External Aortic Root Support Research Articles

366 A Case Study: Application of Personalised External Aortic Root Support to Overcome a Failing Ross Procedure

Abstract Aortic root aneurysms are traditionally treated by aortic root replacement surgery alone or in combination with aortic valve replacement in a Modified Bentall procedure. We present a novel surgical approach using a Personalised External Aortic Root Support (PEARS) in the management of an aortic root aneurysm in a 24-year-old male, initially presenting in infancy with mixed aortic valve disease who underwent a free root Ross procedure in 2010 aged 11. Follow-up cardiac magnetic resonance imaging and transthoracic echocardiography showed mild aortic and pulmonary valve regurgitation with aortic root dilatation (51mm). In 2022, Computerised tomography (CT) exhibited dilation of the Sinus of Valsalva (43mm) and ascending aorta (56 mm). MDT review deemed redo valve-sparing root replacement appropriate as the ascending aorta was >55mm with an approximate 8mm increase over three years. As the young patient wished to avoid warfarinisation and the autograft valve maintained good function, a reduction PEARS was considered. In September 2023, a reduced aortic PEARS graft (80% reduction) was implemented along with a redo of the right ventricle to pulmonary artery conduit. Whilst applying the PEARS it was noted that there was a retroaortic circumflex artery, care was taken to mobilise this aberrant vessel to avoid compression by the graft. Cardiopulmonary bypass and cross-clamp times were 180 and 116 minutes respectively. Intraoperative transoesophageal echocardiography confirmed good bi-ventricular function with no pulmonary regurgitation additionally on postoperative CT the aortic diameter was 38mm. In conclusion, application of a reduction PEARS is a potential alternative to a valve-sparing aortic root replacement method in young patients.

Autograft Reoperation Following the Ross Procedure: Evolving Strategies and Future Perspectives.

Background: Pulmonary autograft failure remains a cause of reoperation following the Ross procedure. The aim of this study is to describe our evolving approach to autograft reoperations. Methods: Retrospective study of all patients who underwent a pulmonary autograft reoperation following a Ross procedure between June 1997 and July 2022. Results: Two-hundred and thirty-five Ross procedures were performed. Thirty-six patients (15%) plus one referral underwent an autograft reoperation at a median of 7.8 years (IQR 4.6-13.6). The main indication was: neoaortic root dilatation associated with mild/moderate (n = 12) or severe (n = 8) aortic regurgitation; isolated severe aortic regurgitation (n = 6); infective endocarditis (IE) (n = 8); and aortic root pseudoaneurysm with no history of IE (n = 3). The autograft was spared in 29 cases (78%): 9 patients (24%) underwent aortic valve repair or aortic root remodeling, 15 patients (40%) aortic root reimplantation, 5 patients neoaortic root stabilization with a Personalized External Aortic Root Support (PEARS) sleeve. There were no in-hospital deaths. At a median follow up of 37 months (IQR 8-105), all patients were alive, 30 (81%) were asymptomatic. Eight patients (22%) required nine further reoperations. Estimated freedom from further reoperation was 90%, 72%, and 72% at 12-, 36-, and 60-months. Conclusions: Autograft reoperations following the Ross procedure can be safely performed and do not affect overall survival in the early and mid-term. Valve-sparing autograft replacement is technically feasible but remains at risk of further interventions. Alternative strategies, such as the PEARS sleeve, are becoming increasingly available but requires validation in the long term.

Our 7-year experience supporting the Ross autograft with the novel technique of Personalized External Aortic Root Support

ObjectiveThe Ross operation is a widely accepted option for aortic valve replacement in children, and evidence shows its excellent results in terms of hemodynamics and durability. However, indications are still limited due to the fact that it is a technically demanding procedure, only performed by specialized surgeons. On top of that, and despite numerous techniques being applied, autograft dilatation remains a key disadvantage, which can lead to graft failure. In recent years, the ExoVasc Personalized External Aortic Root Support (PEARS) has proven to be a safe and effective option to prevent aortic root dilatation in various aortopathies and is a technique that lends itself to support the pulmonary autograft in the Ross operation. MethodsDuring the past 7 years, we have used the ExoVasc PEARS graft, manufactured from the patients' pulmonary artery measurements from computed tomography scan data, to support the pulmonary autograft in the Ross operation. This graft (manufactured by Exstent Ltd, UK) is implanted at the same time as the autograft. We have reviewed all the patients who underwent this surgery, including demographic data, aorta measurements, operative data, and follow-up assessment consisting of periodic echocardiograms and magnetic resonance imaging scans. ResultsFifty patients were included in the study. Mean age at the time of the operation was 29.84 years, the youngest patient was 9 years-old. Nineteen patients (38%) had previous sternotomies; 11 of them having had a previous aortic valve replacement. Seventy-two percent of patients had initially a bicuspid aortic valve. Mean diameter of the ascending aorta was 3.83 cm. Forty-four percent of patients required a concomitant reduction aortoplasty due to mismatch sizes between the ascending aorta and the autograft. Mean bypass and crossclamp times were 200.66 and 151.14 minutes, respectively. Median length of stay was 6 days. Mean follow-up was 16.88 months. Two patients required subsequent aortic valve replacement (1 had rheumatic valve disease and the other had iatrogenic damage in his autograft valve leaflet). Ascending aorta dimensions remain stable when compared with immediate postoperative studies. There were no deaths. ConclusionsThe ExoVasc PEARS graft has proven to be an excellent support in the Ross operation to prevent the autograft failure related to autograft dilatation that can offer several advantages compared with other existing techniques. With this type of support, we believe the Ross indications can be expanded to multiple clinical scenarios, given the good long-term results this operation offers in terms of durability, life expectancy, and hemodynamics.

Ross procedure with personalized external aortic root support

The Ross–Personalized External Aortic Root Support procedure is a surgical aortic valve replacement technique in which the autologous pulmonary valve is transposed in the aortic position to replace the malfunctioning aortic valve and a homograft is implanted in the pulmonary position. To prevent autograft dilatation, a Personalized External Aortic Root Support prosthesis is included in the proximal autograft anastomosis and wrapped around the ascending aorta. The aorta is transected transversely, the aortic valve is resected, and the coronary arteries are mobilized and cut out of the sinuses, leaving a rim. The pulmonary autograft is harvested by transecting the pulmonary artery and part of the right ventricular outflow tract. The autograft is approximated to the aortic root and inverted inside the ventricle. The proximal anastomosis is performed including the prosthesis between the aortic root and the autograft. The coronary buttons are threaded through appropriately positioned and sized holes in the prosthesis and reimplanted into the autograft. The ascending aorta is appropriately adapted and anastomosed with the distal autograft. When the patient is off cardiopulmonary bypass, the prosthesis can be closed longitudinally and is anchored to the distal aortic adventitia.

Matched comparison between external aortic root support and valve-sparing root replacement

ObjectivesDifferences in indication and technique make a randomised comparison between valve-sparing root replacement (VSRR) and personalised external aortic root support (PEARS) challenging. We performed a propensity score (PS)-matched comparison of...

Personalized external aortic root support in aneurysm disease.

To bring together and annotate publications about personalised external aortic root support reported in the 18 months preceding submission. The total number of personalised external aortic root support (PEARS) operations is now approaching 700 in 30 centres in Australia, Belgium, Brazil, Czech Republic, Great Britain, Greece, Ireland, Malaysia, Netherlands, New Zealand, Poland and Slovakia. There are continued reports of stability of aortic dimensions and aortic valve function with the only exceptions known being where the surgeon has deviated from the instructions for use of the device. The median root diameter of Marfan patients having PEARS was 47 mm suggesting that the existing criterion of 50 mm is due for reconsideration. The peri-operative mortality currently estimated to be less than 0.3%. The first recipient remains alive and well after 18 years. The use of PEARS as an adjunct to the Ross operation to support the pulmonary autograft is being explored in several centres. The operation requires proctoring and adherence to a strict operative protocol and with those precautions excellent results are attained. The evidence and opinions provided in the cited publications indicate that PEARS is a proven and successful prophylactic operation for aortic root aneurysm.

What's in a wrap?

What's in a wrap?

Early Repair of Aortic Wall Structural Defect by "Net" Endoprosthesis to Arrest the Aneurysm without Interference with Aortic Branch Vessel Perfusion.

Current treatments of aortic aneurysm include surgical or endovascular, respectively, anatomical or functional, substitution of the aneurysm tract; however, with these methods, perfusion of at least some collateral branches cannot be fully restored, leading to the risk of paraplegia. We present a novel endovascular "net" prosthesis to strengthen the aortic wall while preserving perfusion of collateral branches. This consists of a polyester mesh "net"-layered conduit in a variable cylindrical shape, which is personalized based on patient computed tomography scan images, and is defined by circular crossing spirals of a thin nitinol wire. The prosthetic conduit, shrunk by compressing the nitinol spirals, can be inserted into the vascular lumen and expanded in situ. Then, the insertion control device can be fully removed. Thus, the, "net" prosthesis, positioned inside the aorta in stable contact with the intimal wall for 2 to 5 months, is colonized by neointima and spontaneously moved deeper into the aortic wall in contact with the media, thus being ideally able to stabilize aortic diameter without interference with collateral branch blood perfusion. This new, (ideally) paraplegia-free procedure is aimed at curing the aortic wall structural defect, thus arresting the aneurysm from further progression. This contrasts with current treatments, indicated by aneurysm dimensions for their implied complication risk, which are actually for prophylaxis of impending rupture or dissection rather than fortification of the natural aorta. Moreover, this new approach can be used alongside open surgical procedures (personalized external aortic root support) as well as a frozen "net" elephant trunk technique, for full aortic stabilization.

Cerebral hemodynamics during sustained intraoperative hypotension.

Static cerebral autoregulation (CA) maintains cerebral blood flow (CBF) relatively constant above a mean arterial blood pressure (BPmean) of 60-65 mmHg. Below this lower limit of CA (LLCA), CBF declines along with BPmean. Data are lacking in describing how CA reacts to sustained hypotension since hypotension is usually avoided. In this study, we took advantage of a procedure requiring sustained hypotension. We assessed static CA for LLCA determination, and a more continuous CA, which counters short-term blood pressure variations. With these data, we analyzed CA during longstanding hypotension. Continuous arterial blood pressure and middle cerebral artery blood flow velocity (MCAVmean) were monitored in 23 patients that required deep intraoperative hypotension. The LLCA was determined for every patient, and BPmean below this LLCA was classified as the patient-specific hypotension. With the mean flow index (Mxa), continuous CA (Mxa-CA) was quantified. Mxa was calculated and averaged after induction of general anesthesia (baseline), every 15 min during, and 15 min after 1 h of hypotension. Functioning CA was defined as Mxa < 0.4. Data are expressed as median (25th-75th percentile). The LLCA was located at 56 (47-74) mmHg. At baseline, Mxa was 0.21 (0.14-0.32) and 0.61 (0.48-0.78) during hypotension (P < 0.01), with no appreciable change over time, n = 12. After blood pressure restoration, Mxa improved, 0.25 (0.06-0.35, n = 9). Mxa-CA became and remained disturbed during the 1 h of hypotension, and improved after blood pressure restoration. This completely reversible situation suggests no ischemic hyperemia occurs and renders an adaptation mechanism during sustained hypotension unlikely.NEW & NOTEWORTHY Intraoperative hypotension is normally avoided by anesthesiologists. However, for the Personalized External Aortic Root Support (PEARS) procedure, deep-induced hypotension is an essential requirement for the surgeon to be able to manipulate the aortic root. In this procedure, blood pressure and middle cerebral artery blood flow velocity were monitored. In this study, we assessed cerebral autoregulation during sustained hypotension, to give an insight into its behavior during hypotension.

Report of Evaluation of Personalised External Aortic Root Support (PEARS) Using the Ideal Framework after 18 Years: Have Questions Merged that are Amenable to a Randomised Controlled Clinical Trial?

Report of Evaluation of Personalised External Aortic Root Support (PEARS) Using the Ideal Framework after 18 Years: Have Questions Merged that are Amenable to a Randomised Controlled Clinical Trial?

Personalized external aortic root support – how to implant it

Personalized External Aortic Root Support (PEARS) is an evolving method of treatment for patients with a dilated aortic root or ascending aorta. This treatment is being adopted in an increasing number of centres. For the sake of the safety of the procedure a standardized surgical technique is necessary. The authors describe a surgical technique of implantation that is derived from their extensive experience.

Inflammatory response after ExoVasc&lt;sup&gt;® &lt;/sup&gt;personalized external aortic root support (PEARS) procedure in patients with Marfan syndrome or non-Marfan genetic aortopathy

Kontext: Cílem studie bylo zjistit závažnost zánětlivé odpovědi po výkonu PEARS (personalized external aortic root support) s vytvořením personalizovaného externího stentu pro aortální kořen ve srovnání se standardní profylaktickou operací aortálního kořene (standard prophylactic aortic root surgery, SPARS). Materiál a metody: Studie byla monocentrickou, retrospektivní analýzou nemocničních záznamů pacientů, u nichž byla v období 1998-2017 provedena buď PEARS (skupina PEARS), nebo SPARS (skupina SPARS). U všech pacientů se rutinně stanovovaly hodnoty C-reaktivního proteinu (CRP) a počet bílých krvinek (white blood count, WBC) a provádělo se echokardiografické vyšetření. Horečka byla definována jako tělesná teplota &#8805; 38 °C. Diagnóza perikarditidy se stanovovala na základě nejméně tří známek z bolesti na hrudi, perikardiálního výpotku, elevace úseku ST, zvýšených hodnot CRP a tělesné teploty. Výsledky: Do skupin PEARS a SPARS bylo zařazeno 13, resp. 14 pacientů s indikací k profylaktické operaci aortálního kořene. Většina pacientů v obou skupinách měla Marfanův syndrom s kauzální mutací v genu pro fibrilin 1 (FBN1) (62 % vs. 79 %). Vstupní charakteristiky pacientů v obou skupinách byly podobné s výjimkou aortálního kořene, který byl ve skupině SPARS statisticky významně větší než ve skupině PEARS (60 &#177; 12 mm vs. 48 &#177; 5 mm; p = 0,003). Všechny operace byly úspěšné a proběhly bez větších komplikací. Nejvyšší hodnoty CRP a WBC byly statisticky významně vyšší ve skupině PEARS (264,5 &#177; 84,4 mg/l vs. 184,6 &#177; 89,6 mg/l; p = 0,034, resp. 15,2 &#177; 3,8 109/l vs. 11,9 &#177; 3,3 109/l; p = 0,029). Časná a recidivující horečka vyžadující opětovnou hospitalizaci se vyskytla častěji ve skupině PEARS (77 % vs. 36 %; p = 0,032, resp. 46 % vs. 7 %; p = 0,020). Časná a recidivující perikarditida vyžadující hospitalizaci byla rovněž častější ve skupině PEARS (31 % vs. 0 %; p = 0,024, resp. 31 % vs. 0 %; p = 0,024). Závěry: Metoda PEARS je velmi slibná chirurgická metoda; pooperační zánětlivá odpověď se však vyskytuje častěji a ve srovnání s metodou SPARS je závažnější. Tyto výsledky je však samozřejmě nutno dále zkoumat a ověřovat. &#169; 2021, ČKS.

Personalised external aortic root support for elective treatment of aortic root dilation in 200 patients

Background and objectivesIn personalised external aortic root support (PEARS), a custom-made, macroporous mesh is used to stabilise a dilated aortic root and prevent dissection, primarily in patients with genetically driven...

Establishment of a Personalized External Aortic Root (PEARS) Program: A Single Center Experience

Objective: Personalized external aortic root support (PEARS) is a novel approach in the management of aortic root aneurysms in those with connective tissue disorders. The objective of this study is to review the initial experience and outcomes from a single center. Methods: A PEARS program was established with a proctor present for the first three cases. A retrospective review of all patients undergoing PEARS from 2016 to present was undertaken. Results: We have treated 14 patients to date, 12 isolated PEARS and 2 with concomitant procedures. Of the isolated PEARS patients, mean duration of procedure was 196 ± 31 minutes. Median hospital stay was 7 days (range 4-118). There were no mortalities. Complications included atrial fibrillation (n=2) and transient ST elevation (n=4), late onset pericarditis (n=1). One patient developed intra operative ischemia following mitral repair and PEARS requiring emergency CABG and resulting in a prolonged stay. One patient with Loeys Dietz developed a right coronary artery dissection post operatively which was managed with re-operation, vessel ligation and CABG. Two patients had moderate aortic incompetence which was significantly improved following PEARS. Mean follow up is 1.2 ± 1 years and all patients are well with no acute aortic events. Conclusions: We successfully established a PEARS program. Coronary complications post PEARS can be life threatening. We recommend requesting pre discharge CT aorta for all patients. Longer term follow of aortic dimensions is required to determine efficacy. Further investigation of the role of PEARS in treating patients with aortic regurgitation is required to establish the role of PEARS in this context.

Personalized External Aortic Root Support (PEARS) for Aortic Root Aneurysm

The Personalized External Aortic Root Support (PEARS) procedure offers a novel alternative to traditional surgical options for aortic root aneurysms in patients with connective tissue disorders and neo-aortic root dilatation following the arterial switch or Ross procedures. It has a lower biological insult than conventional surgical management with shorter operating times and avoidance of cardiopulmonary bypass and cardioplegic arrest in most cases. The patient's own valve, root architecture, and blood to vessel wall interface are maintained. Avoidance of mechanical valve replacement negates the requirement for anticoagulation which is especially beneficial in young patients. This article aims to describe the key principles and operative steps for implanting the PEARS device. We describe the technical steps applicable to all PEARS implants and have included our tips and tricks at each stage. We consider PEARS to be a valid alternative therapeutic option for surgical teams managing patients with aortopathies.

Personalized External Aortic Root Support (PEARS) for Neoaortic Valve Insufficiency After Arterial Switch Operation

•A comprehensive overview of a novel management option for aortic root aneurysms in patients with neoaortic root dilatation following the arterial switch operation: Personalized External Aortic Root Support (PEARS) •Includes a description of the key principles of patient selection, surgical steps and postoperative care •Detailed figures describing the implantation of a PEARS device with attention to the unusual anatomy encountered in the post-ASO patient The PEARS procedure offers a novel alternative to traditional surgical options for aortic root aneurysms in patients with neoaortic root dilatation following the arterial switch operation. The patient's own aortic valve, root architecture and blood to vessel wall interface are preserved. Avoiding a mechanical prosthesis negates the requirement for anticoagulation which is especially beneficial in young patients. This article aims to describe the key principles and operative steps for implanting the PEARS device around the dilated neoaortic root after the arterial switch operation. The PEARS procedure offers a novel alternative to traditional surgical options for aortic root aneurysms in patients with neoaortic root dilatation following the arterial switch operation. The patient's own aortic valve, root architecture and blood to vessel wall interface are preserved. Avoiding a mechanical prosthesis negates the requirement for anticoagulation which is especially beneficial in young patients. This article aims to describe the key principles and operative steps for implanting the PEARS device around the dilated neoaortic root after the arterial switch operation. Commentary: PEARS – Good Fruit for the Congenital Heart Surgeon?Operative Techniques in Thoracic and Cardiovascular SurgeryVol. 26Issue 2PreviewRobicsek et al. introduced the concept of aortic wrapping in 1971 using synthetic vascular grafts.1 In 2014, Treasure reported their first cohort of 30 patients with connective tissue disease and the use of a personalized external aortic root support (PEARS).2 Unlike vascular grafts, PEARS is personalized to each patient's anatomy and has interstices that provide flexibility and importantly prevent entrapment of fluid between the graft and the aortic wall. Kenny et al. in the current report describe PEARS to stabilize the post arterial switch (ASO) aneurysmal neo-aortic root. Full-Text PDF

A contemporary approach to a young female patient with Loeys-Dietz syndrome and an uncomplicated type B aortic dissection: a case report

BackgroundAortic dissection is a relatively uncommon, but often catastrophic disease that requires early and accurate diagnosis. It often presents in patients with congenital connective tissue disorders. The current aortic surgical techniques are related with serious early and late complications. This case report emphasizes the importance of early diagnosis of aortic root dilatation and the risk of dissection, especially in patients with congenital connective tissue disorders. We present an alternative, contemporary and multidisciplinary approach based on the present state of knowledge.Case presentationWe present a rare case of a young female patient with Loeys-Dietz syndrome who was admitted with an uncomplicated aortic dissection (Stanford type B / DeBakey type III) and a dilated aortic root. After a period of close surveillance and extensive vascular imaging, thoracic endovascular aortic repair was deemed to be technically not possible. Medical treatment was optimized and our patient successfully underwent a personalised external aortic root support procedure (PEARS) as a contemporary alternative to existing aortic root surgical techniques.ConclusionsThis case highlights the importance of interdisciplinary approach, close follow-up and multimodality imaging. The decision to intervene in a chronic type B aortic dissection is still challenging and should be made in experienced centers by an interdisciplinary team. However, if an acute complication occurs, thoracic endovascular aortic repair TEVAR is the method of choice. In all cases optimal medical treatment is important. There is increasing evidence that personalized external aortic root support procedure PEARS is effective in stabilizing the aortic root and preventing its dilatation and dissection not only in patients with Marfan syndrome, but also in other cases of aortic root dilation of other etiologies. Moreover, many publications have reported the additional benefit of reduction or even eradication of aortic regurgitation by improving coaptation of the aortic valve leaflets in dilated aortas.

Personalized external aortic root support

Implantation of a personalized external aortic root support (PEARS) can prevent dilatation of the aortic root and ascending aorta in patients with aortopathy of various aetiologies. Because PEARS is an emerging technology, all aspects concerning indications, surgical technique and safety should be elucidated. Our goal was to summarize all of these aspects so that physicians and patients would have sufficient information to evaluate this alternative approach. Between April 2004 and March 2020, 317 patients underwent PEARS operations at 25 surgical centres in 9 countries. The most common indication was Marfan syndrome (57%). The single perioperative death represented a mortality of 0.3%. The long-term experience comprises 871 patient/years with 1 patient living for 15 years and 19 patients living for more than 10 years. PEARS seems to be a promising method of treatment of dilatation of the aortic root and/or ascending aorta. Multicentre observational studies are needed to gain more experience because this operation is still uncommon and the number of operations per surgeon/centre is low.

Personalised external aortic root support (PEARS) to stabilise an aortic root aneurysm.

Patients with congenitally determined aortic root aneurysms are at risk of aortic valve regurgitation, aortic dissection, rupture and death. Personalised external aortic root support (PEARS) may provide an alternative to aortic root replacement. This was a multi-centre, prospective cohort of all consecutive patients who received ExoVasc mesh implants for a dilated aortic root between 2004 and 2017. Baseline and peri-operative characteristics, as well as early postoperative outcomes are described, and time-related survival and re-operation free survival are estimated using the Kaplan-Meier method. From 2004 through 2017, 117 consecutive patients have received ExoVasc mesh implants for aortic root aneurysm. The inclusion criteria were an aortic root/sinus of Valsalva and ascending aorta with asymptomatic dilatation of between 40 and 50 mm in diameter in patients aged 16 years or more. Patients with more than mild aortic regurgitation were excluded. There was one early death. The length of stay was within seven days in 75% of patients. In conclusion, the operation achieves the objectives of valve-sparing root replacement. PEARS may be seen as a low-risk conservative operation, which can be applied earlier on in the disease process, and which is complementary to more invasive procedures, such as valve-sparing root replacement or total root replacement.

617 PEARS: an Alternate Procedure in Pregnant Patients With Marfan Syndrome

Marfan syndrome patients with a dilated aortic root carry an increased risk of aortic dissection during pregnancy. A 21-year-old patient with Marfan Syndrome presented in the first trimester of pregnancy with a dilated aortic root at 47mm. There was no aortic regurgitation. Associated with Marfan Syndrome was pectus excavatum. This resulted in two further anomalies; a restricted lung capacity of FEV1 56% predicted and significant displacement of cardiac structures, including the aorta, into the left chest. The scenario was presented at a multidisciplinary meeting the consensus opinion being that surgical intervention was required. The dilemma was to avoid cardiopulmonary bypass, to avoid foetal injury. Thus valve sparing root surgery was relatively contraindicated. A PEARS (Personalised External Aortic Root Support) procedure was thus the procedure of choice. A macroporous fabric mesh was constructed based on a 3D printed model of the patient’s aortic root. This scaffolding integrates with the aortic wall and prevents further dilatation. This was performed during the second trimester (week 14). Cardiopulmonary bypass was avoided. Post operatively the patient’s course was uneventful. She was extubated day 0 and discharged day 7. There were no issues to foetal survival, this being confirmed on serial foetal ultrasound. Subsequently, the patient had an elective Caesarean section at 37 weeks, with delivery of a live normal infant. This case report is the first internationally of a PEARs procedure during pregnancy. Does this represent the management in the future of pregnant females with Marfan Syndrome and a dilated aortic root?