Personalised 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.

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.

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?

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...

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?

Aortic Root Surgery in Marfan Disease: Outcome After Contemporary Surgery, Personalised External Aortic Root Support and Microsimulation

Objective: Total aortic root (TRR) and valve-sparing aortic root (VSRR) replacement surgery has improved life expectancy in Marfan disease patients (MFS). Determining the difference in outcomes aft...

Pears vs Standard Aortic Root Surgery: Financial and Clinical Outcome Comparisons

Personalised external aortic root support (PEARS) is an alternative to aortic root replacement. It is valve and tissue-sparing, and was initially aimed at patients with Marfan Syndrome. The first four cases in the southern hemisphere were successfully completed at Waikato Hospital in April 2016. For further cases to be approved by hospital management, an assessment of financial and clinical outcomes compared to established operations was required, in part due to the high cost of producing the individualised prosthesis. The four patients who underwent PEARS were compared to similar patients. The comparative group included all patients who underwent elective aortic root replacement in the past five years. Other criteria included being aged 50 years or younger, and aneurysm as an indication for surgery (not infection or dissection). Data collected included basic patient epidemiology, theatre, critical care and hospital time and resources involved, complications and follow-up. Twelve patients were identified from theatre records that fulfilled criteria for comparison to PEARS, 3 valve-sparing root replacements and 9 total root replacements. Main financial differences favouring PEARS were seen in theatre time, blood product usage, and critical care and hospital length of stay. These were reflected by the cost-weight calculation for the admission. Two additional patients were analysed to show the costs associated with a complicated recovery and discuss potential future direction for the technique. PEARS offers financial and clinical outcome advantages compared to established operations despite the high up-front cost of the individualised prosthesis.

An integrative approach to the Marfan aortic root between the patient, the physician and basic scientists: A case study in personalised external aortic root support (PEARS)

An integrative approach to the Marfan aortic root between the patient, the physician and basic scientists: A case study in personalised external aortic root support (PEARS)

Aortic flow patterns before and after personalised external aortic root support implantation in Marfan patients

Implantation of a personalised external aortic root support (PEARS) in the Marfan aorta is a new procedure that has emerged recently, but its haemodynamic implication has not been investigated. The objective of this study was to compare the flow characteristics and hemodynamic indices in the aorta before and after insertion of PEARS, using combined cardiovascular magnetic resonance imaging (CMR) and computational fluid dynamics (CFD). Pre- and post-PEARS MR images were acquired from 3 patients and used to build patient-specific models and upstream flow conditions, which were incorporated into the CFD simulations. The results revealed that while the qualitative patterns of the haemodynamics were similar before and after PEARS implantation, the post-PEARS aortas had slightly less disturbed flow at the sinuses, as a result of reduced diameters in the post-PEARS aortic roots. Quantitative differences were observed between the pre- and post-PEARS aortas, in that the mean values of helicity flow index (HFI) varied by −10%, 35% and 20% in post-PEARS aortas of Patients 1, 2 and 3, respectively, but all values were within the range reported for normal aortas. Comparisons with MR measured velocities in the descending aorta of Patient 2 demonstrated that the computational models were able to reproduce the important flow features observed in vivo.

Biomechanical properties of the Marfan's aortic root and ascending aorta before and after personalised external aortic root support surgery

Marfan syndrome is an inherited systemic connective tissue disease which may lead to aortic root disease causing dilatation, dissection and rupture of the aorta. The standard treatment is a major operation involving either an artificial valve and aorta or a complex valve repair. More recently, a personalised external aortic root support (PEARS) has been used to strengthen the aorta at an earlier stage of the disease avoiding risk of both rupture and major surgery. The aim of this study was to compare the stress and strain fields of the Marfan aortic root and ascending aorta before and after insertion of PEARS in order to understand its biomechanical implications.Finite element (FE) models were developed using patient-specific aortic geometries reconstructed from pre and post-PEARS magnetic resonance images in three Marfan patients. For the post-PEARS model, two scenarios were investigated—a bilayer model where PEARS and the aortic wall were treated as separate layers, and a single-layer model where PEARS was incorporated into the aortic wall. The wall and PEARS materials were assumed to be isotropic, incompressible and linearly elastic. A static load on the inner wall corresponding to the patients’ pulse pressure was applied.Results from our FE models with patient-specific geometries show that peak aortic stresses and displacements before PEARS were located at the sinuses of Valsalva but following PEARS surgery, these peak values were shifted to the aortic arch, particularly at the interface between the supported and unsupported aorta. Further studies are required to assess the statistical significance of these findings and how PEARS compares with the standard treatment.

Personalised External Aortic Root Support (PEARS) Compared with Alternatives for People with Life-Threatening Genetically Determined Aneurysms of the Aortic Root.

Personalised external aortic support was first proposed in 2000 by Tal Golesworthy, an engineer with familial Marfan syndrome and an aortic root aneurysm. After putting together a research and development team, and finding a surgeon to take on the challenge to join him in this innovative approach, he was central to the manufacture of the device, custom made for his own aorta. He was the patient for the ‘first in man’ operation in 2004. Ten years later he is well and 45 other people have had their own personalised device implanted. In this account, the stepwise record of proof of principle, comparative quantification of the surgical and perioperative requirements, 10 years of results, and development and research plans for the future are presented.

Personalised external aortic root support (PEARS) in Marfan syndrome: analysis of 1–9 year outcomes by intention-to-treat in a cohort of the first 30 consecutive patients to receive a novel tissue and valve-conserving procedure, compared with the published results of aortic root replacement

ObjectiveAmong people with Marfan syndrome who have a typical aortic root aneurysm, dissection is a characteristic cause of premature death. To pre-empt Type A dissection, composite root replacement with a...