Aortic Valve-sparing Operations Research Articles

Losartan treatment in adult patients with Marfan syndrome: can we finally COMPARE?

This editorial refers to ‘Losartan reduces aortic dilatation rate in adults with Marfan syndrome: a randomized controlled trial’[†][1], by M. Groenink et al. , on page 3491 Marfan syndrome (MFS)1 is an autosomal dominant connective tissue disorder with a prevalence of ∼1 in 5000 individuals. The syndrome results from mutations in the fibrillin-1-encoding gene ( FBN1 ).2 As >600 mutations in FBN1 have been reported, a great variety of phenotypes are encountered. Hence, MFS is a systemic disorder which may differently affect the cardiovascular, ocular, and musculoskeletal systems. The cardiovascular manifestations, including progressive aortic root dilatation, or aortic dissection or rupture, are the leading cause of mortality in MFS. Myxomatous mitral valve changes may also be present and contribute to an adverse outcome.3 The diagnosis of MFS continues to rely on a clinical assessment, as molecular testing for FBN1 mutations is neither sensitive nor specific. Accordingly, the established Ghent criteria4 use a combination of clinical findings in the various organ systems, the family history, and an FBN1 mutation to make the diagnosis of MFS. Currently, the medical management of MFS patients employs serial cardiac imaging studies to measure aortic dimensions and pharmacological treatment to reduce the haemodynamic stress on the aortic wall. Once the aortic diameter reaches a certain threshold, prophylactic aortic root replacement, either by a composite valve graft repair or by an aortic valve-sparing operation, is undertaken. This strategy has extended the average life expectancy from ∼40 years before the era of open heart surgery, up to ∼70 years in patients with MFS.5 However, in spite of this progress, morbidity in patients with MFS remains high as the great majority will suffer an adverse cardiovascular event, such as surgical repair of the aortic root, fatal or non-fatal aortic dissection, or mitral valve surgery. The pharmacological … [1]: #fn-2

The new 2010 Ghent criteria for the indication to surgical treatment of patients affected by Marfan syndrome. Experience of a single cardiac surgery center

The diagnosis and surgical treatment of patients with Marfan syndrome remain controversial. It is of utmost importance to identify patients at risk for acute aortic events to establish the correct surgical timing and the appropriate surgical treatment. From May 2008 to December 2012, 500 patients were screened at the Marfan Presidium of the Tor Vergata University Hospital of Rome (Italy). Patients were evaluated by a cardiac surgeon, including echocardiographic, orthopedic, ophthalmologic and dental examinations. All patients received genetic counseling, and genetic sampling was performed if appropriate. The diagnosis of Marfan syndrome was confirmed in 146 patients (29.2%). Fifty-four patients (37%) underwent cardiac surgery on the aortic root, 4 patients had surgery on the mitral valve, 13 patients had combined surgery; 11 cases were emergent surgery for acute aortic dissection. Twenty-eight patients (52%) were operated on at our Division: 13 underwent valve-sparing aortic root replacement (David procedure), 1 underwent Yacoub remodeling procedure and 14 underwent Bentall procedure. Following the establishment of the Marfan Center, the David aortic valve-sparing operation was the most frequently performed procedure compared to the previous period of surgical activity (63 vs 22%, p<0.0001). Regular follow-up twice a year may allow to identify patients at risk for acute aortic syndromes. Early surgical treatment is recommended in these patients to achieve optimal results of valve-sparing procedures and life-saving management, especially for patients who live far away from a cardiac surgery center.

Surgical treatment of aortic valve disease

The development of intraoperative transoesophageal echocardiography together with improved understanding of the functional anatomy of the aortic valve have allowed the design of several new conservative procedures, such as aortic valve-sparing operations, to treat patients with aortic root aneurysms or aortic insufficiency. The long-term results of these procedures have been excellent, and >90% of patients are free from reoperation on the aortic valve 10-15 years after surgery. Incompetent bicuspid aortic valves can also be repaired if the cusps are pliable and without calcification. Nevertheless, most patients with aortic valve disease, particularly those with aortic stenosis, need aortic valve replacement. Matching a patient to the type and size of prosthetic aortic valve is difficult, because of the limited durability of bioprosthetic valves and the need for lifelong anticoagulation with mechanical valves. Prosthesis-patient mismatch might not affect survival in most patients, but is a determinant of prognosis in patients with impaired ventricular function. Young adults with aortic stenosis, particularly women during childbearing years, can be treated with the Ross procedure. Finally, poor candidates for surgery who have aortic stenosis can now be treated with catheter-based aortic valve implantation but, in this article, the current status of aortic valve surgery is reviewed.

Total aortic arch replacement with the frozen elephant trunk technique: 10-year follow-up single-centre experience†

Since August 2001, the frozen elephant trunk (FET) technique has been used at our institution to treat degenerative or dissecting aneurysms involving the aortic arch and descending aorta as a potential 'single-stage' procedure. The aim of this study was to review our FET experience and to present the 10-year results. Between August 2001 and January 2012, 131 patients underwent FET implant with three different prostheses: the custom-made Chavan-Haverich (n = 66), the Jotec E-vita (n = 30) and the Vascutek Thoraflex (n = 35) prostheses. Concomitant procedures included aortic valve-sparing operations (David, n = 17) and aortic root replacement (Bentall, n = 25). Patient records and the first postoperative and last available computer tomography (CT) were retrospectively reviewed. Incidence of rethoracotomy for bleeding, stroke, spinal cord injury, prolonged ventilatory support (>96 h) and acute renal failure requiring dialysis were 18, 11, 1, 41 and 16%, respectively. In-hospital mortality was 15%. The mean follow-up was 42 ± 37 (range 1-134 months). At 1, 5 and 10 years, survivals were 82 ± 3, 72 ± 5 and 58 ± 8%, respectively. Freedoms from distal aortic operation were 81 ± 4, 67 ± 5 and 43 ± 13%, respectively. Thirty-six patients underwent 40 distal aortic operations, either open surgical (n = 22, 55%) or endovascular (n = 18, 45%). Chronic aortic dissection was identified as an independent risk factor for distal aortic operation (odds ratio = 3.8; 95% confidence interval 1.5-9.3; P = 0.004). At last CT control, false-lumen thrombosis rates up to 93% were achieved around the stent graft. An FET concept adds to the armament of the surgeon in the treatment of complex and diverse aortic arch pathologies. The preoperative patient risk profile explains the postoperative morbidity and in-hospital mortality. The FET can potentially be still a 'one-stage' procedure in selected patients. However, the extension of FET to patients with extensive aortic aneurysms has led to an increase in second-stage procedures.

Hybrid Endovascular Treatment of an Aortic Root and Thoracoabdominal Aneurysm in a High-Risk Patient With Marfan Syndrome

This report describes the hybrid endovascular treatment of an aortic root dilatation and a thoracoabdominal aneurysm in a high-risk patient with Marfan syndrome. A 50-year-old male, in hemodialysis for polycystic kidney and polycystic liver, was referred to our department for aortic root dilatation of 5 cm and a 6.3-cm thoracoabdominal aneurysm . He already underwent surgical repair of abdominal aortic aneurysm 10 years ago, complicated by pseudoaneurysm of the proximal anastomosis that had been treated in another center, with an endoprosthesis. The patient underwent aortic root replacement, aortic valve sparing operation, and rerouting of the superior mesenteric artery and celiac trunk to the ascending aorta. The thoracoabdominal aneurysm was excluded with an endoprosthesis few days after the surgical step. The 12-month computed tomography scan confirmed the complete exclusion of the thoracoabdominal aneurysm.

ASSA13-08-14 Aortic Valve-Sparing Surgery For Aortic Root Aneurysms: A Six-Year Experience

Objective To evaluate outcomes of aortic valve-sparing operations in patients with aortic root aneurysms (ARA) combined with aortic insufficiency (AI) Methods Since March 2006, in our clinic 264 patients with ascending aortic aneurysms were operated on. 140 patients had ARA combined with aortic valve (AV) disease. 50 patients underwent aortic valve-sparing surgery. We performed 49 Tirone David I (TD-I) and 1 Yacoub procedures. Additional procedures were hemiarch repair (n = 1), mitral valve repair (n = 9) and CABG (n = 6). We assessed hospital and long-term results of aortic valve-sparing operations. Results Total hospital (30-day) mortality was 4% (n = 2). 2(4%) patients required reoperation due to post-operative bleeding. Echocardiography showed none or trivial AI in 38%, mild AI in 54% and moderate AI in 8%. We revealed positive correlation between residual AI and size of aortic annulus, previous AI grade, and size of aortic prosthesis (optimal result in linear aortic graft size 3–5 mm exceeding aortic annulus size). Follow-up was 60% completed. Late mortality was 2% (1 patient). Echocardiography revealed none or trivial AI in 53%, mild AI in 20%, moderate AI in 17% and severe AI in 10% (3 patients). One patient required reoperation 3 years after TD-I operation, the AV replacement with mechanical prosthesis was performed. Another two patients with severe AI are under close surveillance due to normal LV size and NYHA class 1–2. We revealed positive correlation between late AI and residual AI grade, and aortic leaflets coaptation point (optimal result in cases with location of coaptation point at the aortic annulus level or 1–2 mm upper). Conclusions TD-1 aortic valve-sparing reimplantation is optimal method of treatment in patients with ARA, AI and unaltered AV leaflets. Concordance of linear aortic graft size 3–5 mm exceeding aortic annulus and positioning of AV leaflets coaptation point at the level of aortic annulus or 1–2 mm upper are precursors of good result of valve-sparing operation.

Differences in aortic cusp coaptation between the reimplantation and the remodeling techniques of aortic valve–sparing surgery: An in vitro porcine model study

We sought to evaluate the effects of the reimplantation type versus the remodeling type of aortic valve-sparing technique on the geometry of the same aortic root. Fifteen fresh isolated porcine hearts with normal aortic valves and a standard aortoventricular junction size of 23 mm were processed. An aortic valve-sparing replacement was performed by reimplanting the native aortic root inside a 28-mm Valsalva graft (Vascutek Ltd, Renfrewshire, UK). Hearts were subsequently implanted with instruments in a test circuit, and the aortic roots were pressurized at a fixed pressure of 100 mm Hg. Diameters of the aortoventricular junction, of the sinuses, and of the sinotubular junction, as well as effective height and coaptation height of aortic valve leaflets, were measured by echography. Transition from the reimplantation to the remodeling configuration was then achieved by longitudinally cutting the skirt of the graft from the annulus to the top of each commissure. The same measurements were then repeated. After transition from the reimplantation to the remodeling configuration, significant increases in the sizes of the aortoventricular junction and of the sinuses were observed. Effective height and coaptation height significantly decreased, and the rounded cross-sectional profile of the aortic valve leaflets flattened. In the same aortic root, transition from the reimplantation to the remodeling configuration of aortic valve-sparing surgery results in a significant increase in aortic root sizes and in a significant reduction of effective height and coaptation height, suggesting a less satisfactory result.

Aortic valve sparing operations in aortic root aneurysms: remodeling or reimplantation?

Over the past two decades, there has been a significant paradigm shift towards aortic valve sparing (AVS) operations over the more traditional method of prosthetic replacement for suitable aortic pathologies. Such operations, by virtue of preserving the patient’s native aortic valvular anatomy, carry numerous benefits, most notably the obviation of life-long anticoagulation medication and the reduced need for reoperation when compared to mechanical and biosynthetic valves. Two main valve-sparing operations have dominated modern surgical practice: the David ‘reimplantation’ technique, whereby the entire aortic valve is preserved and securely sewn within a synthetic tube graft (1), and the Yacoub ‘remodeling’ technique, which replaces all three sinuses by means of a triple-tongue-shaped graft (2). Whether one technique is superior than the other has polarised the surgical community. The present article summarises the recent evidence comparing remodelling and reimplantation techniques (3).

Aortic valve sparing operations: outcomes at 20 years.

Aortic valve sparing operations have now been performed for over two decades in our institution (1). There are basically 2 types of aortic valve sparing operations: reimplantation of the aortic valve and remodeling of the aortic root (2,3). This presentation summarizes our clinical experience with the original procedures as we have described them (2,3) (video 1). Video 1 Aortic valve sparing operations: outcomes at 20 years

Graft sizing for aortic valve sparing surgery.

Valve-sparing aortic root replacement has been demonstrated as an effective technique not only for the treatment of aortic root pathology, but also for facilitating repair of regurgitant aortic valves. Graft sizing is an important step for valve sparing procedures and sizing methods have generated significant controversy among surgeons. The purpose of this manuscript is to review the fundamentals of aortic root anatomy and valve function as they pertain to graft sizing, to explore the existing methods for graft sizing, and to discuss implications of inappropriate sizing on the outcome of the procedure.

Longterm results of aortic valve-sparing operations in patients with aortic valve insufficiency and aortic root aneurysm

Longterm results of aortic valve-sparing operations in patients with aortic valve insufficiency and aortic root aneurysm

大動脈弁輪拡張をきたした8歳，男児の Loeys-Dietz 症候群に対して自己弁温存大動脈基部置換術を施行した1例

大動脈弁輪拡張をきたした8歳，男児の Loeys-Dietz 症候群に対して自己弁温存大動脈基部置換術を施行した1例

A simple technique of commissural reconstruction in aortic valve–sparing surgery

From the Divisions of Cardiothoracic and Vascular Surgery, Universit e Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication April 28, 2012; revisions received Oct 4, 2012; accepted for publication Nov 6, 2012; available ahead of print Dec 10, 2012. Address for reprints: Gebrine ElKhoury, MD, Service de Chirurgie Cardiovasculaire et Thoracique, Cliniques Universitaires Saint-Luc UCL, Ave Hippocrate 10, Brussels B-1200, Belgium (E-mail: gebrine.elkhoury@uclouvain.be). J Thorac Cardiovasc Surg 2013;145:882-6 0022-5223/$36.00 Copyright 2013 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2012.11.021

Aortic Valve Sparing Operations: A Review

Aortic valve sparing operations were developed to preserve the native aortic valve during surgery for aortic root aneurysm as well as surgery for ascending aortic aneurysms with associated aortic insufficiency. There are basically two types of aortic valve sparing oprations: remodeling of the aortic root and reimplantation of the aortic valve. These operations have been performed for over two decades and the clinical outcomes have been excellent in experienced hands. Although remodeling of the aortic root is physiologically superior to reimplantation of the aortic valve, long-term follow-up suggests that the latter is associated with lower risk of developing aortic insufficiency. Failure of remodeling of the aortic root is often due to dilatation of the aortic annulus. Thus, this type of aortic valve sparing should be reserved for older patients with ascending aortic aneurysm and normal aortic annulus whereas reimplantation of the aortic valve is more appropriate for young patients with inherited disorders that cause aortic root aneurysms. This article summarizes the published experience with these two operations. They are no longer experimental procedures and should be part of the surgical armamentarium to treat patients with aortic root aneurysm and ascending aortic aneurysms with associated aortic insufficiency.

Early and Late Results of Graft Replacement for Dissecting Aneurysm of Thoracoabdominal Aorta in Patients With Marfan Syndrome

When treating dissecting aneurysm of the thoracoabdominal aorta surgically in patients with Marfan syndrome, we have usually performed graft replacement- including the entire thoracoabdominal aorta and reconstruction of all visceral branches, even if dilatation is mild in some segments-to avoid further aortic operations in the follow-up period. From October 1999 through July 2011, 20 consecutive patients with Marfan syndrome underwent repair of dissecting aneurysm of the thoracoabdominal aorta (median age, 45 years; range, 19-65 years). All patients underwent surgical intervention with cerebrospinal fluid (CSF) drainage and distal aortic and selective organ perfusion. Deep hypothermia was used in 13 patients for spinal cord protection. No in-hospital mortality was observed. One patient had temporary spinal cord ischemia but was fully recovered by discharge. Other complications included exploration for bleeding (n=1), prolonged ventilation (n=1), and graft infection (n=1). At a mean follow-up of 54 months (range, 9-129 months), 1 patient had died of interstitial pneumonia at 38 months postoperatively. Survival at 8% years was 91.2±9.0%. Two patients required additional aortic procedures (total arch replacement and aortic valve-sparing surgery). Actuarial rate of freedom from aortic operations at 8 years was 83.9%±10.5%, but no patient needed required repeated thoracotomy for an aortic procedure. Neither false nor patch aneurysms were observed using computed tomography (CT) during follow-up surveillance. Graft replacement for dissecting aneurysm of the thoracoabdominal aorta in Marfan syndrome offers good early and long-term results. We believe total aortic replacement including the entire thoracoabdominal aorta and reconstruction of all visceral arteries should be recommended for selected patients with Marfan syndrome.

Total aortic arch replacement with a novel four-branched frozen elephant trunk graft: first-in-man results†

The combined disease of the aortic arch and the proximal descending aorta remains a surgical challenge. With the 'frozen elephant technique', the ascending aorta, along with the aortic arch, is replaced conventionally and an endovascular stent graft is placed into the descending aorta in the antegrade manner through the open aortic arch, thereby potentially allowing for a 'single-stage' operation. The purpose of this study was to assess the feasibility of a novel four-branched hybrid graft (Vascutek, Scotland). From April 2010 to August 2011, 34 patients (25 males, age 60 ± 14 years) were operated on [14 aneurysms, 20 dissections (18 acute)]. Ten of these patients had undergone previous cardiac operations. The collapsed endoprosthesis was deployed in the descending aorta through the opened aortic arch. A sewing collar between the graft segments simplified the 'distal' anastomosis. The four-branched graft segment allowed the replacement of the aortic arch and supra-aortic vessels individually. Concomitant procedures were performed if necessary. There were three deaths within the 30 postoperative days. All of them were of AADA patients. The mean cardiopulmonary bypass time was 254 ± 53 min, aortic cross clamp time was 148 ± 48 min and circulatory arrest time was 48 ± 22 min. Aortic valve-sparing root surgery was performed in 12 patients, Bentall procedure in four, CABG in three and mitral valve repair in two. In one patient, a secondary endovascular extension of the stent graft was necessary to reach the landing zone. In all others, postoperative CT-Scans confirmed the desired results. The graft adds to the 'frozen elephant trunk' concept for treating the arch and proximal descending aorta. Early experience demonstrates an excellent 30-day survival. Combining the frozen elephant with a four-branched arch graft increases the armament of the surgeon in the treatment of complex and diverse aortic arch pathology.

Aortic valve sparing operations versus composite graft implantation in acute aortic dissections

ObjectivesType A acute aortic dissection is life threatening disease requiring urgent operation. This type of the operation is often a subject of discussion. In our study we present our first experience with two different types of operations with and without preservation of the aortic valve. Patients and methodsFrom January 2009 to December 2011 fifty six patients underwent the operation due to the acute aortic dissection type A. Ascending aorta was replaced in 32 cases and more complex operation was performed in 24 patients due to the simultaneous severe aortic root damage by dissection (study group). In eleven patients (group A) replacement of aortic valve, aortic root and ascending aorta by composite graft (modified Bentall procedure) was performed and in 13 patients (group B) valve sparing operation (reimplantation according to David) was carried out. ResultsThere were no significant differences between the groups in preoperative variables. The only significant difference was mean duration of hospitalisation; 26.7±13.7 days in group A and 16.4±7.7 days in group B. Hospital mortality was 18.2% (n=2) after Bentall procedure, no patient died in group B. There were no or minimal aortic regurgitation in all patients of group B on echocardiography before discharge. The mean follow-up was 17.6 months (3.6–35.8) in group A, and 23.5 months (7.9–38.9) in group B. During this period of time three patients in group A and one patient in group B died; two of cardiac and two of noncardiac reasons. In group B no patient had aortic regurgitation higher than grade I and all patients were in New York Heart Association functional class I or II. ConclusionAortic valve reimplantation in patients with type A dissection can be performed with excellent early and mid-term results. In the hands of an experienced surgeon it represents a good alternative to the Bentall operation. Its main advantage is the preservation of the native valve without the necessity of anticoagulation therapy.

The outcome after aortic valve-sparing (David) operation in 179 patients: a single-centre experience

The David aortic valve-sparing reimplantation (AVr-D) operation is increasingly being used in patients with aortic root aneurysmal disease and pliable aortic cusps. The objective of this study was to assess our early and medium-term outcomes with the AVr-D operation. Between 2003 and 2011, a total of 179 patients underwent AVr-D procedures. The mean patient age was 49.7 ± 15.1 years, and 23.5% (n = 42) were females. Marfan syndrome was present in 17.3% of patients (n = 31), and acute Type A aortic dissection in 15.6% (n = 28). Clinical follow-up was 100% complete and was 1.8 ± 1.6 years (0 days to 7.5 years) long. Echocardiographic follow-up was performed 2.2 ± 1.5 years (0 days to 7.5 years) postoperatively and was 77% complete. Early mortality was 1.1% (n = 2), with both deaths occurring in patients with Type A dissection. Pre-discharge echocardiography revealed no patients with >2+ aortic insufficiency (AI), 19.6% of patients (n = 34) with 1+ or 2+ AI and 80.4% of patients (n = 145) with trace or no AI. Left ventricular end-diastolic diameters decreased significantly from 5.6 ± 0.9 to 5.1 ± 0.8 cm early postoperatively (P < 0.01). Transvalvular maximum gradients were similar before discharge and at last follow-up (10.6 ± 5.4 vs. 10.0 ± 8.2 mmHg, P = 0.4). AI grade increased significantly over time (0.3 ± 0.4 before discharge vs. 0.5 ± 0.6 at follow-up, P = 0.01), but remained less than moderate in 93.6% of patients. Four patients required aortic valve re-replacement during follow-up, two due to early endocarditis and two due to non-coronary leaflet prolapse in Marfan patients. Five-year freedom from aortic valve reoperation was 95.9 ± 2.0%. AVr-D is associated with a low mortality and morbidity rate, even in patients with Type A aortic dissection. Although a slightly higher rate of recurrent AI may be present in patients with Marfan syndrome, freedom from recurrent AI and reoperation remains excellent during medium-term follow-up. The David operation should be considered the gold standard for patients with proximal aortic root pathology (aneurysm or dissection) and pliable aortic cusps.

Treatment of ascending aortic aneurysms by different surgical techniques: Comparison of early and long-term results

Objectives: The proper treatment of aneurysm of the ascending aorta is still under debate. Here we compare the early and late outcome of patients undergoing composite replacement (CR), supracomissural aortic replacement (SCR) and aortic valve sparing operation (AVS) for treatment of aneurysm of the ascending aorta.

Aortic Valve-Sparing Operation after Correction of Heart Displacement due to Pectus Excavatum Using Nuss Procedure in a Marfan Syndrome Patient

Cardiovascular surgery in the setting of chest wall deformities is a clinical challenge. Pectus excavatum, for example, can cause heart displacement to the left thoracic cavity, following the poor operative field. This report highlights a case in which a successful aortic valve-sparing operation via conventional median sternotomy after correction of the heart displacement due to pectus excavatum using Nuss procedure in Marfan syndrome. This technique can be one surgical option in Marfan syndrome patients with pectus excavatum and thoracic aortic aneurysm under close follow up.