prevalences of MR grade >2 (P=0.7). Thirty-three patients (20%) underwent concomitant mitral valve (MV) intervention (repair, n=29; replacement, n=4), including all 15 patients with MR grade >2. Only 1 patient required MV reintervention during follow-up (mean clinical follow-up, 31 ± 10 months). Echocardiography performed 21 ± 13 months postoperatively revealed MR >2 in only 3 patients (2%). One early death and 2 late deaths occurred. Although the majority of patients with Marfan syndrome who undergo elective aortic root replacement have MVP, only 20% have concomitant MV procedures. These concomitant procedures do not seem to increase operative risk. In patients with MR grade ≤ 2 who do not undergo a concomitant MV procedure, the short-term incidence of progressive MR is low; however, more follow-up is needed to determine whether patients with MVP and MR grade ≤ 2 would benefit from prophylactic MV intervention.

How to perform valve sparing reimplantation in a tricuspid aortic valve.

Aortic valve sparing procedures are increasingly being used to treat aortic root pathologies. Reimplantation of the aortic valve, first described by Dr Tirone David, is a technically demanding procedure whose long-term results are critically dependent on perfect intraoperative restoration of valve anatomy and function. There exists significant variation in how this procedure is performed by different surgeons, which is likely contributory to the heterogeneity in reported results. We describe a systematic approach to aortic valve reimplantation procedure focusing on key technical aspects.

Abstract 9355: Mitral Valve Disease in Marfan Syndrome Patients Undergoing Aortic Root Replacement

Background: The primary cardiac manifestations of the Marfan syndrome (MFS) include aortic root dilation and mitral valve prolapse (MVP). There are only scant data describing MV disease in MFS patients who undergo aortic root replacement. Methods: We retrospectively studied 239 patients (90 female; mean age 34 y) with MFS enrolled in a prospective multicenter registry. All patients were referred for repair of aortic root aneurysms with either composite graft aortic valve replacement (AVR, n=59) or an aortic valve-sparing procedure (AVS, n=180). MVP and mitral regurgitation (MR) severity was evaluated by echocardiography preoperatively and during follow-up (postoperatively, 6 months, and 1, 2, and 3 years after surgery). The severity of MR was graded as none, trivial (0), mild (1), moderate (2), moderate to severe (3), or severe (4). Preoperative echocardiography identified MVP in 166 (69%) patients without previous MV intervention. Results: Forty-one (25%) of 166 patients with MVP received AVR, and 125 (75%) received AVS, with similar proportions of patients with preoperative MR grade >2 in the two groups ( p =0.7). Thirty-three patients (20%) underwent concomitant MV intervention: 29 repairs and 4 replacements (15 patients (45%) had MR >2, 11 (33%) had MR=2, and 7 had MR ≤1). All patients with MR >2 underwent a MV procedure. One patient following MV repair required MV replacement on postoperative day 16 after developing grade 4 MR. No other patient required MV reintervention during follow-up (mean clinical follow-up, 30±9 months). Echocardiography performed 21±13 (±1 SD) months postoperatively revealed MR >2 in only 1 of 158 patients. There were 1 early death (bleeding) and 2 late deaths (multi-organ failure and unknown cause); all deaths occurred in patients with concomitant MV surgery. Conclusions: MVP is present in 69% of patients with MFS undergoing aortic root replacement; 20% of patients with MVP underwent a concomitant MV procedure. Short-term results suggest that a simultaneous MV procedure in patients with MR >2 is reasonable because operative risk was not increased and subsequent MV procedures were rare. More follow-up is needed to learn if prophylactic MV intervention at the time of aortic surgery might benefit patients with MR ≤2.

Surgical Management of Aortic Root Dilatation with Advanced Aortic Regurgitation: Bentall Operation versus Valve-sparing Procedure

BackgroundAlthough the aortic valve-sparing procedure has gained popularity in recent years, it still remains challenging in patients with advanced aortic regurgitation (AR). We compared the long-term outcomes of the aortic valve-sparing procedure with the Bentall operation in patients with advanced aortic regurgitation secondary to aortic root dilatation.Materials and MethodsA retrospective review of 120 patients who underwent surgery for aortic root dilatation with moderate to severe AR between January 1999 and June 2009 was performed. Forty-eight patients underwent valve-sparing procedures (valve-sparing group), and 72 patients underwent the Bentall procedure (Bentall group). The two groups' overall survival, valve-related complications, and aortic valve function were compared.ResultsThe mean follow-up duration was 4.9±3.1 years. After adjustment, the valve-sparing group had similar risks of death (hazard ratio [HR], 0.61; p=0.45), and valve related complications (HR, 1.27; p=0.66). However, a significant number of patients developed moderate to severe AR in the valve-sparing group at a mean of 4.4±2.5 years of echocardiographic follow-up (p<0.001).ConclusionBoth the Bentall operation and aortic valve-sparing procedure showed comparable long-term clinical results in patients with advanced aortic regurgitation with aortic root dilatation. However, recurrent advanced aortic regurgitation was more frequently observed following valve-sparing procedures.

First clinical results with the new sinus prosthesis used for valve-sparing aortic root replacement

Sinuses of Valsalva are important in assuring the physiological function of the aortic valve. This study evaluates short-term clinical results of the reimplantation technique for aortic valve-sparing root replacement using a new prosthesis with three separate sinuses of Valsalva (sinus prosthesis). Between February 2009 and February 2011, a total of 23 patients (20 m/3 f; mean age 52 ± 14.8 years; range 24-70 years) with aortic root aneurysm underwent aortic valve-sparing procedures according to the David reimplantation technique using the new sinus prosthesis. Eighteen patients had tricuspid and five patients bicuspid aortic valves. All patients received clinical as well as echocardiographic examinations postoperatively (mean 13 ± 9.3 months; 0.3-28 months). There was no death and no reoperation of the aortic valve. At latest follow-up, most patients were in New York Heart Association class I (n = 22; 95.7%). In 95.7% aortic valve regurgitation (AR) was 0 or 1+; one patient had AR 2+. Pressure gradients were between the normal range (mean pressure gradient 4.7 ± 1.9 mmHg). Echocardiographic images demonstrate physiological aortic root dimensions and configuration with three separate sinuses of Valsalva without systolic contact of leaflets to the wall. The new sinus prosthesis provides near normal root geometry and hemodynamics in valve-sparing aortic root replacement using the reimplantation technique, applicable for tricuspid and also bicuspid aortic valves.

Assessment and repair of aortic valve cusp prolapse: Implications for valve-sparing procedures

Cusp prolapse causing aortic insufficiency is associated with unique echocardiographic, clinical, and surgical features. Recognition and appropriate surgical repair of this pathologic condition can not only treat affected patients but also improve results of aortic valve-sparing procedures, for which pre-existing or induced cusp prolapse is an important cause of failure. Of 428 patients undergoing aortic valve repair, 195 (46%) were treated for cusp prolapse, and 111 (57%) of those had trileaflet aortic valve and make up this cohort. Cusp disease was the sole mechanism for aortic insufficiency (isolated group) in 50 patients whereas aortic dilatation was contributory in 61 (associated group). In total, 144 cusps were repaired in 111 patients. Preoperative echocardiograms, intraoperative findings, and clinical and echocardiographic outcomes were reviewed. On preoperative echocardiography, presence of an eccentric aortic insufficiency jet, regardless of severity, had 92% sensitivity and 96% specificity for the detection of single cusp prolapse. A transverse fibrous band was characteristically identified on the prolapsing cusp (sensitivity 57%; specificity 92%), correctly localizing a prolapsing cusp in all cases. Freedom from aortic valve reoperation at 8 years was 100% in the isolated group and 93% ± 5% in the associated group (p = 0.33). Freedom from recurrent aortic insufficiency (>2+) at 5 years was 90% ± 5% in the isolated and 85% ± 8% in the associated group (P = .54). The choice of surgical technique did not affect aortic insufficiency recurrence at follow-up (P = .6). Recognition and repair of isolated aortic cusp prolapse provides durable midterm outcome. An eccentric aortic insufficiency jet and a fibrous band can aid in the diagnosis and localization of cusp prolapse associated with ascending aortic disease and may help to improve results of aortic valve-sparing procedures.

Aortic valve-sparing procedure (David I) as redo operation: Expanding the frontiers?

Objectives: Aortic valve sparing David procedure has gained wide-spread acceptance. In view of good mid-term results, indication for this procedure has been gradually broadened including even re-do operations. The purpose of this study was to assess the results of patients undergoing David procedure as redo operation in our centre.

Aortic Valve Sparing Procedure Combined with Sternal Turnover for Marfan Syndrome

(J Card Surg 2010;25:570-571)

Should root replacement with aortic valve-sparing be offered to patients with bicuspid valves or severe aortic regurgitation?☆

To examine the results of root replacement with aortic valve-sparing in patients with bicuspid aortic valve (BAV) or severe aortic regurgitation (AR). Between 2000 and 2009, 102 patients (mean age 47±17.5 years) underwent aortic valve-sparing procedures for ascending aortic aneurysm or dissection. Patients were assigned to three different groups according to the aortic valve pathology: BAV (n=11), tricuspid aortic valve (TAV) with AR less than severe (n=51), and TAV with severe AR (n=40). Remodelling of the aortic root was performed in 28 (27.5%) patients, reimplantation of the aortic valve in 74 (72.5%) and a concomitant cusp repair in 30 (29.4%). All patients were prospectively studied with annual clinical assessment and echocardiography. The overall actuarial 5-years' survival was 97.8±1.5% without differences between the groups. Actuarial 5-years' freedom from aortic valve-related re-operation was 92.2±3.2% in all patients, 100% in patients with a BAV, 98±1.9% in patients with a TAV and AR less than severe, and 82.7±7.5% in patients with a TAV and severe AR (p=0.07). The overall actuarial freedom from AR, which was more than mild at 5 years was 73.3±7.7%, being significantly (log-rank test: p=0.005) lower for patients presenting with TAV and severe AR (49.9±16.4%). The outcome in terms of survival is excellent for all patients after aortic valve-sparing operations. There is no significant difference in terms of re-operation between patients, who presented with BAV or TAV. Re-operation rates are higher for patients who presented with severe AR but these rates do not reach statistical significance. Hence, root replacement with aortic valve-sparing should be offered even in the presence of a BAV or severe AR.

Valve-Sparing Operation for Aortic Root Aneurysm in Patients with Marfan Syndrome

We report our experience with aortic valve-sparing procedures in patients with Marfan syndrome and aortic root aneurysm. Between August 2003 and July 2007, we performed aortic valve-sparing procedures in 20 patients with aortic root aneurysm resulting from Marfan syndrome. Mean age was 28 +/- 10 years (range, 10 to 57 years), and there were 9 females and 11 males. A reimplantation technique was used in 9 cases, a remodeling technique in 8 and a patch technique in 3 cases. Additional procedures included total aorta replacement in 1 patient, and aortic arch replacement plus stented elephant trunk in 2 patients. The mean follow-up time was 46 +/- 16 months (range, 17 to 64 months). No in-hospital or late death occurred. Reexploration for bleeding was required in one case on postoperative day 1. No valve-related complications occurred during the follow-up period. At the end of follow-up, trivial or no aortic regurgitation was demonstrated in 14 patients, mild in 4 patients, moderate in 1 and severe in 1. Two patients with moderate and severe aortic regurgitation required reoperation. The early and mid-term results of the valve-sparing operations were favorable, and the durability of the preserved valve should encourage use of this technique in patients with Marfan syndrome.

Bicuspid aortic valve: differences in the phenotypic continuum affect the repair technique☆

Bicuspid aortic valve (BAV) may be considered in the context of a phenotypic continuum of the aortic valve configuration, ranging from severe forms of unicuspid valve to rare forms of quadricuspid valve. In this article, we report our results with BAV repair using surgical techniques tailored to the specific features of the BAV phenotypic continuum. Between September 2003 and May 2009, 31 patients with BAV (mean age 49.9+/-17.3 years; five female; 26 male) were prospectively enrolled for aortic valve repair. The surgical strategy was tailored depending on the anatomical and structural characteristic of the BAV continuum: type 1 real bicuspid (five patients), type 2 bicuspid with raphe (24 patients) and type 3 clefted bicuspid (two patients). An echocardiographic analysis was performed preoperatively, postoperatively, at discharge and every 6 months during follow-up. Kaplan-Meier analysis was used to assess the freedom from re-operation. One patient died in the intensive care unit due to aortic wall rupture. After BAV repair there was an increase of leaflet coaptation length (from 2.0+/-0.5 mm to 8.2+/-1.9 mm, p<0.01) and a decrease of the diameters of the virtual basal ring (from 24.6+/-3.6 mm to 21.5+/-0.71 mm, p<0.01), of the aortic root (from 43.12+/-13.23 mm to 31.0+/-3.2 mm, p<0.01) and of the sino-tubular junction (from 40.1+/-6.95 mm to 33.5+/-9.19 mm, p<0.05). The aortic regurgitation echocardiographic grade > or =II was found preoperatively in 30 patients and postoperatively in one patient (p<0.01). Six patients underwent an associated aortic valve-sparing procedure (three re-implantation and three remodelling). Kaplan-Meier analysis showed a 96.6% freedom from re-operation at 5 years, with a single new repair procedure and a 100% freedom from aortic valve replacement. BAV repair provides a feasible therapeutic option in selected patients with good medium-term results. The surgical techniques should be applied after a careful analysis of the BAV considered in the context of the phenotypic continuum.

Aortic cusp repair with Gore-Tex sutures during aortic valve–sparing operations

Aortic root aneurysms often have normal or near normal aortic cusps, but as the sinotubular junction dilates, the coaptation area of the aortic cusps decreases and the mechanical stress increases; the cusps may become thinner and overstretched, and may develop stress fenestration along the commissures or even become detached from the commissural areas. If the free margin of a cusp is elongated, it will prolapse after correction of the dilation of the sinotubular junction during aortic valve-sparing procedures.

Bioprosthetic replacement of the ascending thoracic aorta: what are the options?

Increasing patient age and improved durability of latest generation bioprostheses have stimulated the use of bioprosthetic devices in the setting of ascending aortic replacement as an alternative to mechanical valved conduits or aortic valve-sparing procedures. We performed an English literature review to assess different surgical options that have been described for bioprosthetic replacement of the ascending aorta. Reported options include: (1) composite valved conduits using a stented bioprosthesis; (2) composite valved conduits using a stentless bioprosthesis; (3) total xenopericardial valved conduits. Composite valved grafts using stented bioprostheses offer a safe and durable option for bioprosthetic replacement of the ascending aorta. Other options are of more recent use and await medium-term results.