Valve-sparing Research Articles

Incidence of branch pulmonary artery stenosis requiring intervention based on surgical repair type for tetralogy of Fallot

BackgroundTetralogy of Fallot is a common form of cyanotic congenital heart disease. The right ventricular outflow tract obstruction and pulmonary stenosis are typically repaired using either a transannular patch or valve sparing repair. Following repair, one recognized complication is branch pulmonary artery stenosis. ObjectiveThis study sought to evaluate if there was a higher incidence of branch pulmonary artery stenosis requiring intervention in patients with tetralogy of Fallot who underwent transannular patch repair as compared to valve sparing repair. MethodsIn this retrospective study, 62 pediatric patients with tetralogy of Fallot underwent surgical repair at our institution between January 1, 2006 and August 2, 2016. Data, including echocardiographic measurements, surgical repair details, and post-operative follow up was recorded. Statistical analysis was performed, including chi-square test, Student t-test, multiple logistic regression, and Kaplan-Meier analysis. ResultsMedian length of follow up was 7.3 years (IQR 4.7–9.1). Of the 62 patients, 8 (13 %) developed branch pulmonary artery stenosis requiring intervention. A significantly higher incidence was seen in the transannular patch group (n = 7, 37 %) compared to the valve sparing repair patients (n = 1, 2 %) (p = 0.0002). Most patients required intervention within one year following repair. The effect of repair type persisted after controlling for multiple potential confounding variables, including Blalock-Taussig shunt placement and patch augmentation of the branch pulmonary arteries. ConclusionThere is a significantly higher incidence of branch pulmonary artery stenosis requiring intervention in patients with classic tetralogy of Fallot who underwent transannular patch repair as compared to valve sparing repair.

Straightforward Contemporary Step-by-Step Approach to Aortic Root Replacement With Valve-Sparing Tricuspid Aortic Valve Repair

Valve-sparing aortic root replacement (VSARR) has become an appealing choice for replacing an aneurysmal root when the patient's anatomic characteristics are favorable, especially in patients with heritable thoracic aortic disease. It is a technically challenging procedure, and the learning curve is considerable. This approach's chief advantages are that the patient's own aortic valve apparatus is preserved, the repair (in expert hands) is durable, and it avoids the need for lifelong anticoagulation associated with the mechanical valves in the aortic root prostheses. In this report, we provide a step-by-step approach for aortic root replacement in patients with a tricuspid aortic valve suitable for VSARR. Valve-sparing aortic root replacement (VSARR) has become an appealing choice for replacing an aneurysmal root when the patient's anatomic characteristics are favorable, especially in patients with heritable thoracic aortic disease. It is a technically challenging procedure, and the learning curve is considerable. This approach's chief advantages are that the patient's own aortic valve apparatus is preserved, the repair (in expert hands) is durable, and it avoids the need for lifelong anticoagulation associated with the mechanical valves in the aortic root prostheses. In this report, we provide a step-by-step approach for aortic root replacement in patients with a tricuspid aortic valve suitable for VSARR. Commentary on Baylor's Technique of Aortic Valve ReimplantationOperative Techniques in Thoracic and Cardiovascular SurgeryPreviewDoctors Preventza, Huu, and Coselli described the technique they use to do reimplantation of the aortic valve to treat aortic root aneurysms.1 I will limit my comments to areas that I disagree with what was written in their manuscript. Full-Text PDF

Comparison of hemodynamics and root configurations between remodeling and reimplantation methods for valve-sparing aortic root replacement: a pulsatile flow study

PurposeTo compare the characteristics of reimplantation (RI) using grafts with sinuses and remodeling (RM) with/without external suture annuloplasty using a pulsatile flow simulator.MethodsPorcine aortic roots were obtained from an abattoir, and six models of RM and RI with sinuses were prepared. External suture annuloplasty (ESA) was performed in the RM models to decrease the root diameter to 22 mm (RM-AP22) and 18 mm (RM-AP18). Valve models were tested at mean pulsatile flow and aortic pressure of 5.0 L/min and 120/80 (100) mmHg, respectively, at 70 beats/min. The forward flow, regurgitation, leakage, backflow rates, valve-closing time, and mean and peak pressure gradient (p-PG) were evaluated. Root configurations were examined using micro-computed tomography (micro-CT).ResultsThe backflow rate was larger in the RM models than in the RI models (RI: 8.56% ± 0.38% vs. RM: 12.64% ± 0.79%; p < 0.01). The RM-AP and RI models were comparable in terms of the forward flow, regurgitation, backflow rates, p-PG, and valve-closing time. The analysis using a micro-CT showed a larger dilatation of the sinus of the Valsalva in the RM groups than in the RI group (Valsalva: RI, 26.55 ± 0.40 mm vs. RM-AP22, 31.22 ± 0.55 mm [p < 0.05]; RM-AP18, 31.05 ± 0.85 mm [p < 0.05]).ConclusionsRM with ESA and RI with neo-sinuses showed comparable hemodynamics. ESA to RM reduced regurgitation.

Abstract 11748: Prophylactic Aortic Arch Replacement in Patients With Loeys-Dietz Syndrome: Surgical Outcomes and Molecular Rationale

Introduction: Loeys-Dietz syndrome (LDS) patients typically develop focal aortic root aneurysm but have substantial risk of distal aortic events (arch aneurysm and type B dissection) after root replacement. We offer prophylactic arch replacement to LDS patients of all genotypes undergoing elective valve-sparing aortic root replacement (VSARR) to prevent late aortic events. We hypothesized that non-dilated LDS aortic arch tissue demonstrates ongoing deterioration at the time of VSARR. Methods: Aortic tissue was anatomically segmented (root, ascending, arch) then examined via histology and single-cell RNA sequencing (‘scRNAseq’, n=4 patients) to comprehensively profile cellular phenotypes. Results: LDS patients (n=8, mean age 37.9 years, 87.5% male) had root aneurysm (mean 45.1 ± 8.9mm) without ascending (35.1± 7.8mm) or arch dilation (28.7 ± 2.8mm) and underwent concurrent VSARR and branched graft total arch replacement. There were no perioperative deaths or strokes and no distal aortic events or reoperations after median 1.26 years follow-up. Histologically, elastin fragmentation and collagen deposition were detectable in each aortic segment (n=4). scRNAseq identified a continuum of smooth muscle cell (SMC) phenotype modulation associated with progressively reduced contractile gene expression. Pathway analysis of 260 genes enriched during SMC modulation identified heightened integrin signaling, transforming growth factor-beta-responsiveness, cell adhesion, and extracellular matrix remodeling. Histologic confirmation using RNA probes specific for modulated SMCs (TGF-beta responsive gene SERPINE1 and glycoprotein TNFRSF11B ) identified these cells in the tunica media layer of each aortic segment, with greatest density in the root aneurysm but extending to the arch. In age-matched donor aortas, TNFRSF11B + cells were restricted to the atherosclerotic tunica intima, confirming specificity of medial SMC modulation in aneurysm. Conclusions: Total arch replacement during elective VSARR is feasible without substantial morbidity. In LDS patients with root aneurysm, matrix deterioration and SMC phenotype modulation are present in the non-dilated aortic arch, providing molecular rationale for aggressive arch replacement.

Abstract 11145: Biomechanical Engineering Analysis of Leaflet Kinematics and Native Coronary Flow After Valve-Sparing Aortic Root Replacement Using Four Graft Configurations

Introduction: Different ex vivo root biomechanics after valve-sparing aortic root replacement (VSARR) using several graft configurations have been described. The impact of graft choice on each cusp’s kinematics and native coronary flow remains unclear. The objective was to analyze valve kinematics and coronary flow after VSARR using 4 graft configurations in a 3D-printed heart simulator ( Fig A ).[YZ1] Methods: Porcine aortic roots with coronary arteries were explanted (n = 5). Native roots served as controls ( Fig B ). Each sample underwent VSARR using straight graft (SG), Valsalva graft (VG), anti-commissural plication (ACP), and Stanford modification (SMOD) in a random order ( Fig C-G ). Hemodynamics and videometric data were analyzed ( Fig H, I ). Results: SG showed the lowest regurgitant fraction (2.8 ± 1.5 %) compared to control (6.3 ± 3.9 %, p = .0002), VG (12.2 ± 3.6 %, p = .002), ACP (12.9 ± 1.3 %, p = .001), and SMOD (12.2 ± 3.0 %, p = .001, Fig J, K ). The left coronary artery flow was higher in SG (0.68 ± 0.16 L/min) compared to VG (0.55 ± 0.22 L/min, p = 0.05) and SMOD (0.51 ± 0.23 L/min, p = 0.05, Fig L ). The right coronary artery flow was higher in SG (0.20 ± 0.10 L/min) compared to VG (0.07 ± 0.04 L/min, p = 0.04) and SMOD (0.08 ± 0.05 L/min, p = 0.04, Fig M ). SG (26.5 ± 17.6 cm/s) compared to VG (48.3 ± 19.0 cm/s, p = .001) and SMOD (39.5 ± 10.1 cm/s, p = .05) showed lower rapid opening velocity in the left coronary cusp (LCC). SG (8.1 ± 6.2 cm/s) compared to VG (15.0 ± 10.6 cm/s, p = .04) showed lower rapid closing velocity in the right coronary cusp. The VG (17.7 ± 9.7 Hz) had higher flutter frequency in the LCC compared to control (11.9 ± 4.1 Hz, p = .02). The SG (11.9 ± 4.5 dB/Hz) compared to ACP (16.4 ± 4.7 dB/Hz, p = .01) showed lower flutter power in the LCC. Conclusions: Compared to other configurations, SG had the most optimal hemodynamics, native coronary flow, and leaflet kinematics. Further in vivo validation studies should be performed to evaluate flow dynamics in the root and assess for clinical applicability.

Abstract 12899: A Patient-Specific Fluid-Structure Interaction-Based Approach to Improve Surgical Predictability in Bicuspid Aortic Valve Patients

Introduction: BAV is the most common congenital heart defect affecting ~1.4% of the population. It also brings with it an increased risk of aortopathy, including coarctation, aneurysm, dissection, and accelerated calcification with either stenosis or aortic insufficiency. Quantifying BAV function, altered blood flow, and corresponding hemodynamic forces and their impact on accelerated BAV deterioration improves BAV diagnosis. Predicting how these parameters improve post-interventions may improve surgical predictability and long-term outcome. Methods: A patient-specific modeling protocol based on MRI-based patient data and strongly coupled fluid-structure interaction (FSI) technique was developed to evaluate BAV. Flow via left ventricle, BAV, ascending and descending aorta (Fig A-B) was simulated to obtain biomechanical insights near valve vicinity and study its effects downstream. Diseased anatomy was simulated, and biomechanics compared with virtual interventions that included 1) surgical aortic valve replacement (SAVR), 2) valve sparing root replacement (VSRR) with a sinus graft, and 3) VSRR without sinus graft (Fig C). Results: Our model predictions showed that viscous dissipation (or energy loss) was the greatest in the diseased BAV indicating a high energy loss that substantially reduced post-virtual interventions. Specifically, energy loss reduced by 2.55-, 1.65-, 2.52- folds for SAVR, VSRR-sinus, and VSRR+sinus respectively at peak-systole (Fig. E-H). Interestingly, while SAVR produced the largest orifice area (OA), OA of BAV marginally reduced post VSRR during peak-systole (Fig. I) Conclusions: These studies provide insights into BAV dynamics and may help determine the optimal interventions for a patient. These insights may help improve diagnosis and surgical predictability, optimize treatment, and help with clinical decision making for BAV patients at risk.

The impact of concomitant mitral valve intervention on outcomes of aortic root replacement.

To investigate the impact of concomitant mitral valve repair (MVr) or replacement (MVR) at the time of aortic root replacement (ARR). We queried our aortic database for consecutive patients undergoing ARR in combination with MVr or MVR from 1997 to 2021. Patients undergoing valve sparing root replacement (VSRR) were excluded. We compared operative mortality (OM) and a composite of major adverse events (MAE) in those undergoing CVG both with (Group 2) and without a concomitant MV procedure (Group 1). We also analyzed outcomes between patients undergoing MV repair versus MV replacement. Sixty-one patients underwent ARR with concomitant MVr (29/47.5%) or MVR (32/52.5%). Compared to patients in Group 2 (n = 955), those in Group 1 presented with worse NYHA class, lower ejection fraction, higher rate of connective tissue disease, and underwent more frequently urgent/emergent procedures. Group 1 had higher incidence of postoperative MAE (8/61(13%) vs 51/955(5%), p = .03). There was no difference in operative mortality between the two groups (0/61(0%)vs. 3/955(0.3%), p = 1). Compared to the ARR + MVR subgroup, the ARR + MVr subgroup had higher incidence of postoperative MAE (5/29(17.2%) vs. 3/32(9.4%), p = 0.02). Multivariate analysis identified MVr (OR 2.78, 95% confidence interval [CI] [1.03;7.48], p = 0.04) as an independent predictor of MAE. Operative mortality remained low in both groups. The addition of MVR/MVr to composite valve-graft replacement of the aortic root does not increase OM in experienced hands. The incidence of MAEs was higher in those undergoing MVr but may be a reflection of greater preoperative comorbidity rather than issues related to a more complex operation.

Valve-sparing David procedure via minimally invasive access does not compromise outcome

ObjectivesAortic valve sparing-aortic root replacement (David procedure) has not been routinely performed via minimally invasive access due to its complexity. We compared our results of elective David procedure via minimally invasive access to those via a full sternotomy.MethodsBetween 1993 and 2019, a total of 732 patients underwent a valve sparing root replacement (David) procedure. Out of these, 220 patients underwent elective David-I procedure (isolated) without any other concomitant procedures at our center. Patients were assigned to either group A (n = 42, mini-access) or group B (n = 178, full sternotomy).ResultsCardiopulmonary bypass time were 188.5 ± 35.4 min in group A and 149.0 (135.5–167.5) in group B (p < 0.001). Aortic cross-clamp time were 126.2 ± 27.2 min in group A and 110.0 (97.0–126.0) in group B (p < 0.001). Post-operative echocardiography showed aortic insufficiency ≤ I° in 41 (100%) patients of group A and 155 (95%) of group B. In-hospital mortality was 2.4% (n = 1) in group A and 0% (n = 0) in group B (p = 0.191). Perioperative stroke occurred in 1 (2.4%) patient of group A and 2 (1.1%) patients of group B (p = 0.483). Reexploration for bleeding was necessary in 4 (9.5%) patients of group A and 7 (3.9%) of group B (p = 0.232). Follow-up was complete for 98% of all patients. The 1-, 2-, 4-, and 6-year survival rates were: 97, 97, 97, and 97%, in group A (mini-access) and 99, 96, 95, and 92% in group B (full sternotomy), respectively. The rates for freedom from valve-related re-operation at 1, 2, 4, and 6 years after initial surgery were: 97, 95, 95, and 84% in group A and 97, 95, 91, and 90% in group B, respectively.ConclusionEarly post-operative results after David procedure via minimally invasive access are comparable to conventional full sternotomy. Meticulous attention to hemostasis is a critical factor during minimally access David procedures. Long-term outcome including the durability of the reimplanted aortic valve seems to be comparable, too.

Aortic flow patterns by 4D flow CMR in Marfan and Loeys-Dietz patients before and after valve sparing aortic root replacement: a comparison with healthy volunteers

Abstract Introduction Abnormal aortic flow patterns in patients with a connective tissue disorder (CTD), such as Marfan or Loeys-Dietz syndrome, may contribute to aortic root dilation [1,2]. Valve sparing aortic root replacement, which is effective in reducing the risk of aortic dissection in case of severe dilation, may also normalize flow patterns beyond the replaced aorta and potentially slow its progressive aortic dilation. Purpose To assess aortic flow dynamics in patients with a CTD by 4D flow cardiovascular magnetic resonance (CMR) before and after valve sparing aortic root replacement, and to compare the results with those of healthy volunteers (HV). Methods Patients with Marfan or Loeys-Dietz syndrome underwent two non-contrast enhanced 4D flow CMR, one before and another after undergoing valve sparing aortic root replacement. Healthy volunteers matched for age, sex and BSA were also included for comparison. Maximum velocity, in-plane rotational flow (IRF), systolic flow reversal ratio (SFRR) and wall shear stress (WSS) magnitude and its axial and circumferential components were obtained at 24 planes covering the thoracic aorta from the sinotubular junction to the descending aorta at the diaphragmatic level [3–5]. Results Sixteen patients and 21 healthy volunteers were included. Demographic and clinical data is presented in Table. The mean time between the CMR prior and posterior to surgery was 15 months. Compared to HV, patients with CTD before intervention presented lower maximum velocity at the proximal ascending aorta (Fig. 1A), lower IRF and circumferential WSS at the arch and the proximal descending aorta (Fig. 1B and F), lower magnitude and axial WSS at the proximal ascending and descending aorta (Fig. 1E and D), and increased SFRR at the proximal descending aorta (Fig. 1C). The intervention completely restored maximum velocity and partially-restored physiological helical flow and circumferential WSS, but barely improved axial WSS and SFRR. Conclusion Valve sparing aortic root replacement in patients with Marfan or Loeys-Dietz syndrome partially restore to physiological level both in-plane rotational flow and circumferential wall shear stress in the descending aorta. This flow normalization may contribute to prevent progressive dilation after the surgery. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III (Spain) (PI17/00381)Spanish Society of Cardiology (SEC/FEC-INV-CLI 20/015)

Valve-sparing aortic root replacement in patients with Marfan syndrome: a systematic review

Aim. To analyze the literature about the results of valve-sparing operations in aortic root surgery in patients with Marfan syndrome. Methods. A comprehensive search included four databases: Pubmed, Embase, Cochrane Library, and Web of Science. Articles for analysis were selected according to the methods presented in the PRISMA 2020 guidelines. Results. The final systematic review included 19 studies and 4 meta-analyses. The findings showed that 30-day and hospital mortality rates did not exceed 2.08%. The incidence of thromboembolism over a 15-year period was 4.1 ± 2.0%. The mean rate of infective endocarditis was 0.25%. Freedom from severe aortic insufficiency 8 years after surgery was 95.2 ± 3.3%. Freedom from reoperation at 8 and 10 years was 97%. Long-term mortality was ≤ 10.57%. The 5-, 10-year survival rates were 95.4 and 84.2% respectively.Conclusion. Valve-sparing operations are more beneficial than valved conduits in patients with Marfan syndrome in the short and long-term periods. Thromboembolism, endocarditis, and bleeding were significantly more common in patients with valved conduits in the long-term period. Received 7 February 2022. Revised 16 May 2022. Accepted 18 May 2022. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Contribution of the authorsConception and study design: A.U. Normuradov, R.M. lsaev, M.A. Soborov, A.I. Ropova, V.D. ReiterDrafting the article: A.U. Normuradov, R.M. lsaev, A.I. Ropova, V.D. ReiterCritical revision of the article: A.U. Normuradov, R.M. lsaevFinal approval of the version to be published: R.N. Komarov, A.U. Normuradov, R.M. Isaev, M.A. Soborov, A.I. Ropova, V.D. Reiter

AORTLANTIC: French registry of aortic valve-sparing root replacement, preliminary multicentre results from western France.

OBJECTIVESAortic root aneurysms often affect younger patients in whom valve-sparing surgery is challenging. Among current techniques, aortic valve-sparing root replacement described by Tirone David has shown encouraging results. The AORTLANTIC registry was instituted for a multicentre long-term evaluation of this procedure. The current initial study evaluates the hospital outcomes of the procedure.METHODSThis is a retrospective study of patients operated between 1 January 2004 and 31 December 2020 in 6 hospitals in western France. All study data were recorded in the national digital database of the French Society of Cardiac Surgery: EPICARD.RESULTSA total of 524 consecutive patients with a mean age of 53 (15.1) years underwent surgery. 13% (n = 68) of patients presented with acute aortic dissection, 16.5% (n = 86) had associated connective tissue pathology and 7.3% (n = 37) had bicuspid aortic valves. Preoperative aortic regurgitation (AR) ≥2/4 was present in 65.3% (n = 341) of patients. Aortic valvuloplasty was required in 18.6% (n = 95) of patients. At discharge, 92.8% (n = 461) of patients had no or 1/4 AR. The stroke rate was 1.9% (n = 10). Intra-hospital mortality was 1.9% (n = 10).CONCLUSIONSThe AORTLANTIC registry includes 6 centres in western France with >500 patients. Despite numerous complex cases (acute aortic dissections, bicuspid aortic valves, preoperative AR), aortic valve-sparing root replacement has a low intra-hospital mortality. The initial encouraging results of this multicentre study warrant further long-term evaluation by future studies.

Tricuspidization technique with reimplantation for a bicuspid aortic valve: a case report

BackgroundBicuspid aortic valve (BAV) is the most frequent congenital cardiac anomaly. We report a successful case in which the tricuspidization technique with valve-sparing aortic root replacement was used for BAV with severe aortic regurgitation.Case presentationA 22-year-old man was admitted for progressively worsening aortic regurgitation due to a congenital BAV. Preoperative examination revealed annuloaortic ectasia and left ventricular dilatation with worsening ejection fraction. The right and left coronary cusps of the aortic valve were fused with severe prolapse. During surgery, as there was no obvious calcification or degeneration of each coronary cusp and the commissural orientation was nearly 120°, we judged that tricuspid reconstruction was preferable. Neo-left and right commissure reconstruction by raphe suspension and free margin resuspension of the non-coronary cusp were performed with valve-sparing aortic root replacement (reimplantation technique). Postoperatively, the coaptation height of each coronary cusp was remarkably increased, and aortic regurgitation and left ventricular function improved. The patient was discharged 12 days postoperatively without any complications.ConclusionsThe tricuspidization technique with valve-sparing aortic root replacement was a valuable strategy for repairing the bicuspid valve (type I) with severe aortic valve regurgitation. Although we believe that our tricuspidization technique has the potential for good durability, further experience is warranted to confirm the safety and efficacy of this technique.

Fifteen-year experience with the Tirone David procedure in bicuspid aortic valve: A safe option.

We evaluated shortand midterm outcomes with use of aortic valve-sparing root replacement to treat bicuspid aortic valves (BAVs). From December 2007 to January 2022, all patients with BAVs who underwent aortic root replacement using Tirone's procedure were included. This study based on department database information for retrospective and follow-up data. Among 51 adults undergoing aortic root replacement using Tirone's procedure, the mean age was 47.4 ± 12.5 years, and most were men (92.2%). Three presented with a dysmorphic syndrome and one had Marfan's syndrome. All patients were alive at 30 days, and as of January 2022, 45 were alive, two were lost to follow-up, and there were four noncardiac deaths. Two patients had infectious endocarditis and needed a Bentall's procedure. One patient had a double biologic valve replacement in the context of severe mitral insufficiency with moderate aortic stenosis at 4.5 years postprocedure. Echocardiographic follow-up showed a left ventricular ejection fraction of 63 ± 7% (n = 36), Vmax 2 ± 0.6 m/s (n = 17), and a mean gradient of 9.4 ± 5.4 mmHg (n = 27). No patients had grade 3 or 4 aortic regurgitation, one patient had grade 2, and four had grade 1. Tirone's procedure is an option for BAV surgery, with good safety and outcomes, especially in younger patients.

Outcomes after ROSS procedure with pulmonary autograft reinforcement using reimplantation technique

Pulmonary autograft reinforcement to prevent dilatation and subsequent neo-aortic valve regurgitation was reported. However, the late functional outcome of the native pulmonary valve inside a rigid Dacron conduit requires to be documented. We aimed to assess the results of modified Ross procedure associated with autograft reinforcement reimplantation technique. Outcomes of 61 consecutive patients who underwent Ross procedure with reinforcement between 2009 and 2021 were analyzed. Majority of cases has presented with mono or bicuspid aortic valve ( n = 52; 85%), predominant aortic valve regurgitation ( n = 47; 77%) and dilatation (> 30 mm) of the ascending aorta ( n = 33; 54%). Forty-seven patients (77%) had prior aortic valve procedure including 38 surgical repair (62%) and 9 balloon dilatation (15%). Pulmonary autograft was reimplanted in a Dacron conduit of a median diameter = 25.6 mm (ranges: 20–30) using Tirone David's valve sparing aortic root replacement technique. No death occurred. Median age at procedure was 16.8 years (range: 6–38). Two patients (3%) required early neo-Aortic root revision, one other was reoperated later on resulting in neo-aortic valve replacement in 3 (4.9% IC 95% [0.34%; 12.7%]) because of respectively infective endocarditis, left ventricular false aneurysm and leaflet perforation. Six patients required right ventricular outflow conduit replacement including one percutaneous replacement. At mean 66 ± 50.5 months postoperatively, the survival rate with freedom from reintervention was 83% [71.9; 93.5] and the deterioration of the initial neo-Aortic valve function (regurgitation or stenosis) was not observed ( Fig. 1 ). Autograft reinforcement by means of reimplantation technique allowed to extend the indications for Ross procedure to all patients requiring Aortic valve replacement and prevented neo-Aortic root dilatation. Failures were early and rare, and late controls confirmed the stability of the neo-aortic valve function in follow-up.

Immediate Higher-Dose Prothrombin Complex Concentrate Without Fresh Frozen Plasma or Fibrinogen Concentrate for Significant Coagulopathic Cardiac Surgical Field Bleeding

Treatment of significant coagulopathic cardiac surgical field bleeding with immediate higher-dose prothrombin complex concentrate (PCC) without fresh frozen plasma (FFP) or fibrinogen concentrate is unexplored. To study characteristics, chest drainage, and clinical outcomes of patients with significant coagulopathic surgical field bleeding treated with immediate higher-dose (defined at >15 IU/kg based on factor IX) PCC without FFP or fibrinogen concentrate. We screened sequential cardiac surgery patients. We reviewed electronic blood bank data, Australian Society of Cardiothoracic Surgery database information and anaesthetic, intensive care unit (ICU), ward and radiological charts and electronic data. We identified patients deemed by the operating surgeon to require treatment for significant coagulopathic surgical field bleeding who underwent immediate higher-dose PCC without FFP or fibrinogen concentrate. Among 168 patients, we identified 30 who underwent immediate higher-dose PCC without FFP or fibrinogen concentrate. Median age was 68 years, 23 were male, 17 underwent coronary artery bypass surgery and three underwent complex surgery (David procedure, redo mitral valve surgery, and redo thoraco-abdominal aneurysm repair). Median dose of PCC was 2,500 IU. In addition, 27% underwent platelets and one underwent cryoprecipitate. Chest drainage at 24 hours was 505 ml. Survival to hospital discharge was 100%. There were no cases of pulmonary embolism, stroke, or other thrombotic events. Stage 1 AKI occurred in one patient. In a pilot cohort of patients with significant coagulopathic surgical field bleeding, immediate higher-dose PCC without FFP or fibrinogen concentrate was feasible and had an acceptable efficacy and safety profile, which justifies future controlled studies.

An Aortic Valve 21 Years After Repair.

A 52-year-old woman with Marfan syndrome was operated for an aortic arch aneurysm. She had undergone an aortic valve sparing with sinuses reconstruction 21 years earlier. During surgery the aortic valve was directly evaluated (A). At one year follow-up the patient is asymptomatic and the valve maintains its normal function and a perfect root anatomy (B).

Case report: giant ascending aorta at a young age

Erina Aukščiūnienė1, Rūta Dirsienė2, Vaida Mizarienė2 1 Lithuanian University of Health Sciences, Kaunas, Lithuania 2 Department of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania Abstract Introduction: The aneurysms of the thoracic aorta are most common in the VI–VII life decade. In this case report we present a young female with an aneurysm of ascending aorta and severe aortic valve regurgitation. Case report: A 33-year-old woman with shortness of breath and other typical symptoms of the aneurysm of the aorta and a severe regurgitation of the aortic valve had underwent several tests to find the main cause of this mentioned disease. The patient was treated surgically – the David Procedure was performed, and the aortic valve was repaired. Conclusion: This case report shows that the aneurysm of ascending aorta could be present at a young age without any specific obvious predisposing factors such as congenital bicuspid aortic valve, phenotypic signs of Marfan syndrome or known familiar history. KEYWORDS: thoracic aorta aneurysm; aortic valve regurgitation; familial aneurysms syndrome.

EVALUATION OF STRUCTURAL FND FUNCTIONAL FEATURES OF REIMPLANTED AORTIC VALVE AFTER DAVID I PROCEDURE WITH THE USE OF HIGH-PRECISSION 3-DIMENSIONAL SEGMENTATION OF THE AORTIC ROOT

Aneurysm of the aortic root accompanied by aortic insufficiency is a common cardiovascular pathology. The optimal method of surgical treatment of this pathology is the reimplantation of the aortic valve into the aortic root synthetic prosthesis (David procedure). Currently, there is no comprehensive data on the influence of initial geometric parameters of the aortic root structures on the functioning of the reimplanted aortic valve after valve-preserving aortic root replacement. We have introduced a novel technique for creation and segmentation of a three-dimensional reconstruction of the aortic valve and root, which involves the sequential application of two computer-aided design environments: In Vesalius v 3.1.1 (Centro de Tecnologia da Informação Renato Archer (CTI)) and 3- Matic v. 13.0 (Materialise, Leuven, Belgium). The proposed method allows accurate measurement and evaluation of spatial parameters of the AV leaflets, fibrous ring, sinuses of Valsalva and sinotubular junction. The developed technique was used to evaluate the anatomical and functional features of the aortic valve in a 68-year-old patient who underwent David I procedure. Segmentation and measurement of the geometric parameters of the aortic root were performed before operation, as well as 18 months after surgical treatment. To assess the function of the reimplanted aortic valve during the long-term follow-up, a detailed echocardiographic assessment was used. Echocardiographic assessment included measuring volume and area of the regurgitation flow, the width of vena contracta, and the regurgitation fraction. The application of high-precision 3D reconstruction opens up additional opportunities in the field of surgical treatment of the aortic root and AV pathology: advantages in choosing an individual patient-oriented surgical tactics, parameters of the implanted surgical material and/or device, and in predicting long-term results of surgical treatment.

A case report of valve-sparing aortic root replacement in a patient with full metal jacket aorta

Video 1 A case report of valve-sparing aortic root replacement in a patient with full metal jacket aorta.

Aortic root replacement in bicuspid versus tricuspid aortic valve patients.

BackgroundConcomitant replacement of the aortic root and aortic valve is a widely used treatment strategy in elective patients with aortic valve stenosis and root aneurysm. It is also a strategy frequently employed in patients with acute aortic dissection type A (AADA), involving the aortic root. Although more patients have undergone valve sparing procedures over the past decades, the classic ‘modified Bentall technique’ remains a valid option, particularly for patients with a bicuspid aortic valve (BAV). We aimed to compare the results of elective and emergency modified Bentall procedures in patients with bicuspid and tricuspid aortic valves (TAVs).MethodsWe retrospectively reviewed our database for patients undergoing either elective or emergency modified Bentall procedures between 2000 and 2018 and identified 827 elective cases (44% BAV) and 258 emergency cases (15% BAV). Analysis of intra- and postoperative outcomes and early mortality was performed. Due to inequality of the groups, a matching analysis was performed.ResultsWe found BAV patients to be significantly younger (elective: 58±18 vs. 65±14, P<0.001; emergency: 49±17 vs. 62±19, P<0.001) and healthier at time of surgery. In the AADA cohort, malperfusion rate was not different between bicuspid and tricuspid patients, however bicuspid AADA patients presented more often with an entry in the aortic root. After matching, procedure times and early outcomes did not differ between the groups, except for significantly higher rates of respiratory failure in elective TAV patients (10% vs. 5%, P=0.033). The 30-day mortality was 2% in elective cases and 22% in emergency AADA surgery. A subgroup analysis of elective patients with aortic diameter <55 mm also showed excellent outcomes.ConclusionsAfter adjustment for preoperative inequalities, no differences in early mortality and outcomes were found between bicuspid and tricuspid patients receiving elective or emergency modified Bentall surgery.