Normal Aortic Annulus Research Articles

Management of Small Aortic Root during Aortic Valve Replacement

Background: Concomitant aortic root enlargement (ARE) increases the risk of aortic valve replacement (AVR). The objectives of this study were to identify the patients who needed aortic root enlargement and compare the outcomes and the risk of adding ARE to AVR.
 Methods: We retrospectively reviewed 62 patients who underwent isolated mechanical aortic valve replacement between 2017 and 2019. We divided the patients into two groups: group A included patients with small aortic root who had AVR with one of the different surgical strategies for small aortic annulus (n= 32) and group B, which included patients with a normal aortic annulus and underwent conventional AVR (n= 30). Group A was further sub-divided based on the surgical strategy into 4 categories; patients who had supra-annular implantation of size 19 mm St. Jude prosthetic valve (n= 11; 34.4%), Nicks procedure (n= 13 40.6%), Manougian procedure (n= 4; 12.5%), Konno procedure (n= 4; 12.5%). 
 Results: Group A patients were significantly younger (26.16 ± 11.49 vs. 34.63 ± 8.9 years; p< 0.001) and had lower body weight (55.09 ± 21.41 vs. 69.80 ± 19.20; p= 0.01). Group A had significantly smaller valves (p = 0.03), and total cardiopulmonary bypass (148.65 ± 44.09 vs. 97.46 ± 20.90 minutes; p<0.001) and aortic cross-clamp times (118.13 ± 36.70 vs. 78.06 ± 16.01 minutes; p < 0.001) were significantly longer in group A. There was no significant difference in operative complications between groups. Among patients with small aortic root; Konno procedure had the longest bypass time (236.3 ± 19.70 minutes; p<0.001); cross-clamp time (192.5 ± 22.2 minutes; p <0.001); mechanical ventilation (4.75 ± 0.50 hours; p<0.001) and intensive care unit stay (6.50 ± 0.57 days; p <0.001). Patients with supra-annular implantation of the St. Jude valve had a significantly higher postoperative pressure gradient (14.64 ± 6.84 mmHg; p= 0.02). No difference in procedure complications was observed among aortic root enlargement procedures.
 Conclusion: Patients who had aortic root enlargement procedure were younger, with lower weight and body surface area. Surgical procedures used to manage small aortic root had comparable early results, and no technique was superior to the others.

Updates in Aortic Valve Sparing Surgery

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

Comparison of Aortic Annulus Dimension After Aortic Valve Neocuspidization With Valve Replacement and Normal Valve

Aortic valve replacement (AVR) remains the standard surgical intervention for aortic valve disease and is preferred by many surgeons, despite its associated clinical issues. The clinical efficacy of aortic valve neocuspidization (AVNeo) with glutaraldehyde-treated autologous pericardium, the Ozaki procedure, has recently been reported. Although it is presumed to preserve the normal aortic annulus motion, changes to the aortic annulus during the cardiac cycle after AVNeo remain unclear. From March to December 2014, aortic annular dimensions were measured for 23 patients; the sample included 8 patients who had undergone AVNeo, 10 patients with normal aortic valves, and 5 patients who had undergone AVR. Measurements were recorded using electrocardiography-gated multidetector computed tomography. Data were analyzed using automated aortic root analysis software. Postoperative peak pressure gradients for the AVNeo and AVR groups were compared. No statistically significant differences in annulus variation were observed between patients who had undergone AVNeo and those with normal aortic valves. Annular area was larger during systole than during diastole in both groups. Postoperative peak pressure gradients were significantly lower in the AVNeo group than in the AVR group. The results of the present study demonstrated that aortic annular dimensions after AVNeo are similar to the dimensions of normal aortic valves. This was evidenced using electrocardiography-gated multidetector computed tomography, previously reported as the most reliable method, to evaluate annulus motion during the cardiac cycle. Lower postoperative peak pressure gradients might underlie the observed changes. These advantages will help in rectifying AVR defects.

Uhl's anomaly: Clinical spectrum and pathophysiology

A 28 year-old woman from Afghanistan was referred for prenatal evaluation. She and her husband were consanguineous and had a previous female baby with a rare congenital cardiac defect that consisted of Uhl's anomaly, Ebstein's malformation and pulmonary atresia. The child died after the first palliative step towards a Fontan circulation. A fetal echocardiogram performed at 18 + 2 weeks' gestation showed distinctive right-sided cardiac abnormalities similar to those found in their previous daughter. A dilated, extremely thin walled right ventricle (RV) with poor systolic function was found with a markedly dysplastic tricuspid valve (Fig. 1A, Video 1). There appeared only to be a rudimentary anterior tricuspid valve leaflet. The tricuspid orifice was larger than the mitral valve annulus, 4.9 mm (Z-score +1.5) and 3.6 mm (Z-score -1.5) respectively [1] and free regurgitation through the rudimentary tricuspid valve was present. The oval fossa was wide open with right to left shunting over it (Fig. 1A–B, Video 2). The pulmonary valve annulus diameter was small (2.3 mm, Z-score -0.9) and the pulmonary arteries were underdeveloped (Fig. 1E). The left side of the heart appeared structurally normal (Fig. 1A–C) with normal aortic annulus dimension (3.0 mm, Z-score +2.9). No prograde flow could be detected over

Rationale and results of the Stanford modification of the David V reimplantation technique for valve-sparing aortic root replacement

Even though the concept of valve-sparing aortic root replacement was introduced 35 years ago, confusion still exists about the strengths and weaknesses of the different surgical procedures used when relatively normal aortic cusps call for replacing the aortic root and preserving the regurgitant aortic valve rather than replacing the valve with a composite valve graft. Valve-sparing aortic root replacement operations are subdivided into 2 general families: (1) the Yacoub ‘‘remodeling’’ technique used since 1979 and (2) the David ‘‘reimplantation’’ technique performed since 1988. Innumerable individual modifications of the David reimplantation procedure have been described, but many surgeons are still unclear about the rationale behind these different approaches and what they strive to accomplish. At the base, all reimplantation methods firmly anchor the aortic graft proximally at theventriculoaortic junction below the leaflets in the left ventricular outflow tract with the commissures sewn inside the polyester fabric graft. This is unphysiologic because it abolishes the pronounced 3-dimensional dynamicmotion of the normal aortic annulus, but the annulus cannot dilate postoperatively, causing recurrent aortic regurgitation (AR). To Tirone David’s chagrin, in 2003 I attempted to track the evolution of his personal surgical valve-sparing techniques. The ‘‘David I’’ is the original reimplantation procedure, which uses a 26to 30-mm cylindrical tube graft. The ‘‘David II’’ and ‘‘David III’’ are variations of Yacoub’s remodeling procedure (the David III incorporated a strip of polytetrafluoroethylene felt externally across the base of the noncoronary sinus from trigone to trigone of themitral valve tominimize subsequent annular

Aortic valve repair: a ten-year single-centre experience

Aortic valvuloplasty could represent an alternative to valve replacement resulting in optimal haemodynamic conditions, avoiding anticoagulation and allowing, in young people, normal aortic annulus growth. We analysed our results of aortic valve repair for incompetence due to leaflets and root pathology. From January 2003 to January 2013, 235 patients affected by aortic valve regurgitation, pure or associated with aortic dilatation, were treated with a combination of the principal leaflet repair techniques and, when necessary, sparing procedures. Of these patients, 218 were considered eligible in this study. All of them were submitted to pre- and postoperative transthoracic echocardiography and pre- and post-repair transoesophageal echocardiography. Follow-up was achieved with periodic echocardiograms and clinical evaluations. Eight patients (3.40%) died before discharge. Median clinical and echocardiographic follow-up for all patients was 2.94 (1.41-5.41) years. Mean cross-clamping time was 101.94 ± 40.22 min and mean hospital stay was 10 ± 6.69 days. Kaplan-Meier freedom from aortic regurgitation >2 and freedom from aortic valve replacement were, respectively, 92.9 ± 2.8 and 94.5 ± 2.5% at 9.24 years: 6 patients (2.75%) were reoperated on with aortic valve replacement for severe aortic regurgitation. We also observed a good effect of aortic surgery on the left ventricle: the end-diastolic volume decreased from 137.89 ± 50.23 ml in the preop to 105.17 ± 31.19 ml at follow-up. Aortic valve leaflet repair seems to be a good and feasible option for selected patients, both alone or associated with an aortic sparing technique concerning long-term results.

Current Readings: Aortic Valve–Sparing Operations

It has been more than 2 decades since aortic valve-sparing operations were introduced to preserve the aortic valve in patients with aortic root aneurysm. Remodeling of the aortic root is physiologically superior to reimplantation of the aortic valve, mostly because it preserves the aortic annulus movement during the cardiac cycle. However, several comparative studies have shown that reimplantation of the aortic valve has provided more stable aortic valve function than remodeling of the aortic root. This difference in outcomes is largely because of patients׳ selection. Remodeling of the aortic root has been associated with high failure rates in patients with aneurysms associated with genetic syndromes and bicuspid aortic valves with dilated aortic annulus, but it has provided excellent long-term results in older patients with aortic root aneurysms secondary to ascending aortic aneurysms and normal aortic annulus. Thus, both techniques are useful in preserving the aortic valve. With either technique, restoration of normal aortic annulus and cusp geometry is the single most important technical aspect of these operations. In addition to having a competent valve with no or trivial aortic insufficiency at the end of the operation, there must be no cusp prolapse and the coaptation level of the cusps has to be well above the level of the nadir of the aortic annulus.

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.

Aortic valve haemodynamics after aortic valve-sparing operations

Aortic valve haemodynamics after aortic valve-sparing operations

Aortic Valve Sparing Operations

Aortic valve sparing operations were developed to preserve the aortic valve in patients with ascending aortic aneurysm and aortic insufficiency or patients with aortic root aneurysm. There are 2 types of aortic valve sparing operations, remodeling of the aortic root and reimplantation of the aortic valve. The author believes that remodeling of the aortic root is more appropriate for older patients with ascending aortic aneurysm, dilated aortic sinuses, and normal aortic annulus, whereas reimplantation of the aortic valve is more appropriate for young patients with aortic root aneurysm in whom dilation of the aortic annulus is commonly associated. Although remodeling of the aortic root has been extensively used in patients with aortic root aneurysm, the long-term results are somewhat inferior to reimplantation in most series. The late results of aortic valve sparing operations have been excellent, and these operations have become an important addition to the surgical armamentarium to treat patients with proximal aortic aneurysms.

Implications of incising the ventricular septum in double outlet right ventricle and in the Ross–Konno operation☆

Incision into the ventricular septum in complex biventricular repair is controversial, and has been blamed for impairing left ventricular function. This retrospective study evaluates the risk of a ventricular septal incision in patients undergoing double outlet right ventricle (DORV) repair and Ross-Konno procedure. From January 2003 to September 2007, 11 patients with DORV had a ventricular septum (VS) incision and 12 DORV patients did not. Sixteen patients had a Ross-Konno, and 16 had an isolated Ross procedure. The ventricular septal incision was made to match at least the diameter of a normal aortic annulus. In DORV, the VSD was enlarged superiorly and to the left. In the Ross-Konno, the aortic annulus was enlarged towards the septum posteriorly and to the left. The median follow-up for the study is 19 months (1 month-4 years). For DORV, there were no significant differences in discharge mortality (p=0.22), late mortality (p=0.48), or late mortality plus heart transplant (p=0.093). Although patients with DORV and VSD enlargement have a more complex postoperative course, there were no differences in ECMO use (p=0.093), occurrence of permanent AV block (p=0.55), left ventricular ejection fraction (LVEF) (p=0.40), or shortening fraction (LVSF) (p=0.50). Similarly, for the Ross-Konno there were no significant differences in discharge mortality (p=0.30), late mortality (p=NS), LVEF (p=0.90) and LVSF (p=0.52) compared to the Ross, even though the Ross-Konno patients were significantly younger (p<0.0001). Making a ventricular septal incision in DORV repair and in the Ross-Konno operation does not increase mortality and does not impair the LV function. The restriction of the VSD remains an important issue in the management of complex DORV. These encouraging results need to be confirmed by larger series.

Left Ventricular Outflow Tract after Kawashima Intraventricular Rerouting

Left ventricular outflow tract obstruction is a concern in the long term after Kawashima intraventricular rerouting for Taussig-Bing anomaly. This study assessed the late results and left ventricular outflow tract dimensions after intraventricular rerouting for Taussig-Bing anomaly in 6 children. Age at operation ranged from 8 months to 7 years. The shortest distance from the tricuspid valve to the pulmonary valve ranged from 8 to 18 mm, which was 79%-139% of the normal aortic annulus diameter. All patients survived the operation, but one died of chronic heart failure 4 months after repair. Three patients had no left ventricular outflow tract obstruction 15 to 31 years after repair, and 2 had significant obstruction at 9 and 14 years. One patient underwent successful revision of the intraventricular baffle; the distance between the tricuspid and pulmonary valves was 16 mm (108% of the normal aortic annulus) although it had been 8 mm (79%) at the initial repair. Late results of intraventricular rerouting were considered favorable.

Tricuspidisation of the aortic valve with creation of a crown-like annulus is able to restore a normal valve function in bicuspid aortic valves☆

To evaluate the early results of a new method to repair malfunctioning bicuspid aortic valves by creating a tricuspid valve with a crown-like (i.e. anatomic) annulus. Twelve patients (ages from 10 to 27 years) with chronic regurgitation (and flow-dependent stenosis) of a bicuspid aortic valve underwent repair with the principle of creating a tricuspid valve and a crown-like annulus. The fused leaflets were trimmed and reinserted underneath the existing aortic annulus to create one new native cusp. The third leaflet was fashioned out of a xenopericard patch and was inserted underneath the existing annulus as well to restore the crown-like anatomy of a normal aortic annulus. A tricuspid aortic valve with a morphologically normal annulus was thus created, which resulted in improved coaptation of the leaflets. The repair was immediately assessed by transesophageal echocardiography (TEE) with the heart loaded at 50%. In two patients, a second run helped fine-tune the repair. Median cross-clamping time was 82 min. Follow-up ranged from 3 to 46 months (median 13 months). No significant complication occurred. The function of the aortic valve was excellent with trivial or mild regurgitation in 11 patients and moderate regurgitation in 1 patient. There was no stenosis across the valve. The repair remained stable over time. Remodelling of the left ventricle occurred as expected. Aortic valve repair is feasible in some dysfunctioning bicuspid aortic valves. Tricuspidisation of the valve can result in excellent systolic and diastolic functions. The creation of a crown-like annulus results in improved coaptation of the cusps and could lead to more reliable outcome. Although long-term results are needed, this anatomic correction seems to be a good alternative to valvular replacement in certain sub-groups of patients.

Resultado da substituição aórtica por ampliação anelar anterior e posterior é comparável a do anel normal

OBJETIVO: Comparar resultados tardios da substituicao valvar no anel aortico com ou sem ampliacao. METODO: Incluidos 22 pacientes aorticos com ampliacao anelar anterior e posterior por anel pequeno e 23 com diâmetro anelar normal quando da substituicao valvar aortica. Para grupos, foram comparaveis caracteristicas como sexo, idade, diagnostico valvar, etiologia da doenca e lesoes associadas. Substituicao valvar simples foi rotineira. Para ampliacao anelar posterior foi feita incisao no ponto medio do seio nao coronariano, estendida ao folheto mitral anterior; ampliacao anterior resultou de incisao no anel aortico anterior, estendida por 2 cm no septo interventricular, nao transfixado; reconstrucao aortica foi realizada por enxertos de pericardio bovino. Resultados considerados para toda amostra foram caracteristicas operatorias, evolucao clinica (seguimento de 2 a 11 anos) e gradiente na via de saida do ventriculo esquerdo (VSVE) ao ecocardiograma Doppler. RESULTADOS: Ampliacao aumentou diâmetro anelar aortico de 18,3±2,2 mm para 24,8±2,0 mm (p<0,001), tornando-o comparavel ao normal: 24,9±1,5 mm (NS). Foi necessario maior tempo de circulacao extracorporea para ampliacao anelar (122,1±38,9 min vs 91,0±30,7 min; p<0,005) e de pincamento aortico (91,6±20,7 min vs 68,0±23,5 min; p<0,001). Para ampliacao anelar, o gradiente sistolico maximo na VSVE reduziu de 83,6±22,3 mmHg no pre-operatorio para 26,7±11,4 mmHg (p<0,01), recentemente, e na substituicao valvar simples a reducao foi de 68,2±28,7 mmHg para 32,8±16,2 mmHg (P<0,001); valores comparaveis para intervalos correspondentes (NS). CONCLUSAO: Tecnica de ampliacao anterior e posterior do anel aortico possibilitou aumento do diâmetro anelar e do substituto protetico implantado, sendo que para ate 11 anos de seguimento o resultado clinico e ecocardiografico foi superponivel ao da substituicao aortica em pacientes com anel normal.

Tubular supravalvar aortic stenosis: Replacement of ascending aorta in a young patient

The diffuse form of supravalvar aortic stenosis represents a surgical challenge when ascending aorta and proximal aortic arch are involved. We describe a technique performed on a 14-year-old patient with normal aortic annulus and severe diffuse supravalvar aortic stenosis in which the replacement of ascending aorta and proximal aortic arch with a tubular prosthetic graft completely relieved the obstruction as confirmed by cardiac catheterization.