Preoperative Aortic Insufficiency Research Articles

Incidence, risk factors, and long-term outcomes associated with permanent pacemaker implantation after aortic root replacement

ObjectivePermanent pacemaker implantation (PPI) after aortic valve replacement is associated with long-term mortality. However, data regarding PPI after aortic root replacement (ARR) is lacking. Herein we describe the incidence, risk factors, and long-term outcomes of PPI after ARR. MethodsConsecutive patients undergoing ARR from 2005 to 2020 were selected after excluding those with endocarditis, type A dissection, or preoperative PPI. Patients requiring PPI after ARR were identified, along with the indication and timing. Independent factors associated with PPI after ARR were identified and long-term survival was assessed. ResultsThe incidence of PPI was 3.8% (n = 85) among 2240 patients undergoing ARR. PPI was performed a median of 7 days (interquartile range, 5-12 days) after ARR most commonly for complete heart block (73%). Bicuspid aortic valve (odds ratio [OR], 1.89; P = .02), female sex (OR, 1.74; P = .04), preoperative heart block (OR, 2.70; P = .02), and prior aortic valve replacement (OR, 2.18; P = .01) were independently associated with PPI while preoperative aortic insufficiency (OR, 0.52; P = .01) and valve-sparing root replacement procedure compared with bio-Bentall (OR, 0.40; P = .01) were protective. Patients requiring PPI after ARR were not at increased risk of operative or long-term mortality compared with patients not requiring PPI (P = .26); however, those undergoing PPI experienced significantly longer hospital length of stay (13 vs 7 days; P < .001). ConclusionsThe incidence of PPI after ARR remains low, particularly after VSRR. Preoperative conduction disturbance, prior AVR, and bicuspid aortic valve are all associated with increased risk of PPI. Although PPI is associated with longer length of stay, it is not associated with early or late mortality.

Aortic valve degeneration after valve-sparing root replacement in patients with bicuspid aortopathy or connective tissue disorder

ObjectiveWe sought to evaluate outcomes of valve-sparing root replacement (VSRR) in patients with bicuspid aortopathy (BAV) versus other connective tissue disorder (CTD). MethodsThis was a single-center cohort study of consecutive patients undergoing VSRR via reimplantation from 2000 to 2023 with BAV or CTD. Operative outcomes, Kaplan-Meier survival estimates, and cumulative risk of reoperation and recurrent aortic insufficiency (AI) with the competing risk of death were assessed. ResultsOf 516 patients who underwent VSRR, 109 (51.9%) had BAV and 101 (48.1%) had CTD. Patients with BAV were older (46.9 ± 10.4 vs 38.4 ± 14 years, P < .001) and more likely male (89.0% vs 56.4%, P < .001) and hypertensive (66.1% vs 28.7%, P < .001). Preoperative AI was similar (P = .57) between groups (30.3% mild, 18.3% moderate, 11.1% severe). Most patients had no/trivial immediate postoperative residual AI (96.3% vs 93.1%). Operative mortality was zero; postoperative adverse events were minimal. Mean clinical follow-up was 5.2 ± 4.4 years; 10-year survival was 95.6% versus 95.7% (P = .70). Echocardiographic follow-up was 3.9 ± 4.1 years; incidence of >2+ AI (9.7% vs 10.1%, P = 1.0) was similar between groups, whereas the incidence of moderate or greater aortic stenosis was greater with BAV (7.5% vs 0%, P = .02). Reoperation was low in both groups (3.7% vs 5.9%, P = .65). Competing risk analysis found no difference in reoperation hazard between BAV and CTD groups (hazard ratio, 0.36; 95% confidence interval, 0.07-1.81, P = .21). ConclusionsPatients with BAV and CTD have excellent operative outcomes, no mortality, and minimal residual AI after VSRR. Although the incidence of recurrent AI was similar, patients with BAV are at risk for AS.

Medium-Term Outcomes of Concomitant Aortic Valve Repair in Patients with Continuous-Flow Left Ventricular Assist Device

Our objective was to analyze the development of aortic insufficiency in patients who received central aortic valve repair when undergoing continuous-flow left ventricular assist device implantation. We conducted a retrospective review of patients who underwent HeartMate II or 3 (Abbott Lab) implantation between 2004 and 2022. Ninety-four patients were excluded from analysis for history of aortic valve procedures, a bicuspid aortic valve, baseline trace aortic insufficiency, or other concomitant aortic valve procedure. Patients who had ≥ mild aortic insufficiency had concomitant aortic valve repair. Clinical characteristics, serial echocardiograms, and outcomes were determined. Of the 656 patients who underwent HeartMate II or 3 implantation, 105 patients (59 HeartMate II and 46 HeartMate 3) met study criteria. Median age was 68 years [60-74 years], 91.4% [n=96] were male, 54.4% [n=56] were white, and 68.6% [n=72] received support as destination therapy. Preoperative aortic insufficiency degree was 54.3% (n=57) mild, 23.8% (n=25) mild-to-moderate, 20.0% (n=21) moderate, 1.0% (n=1) moderate-to-severe, 1.0% (n=1) severe. In hospital mortality was 5.7% [n=6]. Freedom from ≥ moderate aortic insufficiency was 96.4% (95%CI: 92.5%-100%), 93.3% (95%CI: 87.6%-99.2%), and 91.0% (95%CI: 84.1%-98.5%) at 1-year, 2-year, and 3-year post-implantation, respectively. One HeartMate II patient experienced severe aortic insufficiency and was treated with a heart transplant. Three-year survival was 63.4% [95%CI: 52.9%-75.9%]. Central aortic valve repair may be an effective technique to mitigate aortic insufficiency in HeartMate II and 3. A larger cohort study with longer duration of follow up is warranted to further investigate the clinical impact.

Midterm Results of an Algorithmic 3-Pronged Approach to Bicuspid Aortic Valve Repair

BackgroundThis study evaluated midterm outcomes of a 3-pronged algorithm for bicuspid aortic valve (BAV) repair. Valve-sparing root reimplantation (VSRR) was performed for patients with aortic root dilatation. In those without a root aneurysm, external subannular ring (ESAR) was performed for annuli ≥28 mm and subcommissural annuloplasty (SCA) for annuli <28 mm. MethodsThis was a retrospective review of prospectively collected data of 242 patients undergoing primary BAV repair from April 29, 2004, to March 1, 2023, at a single institution. Primary end points were mortality, structural valve degeneration (SVD), which was defined as a composite of more than moderate aortic insufficiency or severe aortic stenosis, and reintervention. ResultsThe algorithm was used to treat 201 patients; of these, 130 underwent VSRR, 35 had ESAR, and 36 underwent SCA. Most were men with mean age of 43.8 years (SD, 12.0 years), which was similar between groups. Preoperative aortic insufficiency more than moderate was more common for ESAR compared with VSRR and SCA (74.3% vs 37.7% vs 44.4%, P < .001). At 30 days, mortality was 0.8% (n = 1) for VSRR and 0% for ESAR and SCA. At 6 years, overall Kaplan-Meier survival was 98.9% (95% CI, 97.3%-100%), with no differences between groups (P = .5). The cumulative incidence of SVD was 4.7% (95% CI, 0.1%-9.2%) for VSRR, 6.4% (95% CI, 0%-14.6%) for ESAR, and 0% for SCA (P = .4). Similarly, the cumulative incidence of reintervention with all-cause mortality as a competing risk was 2.2% (95% CI, 0.4%-6.9%), 6.1% (95% CI, 1%-17.9%), and 0% for VSRR, ESAR, and SCA, respectively (P = .506). ConclusionsA 3-pronged algorithmic approach to BAV repair results in excellent survival and freedom from reoperation at 6 years.

Preoperative higher right ventricular stroke work index increases the risk of de novo aortic insufficiency after continuous-flow left ventricular assist device implantation

During continuous-flow left ventricular assist device (CF-LVAD) support, hemodynamic shear stress causes a burden on aortic valve (AV) leaflets, leading to de novo aortic insufficiency (AI). This study investigated the influence of preoperative hemodynamic parameters on de novo AI in CF-LVAD recipients. We reviewed 125 patients who underwent CF-LVAD implantation without concomitant AV surgery between 2005 and 2018. De novo AI was defined as moderate or severe AI in those with none or trivial preoperative AI. During mean 30 ± 16 months of CF-LVAD support, de novo AI-free rate was 86% and 67% at 1 and 2 years, respectively. Multivariable analysis showed that higher right ventricular stroke work index (RVSWI) (hazard ratio, 1.12 /g/m2/beat; 95% confidence interval, 1.00–1.20; p = 0.047) and trivial grade AI (hazard ratio, 2.8; 95% confidence interval, 1.2–6.4; p = 0.020) were independent preoperative risk factors for de novo AI. The longitudinal analysis using generalized mixed effects model showed that higher RVSWI was associated with continuous AV closure after LVAD implantation (Odd ratio, 1.20/g/m2/beat; 95% confidence interval, 1.00–1.43 /g/m2/beat; p = 0.047). Right heart catheterization revealed that preoperative RVSWI was positively correlated with postoperative pump flow index in patients with continuously closed AV (r = 0.44, p = 0.04, n = 22). Preoperative higher RVSWI was a significant risk factor for de novo AI following CF-LVAD implantation. In patients with preserved right ventricular function, postoperative higher pump flow may affect AI development via hemodynamic stress on the AV.

Influence of preoperative aortic regurgitation on long-term autograft durability and dilatation in children and adolescents undergoing the Ross procedure

ObjectivePrimary aortic insufficiency (AI) is a risk factor for autograft reintervention in adults undergoing the Ross procedure. We sought to examine the influence of preoperative AI on autograft durability in children and adolescents. MethodsFrom 1993 to 2020, 125 consecutive patients between ages 1 and 18 underwent a Ross procedure. The autograft was implanted using a full-root technique in 123 (98.4%) and included in a polyethelene terephthalate graft in 2 (1.6%). Patients with aortic stenosis (aortic stenosis group) (n = 85) were retrospectively compared with those with AI or mixed disease (AI group) (n = 40). Median length of follow-up was 8.2 years (interquartile range, 3.3-15.4 years). The primary end point was the incidence of severe AI or autograft reintervention. Secondary end points included changes in autograft dimensions analyzed using mixed-effect models. ResultsThe incidence of severe AI or autograft reintervention was 39.0% ± 13.0% in the AI group and 8.8% ± 4.4% in the aortic stenosis group at 15 years (P = .02). Annulus z scores increased in both aortic stenosis and AI groups over time (P < .001). However, the annulus dilated at a faster rate in the AI group (absolute difference, 3.8 ± 2.0 vs 2.5 ± 1.7; P = .03). Sinus of Valsalva z scores increased in both groups as well (P < .001), but at similar rates over time (P = .11). ConclusionsChildren and adolescents with AI undergoing the Ross procedure have higher rates of autograft failure. Patients with preoperative AI have more pronounced dilatation at the annulus. Akin to adults, a surgical aortic annulus stabilization technique that modulates growth is needed in children.

P97: Concomitant Aortic Valve Replacement and Left Ventricular Assist Device Implantation in Patients with Aortic Insufficiency

Background: Preoperative aortic insufficiency (AI) is one of the most important predictors of progression to moderate to severe AI during left ventricular assist device (LVAD) support. Our group has aggressively corrected preexistent AI, including mild AI, with bioprosthetic aortic valve replacement (AVR). We analyzed the operative and postoperative results of our patients. Methods: We reviewed data of all patients who underwent LVAD implantation and had concomitant AVR in our center between May 2012 and June 2022. We used either a St. Jude or Edwards bioprosthetic aortic valve. Results: Twenty-five patients (19 men, 6 women) with an average age of 61±12 years had concomitant AVR and LVAD implantation (23 patients as destination therapy and 2 as bridge to transplantation). Eight patients were INTERMACS profile 1, 12 profile 2, and 5 profile 3. Twelve patients had mild, 7 mild to moderate, 4 moderate, 1 moderate to severe and 1 severe AVI. Cardiopulmonary bypass time was on average 136±30 min with cross-clamp time of 63±19 min. The median length of stay after LVAD implantation was 24 (IQR 19-32) days. Target INR ranged from 2 to 3. Five patients had gastrointestinal bleeding; thus, their INR target was between 1.8 -2.2. Four patients had strokes 66, 105, 762 and 1127 days after implantation. The median length of LVAD support was 1143 (range 33-2470) days. One patient died in the hospital 33 days after surgery due to nonischemic bowel perforation-related sepsis. Three other patients died 469, 772 and 1710 days after LVAD implantation. Six patients had heart transplantation. Fifteen patients are alive on LVAD support with a median of 1290 days (range 231 to 2470). All 22 patients who reached 1-year follow-up had normal aortic values with 2 patients having trace and 4 mild AI starting 6 months after AVR. One patient had a valvular thrombus 15 months after surgery. Conclusion: Utilization of concomitant bioprosthetic AVR in patients undergoing LVAD implant who had mild to severe AI seems not to be harmful to patient postoperative management or survival.

Early results of geometric ring annuloplasty for bicuspid aortic valve repair during aortic aneurysm surgery.

ObjectivesGeometric ring annuloplasty has shown promise during bicuspid aortic valve repair for aortic insufficiency. This study examined early outcomes of bicuspid aortic valve repair associated with proximal aortic aneurysm replacement.MethodsFrom September 2017 to November, 2021, 127 patients underwent bicuspid aortic valve repair with concomitant proximal aneurysm reconstruction. Patient age was 50.6 ± 12.7 years (mean ± standard deviation), male gender was 83%, New York Heart Association Class was 2 (1-2) (median [interquartile range]), and preoperative aortic insufficiency grade was 3 (2-4). Ascending aortic diameter was 50 (46-54) mm, and all patients had ascending aortic replacement. Forty patients had sinus diameters greater than 45 mm, prompting remodeling root procedures. A total of 105 patients had Sievers type 1 valves, 3 patients had type 0, and 7 patients had type 2. A total of 118 patients had primarily right/left fusion, 8 patients had right/nonfusion, and 1 patient had left/nonfusion. Leaflet reconstruction used central leaflet plication and cleft closure, with limited ultrasonic decalcification in 31 patients.ResultsRing size was 23 (21-23) mm, and 26 of 40 root procedures were selective nonfused sinus replacements. Aortic clamp time was 139 (112-170) minutes, and bypass time was 178 (138-217) minutes. Postrepair aortic insufficiency grade was 0 (0-0) (P < .0001), and mean valve gradient was 10 (7-14) mm Hg. No early and 1 late mortality occurred. Four patients required reoperation for bleeding, and 4 patients required pacemakers. At a mean follow-up of 20 months (maximal 93), there were no valve-related complications, 5 late repair failures prompting valve replacement, and 1 death due to Coronavirus Disease 2019.ConclusionsGeometric ring annuloplasty for bicuspid aortic valve repair with proximal aortic aneurysm reconstruction is safe and associated with good early outcomes. Further experience and follow-up will help inform long-term durability.

David Procedure: A 21-year Experience With 300 Patients

BackgroundValve-sparing aortic root replacement with the David procedure is an alternative to the Bentall procedure in patients with aortic root aneurysm. The aim of this study was to describe our long-term experience with this technique and the predictive factors of late failure. MethodsBetween January 1998 and August 2019, 300 consecutive patients underwent a David procedure. Clinical and echocardiographic early- and long-term outcomes were analyzed. Median follow-up was 7.0 years (range, 4.1-11.5), with 98.3% complete. ResultsEarly mortality was 1%. No early valve-related reoperations occurred. There were 9 cardiac-related deaths and 22 reinterventions (19 valve-related). All patients survived reoperation. In 3 patients reintervention consisted of transcatheter aortic valve implantation. Overall survival rates were 95.3% (95% confidence interval [CI], 92.0-97.2), 91.1% (95% CI, 86.5-94.2), and 82.9% (95% CI, 75.3-88.4) at 5, 10, and 15 years, respectively. Freedom from postoperative aortic insufficiency (AI) grade ≥ 2 was 84.8% (95% CI, 79.9-88.6) and 74.3% (95% CI, 67.4-79.9) at 5 and 10 years, respectively. Freedom from reintervention for aortic valve disease was 97.1% (95% CI, 94.2-98.5), 92.9% (95% CI, 88.2-95.7), and 92.5% (95% CI, 87.1-95.7) at 5, 10, and 15 years, respectively. Preoperative AI ≥ 2 (hazard ratio, 1.782; 95% CI, 1.352-2.350) and a ventriculoaortic junction ≥ 29 mm (hazard ratio, 3.379; 95% CI, 1.726-6.616) were predictive factors for postoperative AI ≥ 2 in a multivariate analysis (P < .001). ConclusionsPreoperative AI ≥ 2 and a ventriculoaortic junction ≥ 29 mm were identified as risk factors for late postoperative AI ≥ 2.

Impact of aortic valve effective height following valve-sparing root replacement on postoperative insufficiency and reoperation

BackgroundThis study evaluated the impact of anatomic aortic root parameters during valve-sparing root replacement on the probability of postoperative aortic insufficiency and freedom from aortic valve reoperation. MethodsFrom 1995 to 2020, 177 patients underwent valve-sparing root replacement (163 reimplantations, 14 remodeling). Preoperative and postoperative echocardiograms were analyzed to measure annulus and sinus diameters, effective height of leaflet coaptation, and degree of aortic insufficiency. Logistic regression was used to evaluate predictors of 2+ or greater late postoperative aortic insufficiency. Fine-Gray regression determined predictors for aortic valve reintervention. ResultsThe study population included 122 (69%) men with a mean age of 43 ± 15 years. A total of 119 patients (67%) had an identified connective tissue disorder. The cumulative incidence of aortic valve reoperation was estimated as 7% at 5 years and 12% at 10 years. The probability of 2+ or greater late postoperative aortic insufficiency was inversely related to effective height during valve-sparing root replacement (P = .018). As postoperative effective height fell below 11 mm, the probability of 2+ or greater aortic insufficiency exceeded 10%. On multivariable logistic regression, effective height (odds ratio, 0.53; 0.33-0.86; P = .010), preoperative annulus diameter (odds ratio, 1.44; 1.13-1.82; P = .003), and degree of preoperative aortic insufficiency (odds ratio, 2.57; 1.45-4.52; P = .001) were associated with increased incidence of 2+ or greater late postoperative aortic insufficiency. On multivariable Fine-Gray regression, risk factors for aortic valve reintervention included preoperative annulus diameter (subdistribution hazard ratio, 1.28 [1.03-1.59], P = .027), history of 3+ or greater aortic insufficiency (subdistribution hazard ratio, 4.28; 1.60-11.44; P = .004), and 2+ or greater early postoperative aortic insufficiency (subdistribution hazard ratio, 5.22; 2.29-11.90; P < .001). ConclusionsMeasures to increase effective height during valve-sparing root replacement may decrease the risk of more than mild postoperative aortic insufficiency after repair and the need for aortic valve reoperation.

Progression of aortic valve insufficiency during centrifugal versus axial flow left ventricular assist device support.

Long-term left ventricular assist device (LVAD) support can cause accelerated progression of aortic insufficiency (AI). The MOMENTUM trial has led to increased use of the HeartMate 3 (HM3) LVAD, due to greater hemocompatibility. However, the differential effect on the rate of progression of AI during HM3 support versus HeartMate 2 (HM2) has not been extensively studied. This analysis compares the rates of progression to moderate or severe AI (MSAI) comparing a cohort of patients supported with the HM2 versus HM3. A retrospective review was performed on all consecutive patients implanted with HM2 or HM3 between May 2005 and June 2020. Follow-up time was limited to the first 6 years after LVAD implantation. Demographics and 4005 echocardiograms were assessed for 536 HM2 and 300 HM3 patients. The primary end point was progression to MSAI. Univariable and multivariable Cox proportional hazard regression and landmark analyses were performed. Progression to MSAI was greater in the HM2 (17%) versus HM3 (9.9%) cohort. On the univariable analysis, the hazard ratio for HM3 was 0.581 (95% confidence interval 0.370-0.909, P = 0.02) whereas on multivariable analysis hazard ratio was 0.624 (95% confidence interval 0.386-1.008, P = 0.0537). Preoperative AI, female sex and body surface area <2 were significantly associated with progression to MSAI. Landmark analysis suggests that LVAD type has the most significant effect on progression to MSAI between 1 and 2 years post-implantation. Current practice strategies achieved low rates of progression to MSAI. Preoperative AI, female sex and body surface area <2 were the most important predictors of progression to MSAI. Pump type appears to be of secondary importance.

Minimally invasive aortic valve repair using geometric ring annuloplasty.

As aortic valve repair (AVr) for aortic insufficiency (AI) expands, minimally invasive (Mi) approaches are increasingly being applied. Cardiac surgical techniques can be more difficult through small incisions, and this report analyzes medium-term outcomes for MiAVr facilitated by geometric ring annuloplasty. Since 2013, 58 patients were selected for AVr through upper sternotomy third-interspace incisions. The average age was 58.9 ± 15.4 (mean ± SD) years, 71% were male, and preoperative AI grade was 3.6 ± 0.8. Sixty-two percent (36/58) had a proximal aortic replacement for ascending aortic aneurysms (n = 26) and/or remodeling grafts for aortic root aneurysms (n = 10). Annuloplasty rings were placed subannularly (69% trileaflet; 31% bicuspid), and leaflet procedures were performed in 70%. The average ring diameter was 21.6 ± 1.4 mm, and the average aortic clamp time was 113 ± 35 min. After repair, AI grade fell to an average of 0.5 ± 0.6 (p < .0001), with a mean valve gradient of 12.5 ± 7.1 mmHg. No operative mortalities or major complications occurred. Three patients required reoperations for bleeding, and two had pacemakers. At an average follow-up of 38 months (maximal 88 months), three late deaths and no valve-related complications were observed. Four patients required reoperative aortic valve replacement over follow-up, and Kaplan-Meier survival and freedom from reoperation both exceeded 80% at 88 months. At the last follow-up, the average AI grade was 0.7 ± 0.7, and the mean valve gradient was 12.7 ± 6.3 mmHg. Geometric ring annuloplasty was safe and seemed to facilitate performing AVr ± proximal aortic replacement through Mi incisions. Hemodynamic improvements were significant, medium-term clinical outcomes were acceptable, and results could improve further with experience.

Development of De Novo Aortic Insufficiency in Patients With HeartMate 3

BackgroundDe novo aortic insufficiency (AI) is a common adverse event after continuous-flow left ventricular assist device (LVAD) placement and is associated with morbidity and mortality. This study aims to compare the development of de novo AI between HeartMate 3 (Abbott) and HeartMate II LVAD recipients. MethodsA retrospective review was conducted of clinical characteristics and serial echocardiograms (1 month, 6 months, and 1 year postimplantation) of HeartMate 3 patients implanted between November 2014 and March 2019 and of HeartMate II patients implanted between April 2004 and December 2015 at Columbia University Irving Medical Center. One hundred twenty-two patients were excluded from analysis for a history of aortic valve surgery, concomitant aortic valve surgery with LVAD implant, or more than trace preoperative AI left untreated. De novo AI was defined as development of more than mild AI after LVAD implant. ResultsIncluded in the study were 121 HeartMate 3 patients and 270 HeartMate II patients. After accounting for competing risks of death and transplantation, there was no significant difference in the development of de novo AI by 1 year postimplantation between HeartMate II and HeartMate 3 patients (P = .68). There was no significant difference in severity of AI developed up to 1 year post-implantation between HeartMate II and HeartMate 3 patients. ConclusionsDevelopment of de novo AI is comparable between HeartMate 3 and HeartMate II patients. There is no significant difference in severity of AI between HeartMate II and HeartMate 3 patients.

Success in Valve-Sparing Aortic Root Replacement: Judgment and Skill

Success in Valve-Sparing Aortic Root Replacement: Judgment and Skill

Preoperative Eccentric Aortic Regurgitation and Outcomes Following Valve-Sparing Root Replacement

The David V valve-sparing root replacement (VSRR) is well-established for the treatment of aortic insufficiency (AI) and advanced root aortopathy. The impact of cusp repair in trileaflet aortic valve (TAV) patients, however, with preoperative moderate-severe AI and an eccentric jet is unclear. This study compares outcomes in TAV patients with pre-operative AI >2+ based on jet centricity and cusp repair status. Review of a single institutional database identified 309 consecutive patients undergoing VSRR from 2005 to 2018. Of these, 51 patients had TAV with AI >2+: 25 concentric and 26 eccentric jets. Mean follow-up was 58 (SD = 44) months. Echocardiographic parameters were compared pre- and post-operatively. Kaplan-Meier analysis, longitudinal mixed modeling, and cumulative incidence were used to compare long-term survival, recurrence of AI >1+, and valve specific re-intervention, respectively. The mean age was 48 (SD = 12) years and 84% were male. Differences in preoperative comorbidities and echocardiographic parameters between groups were not statistically significant. Postoperative outcomes were similar in concentric vs. eccentric and cusp vs. no cusp repair. Recurrence of AI>1+ was minimal and unrelated to jet centricity (concentric = 1, eccentric = 3) and cusp repair (no cusp repair = 1, cusp repair = 3) long-term. Aortic valve replacement cumulative incidence was 0% for central and 5% for eccentric at 3-, 5-, and 10-years, respectively. Long-term mortality was similar regardless of jet centricity and cusp repair. In appropriately selected TAV patients with preoperative AI >2+, current results suggest VSRR provides a durable repair regardless of jet centricity or the need for cusp repair based on low rates of reintervention reported.

Patch Neointima Technique in Acute Type A Aortic Dissection: Midterm Results of 147 Cases

The patch neointima technique is a modified valve-sparing aortic root repair surgery for acute type A aortic dissection and the short-term outcomes are satisfactory. The midterm outcomes have not been reported. From January 2009 to December 2012, 147 patients underwent valve-sparing aortic root repair with the patch neointima technique for type A aortic dissection in our center. The midterm outcomes of the patients were evaluated by echocardiography and aortic computed tomography angiography. Of 147 patients, 32 patients (21.8%) underwent proximal arch repair, and 115 patients (78.2%) underwent proximal arch repair combined with triple-branched stent graft implantation. The perioperative mortality was 5.4%. Preoperative aortic insufficiency (AI) was observed in 94 patients (63.9%); 131 patients (89.1%) left the operating room with 0 AI; the remaining 16 patients (10.9%) had trace or less than 1+ AI. A total of 128 patients (87.1%) completed 7-year follow-up. The mean follow-up time was 5.7 ± 1.2 years. As many as 82% of patients (105) were 0 AI and 15.6% of patients (20) were 0.5+ trace or less than 1+ AI. No reoperation was performed for the aortic root. The diameters of sinotubular junction and sinus were reduced to the normal range (28.3 ± 4.2 mm and 30.5 ± 3.6 mm, respectively) and remained stable (28.9 ± 5.6 mm, P= .300, and 30.8 ± 4.2 mm, P= .540, respectively) during 7 years of follow-up. Valve-sparing aortic root repair with patch neointima technique was associated with stable function of the aortic valves and no expansion of the aortic root in the midterm.

Likelihood of Aortic Valve Preservation During Repair of Acute Type A Aortic Dissection.

We sought risk factors for replacement of the aortic valve with or without the root (AVR/root) in the setting of acute type A aortic dissection (ATAD) repair. All ATAD repairs at our institution from January 2005 to June 2018 were reviewed. Baseline characteristics were recorded. For patients with aortic valve preservation, we documented the degree of aortic insufficiency (AI) postoperatively and on subsequent echocardiograms when available. Logistic regression was used to determine the association between preoperative characteristics and the odds ratio of AVR/root. 206 patients underwent repair of ATAD. Thirty-four were excluded for no documented AI grading. Forty-six underwent AVR/root during repair of the ATAD (including 40 root replacements). Of 126 that did not undergo AVR/root, 42 (33.33%) had follow-up echocardiograms at a median of 68 months postoperatively, 2 required reintervention for valve insufficiency. An increase in the degree of AI, bicuspid valve morphology, size of the aortic root, and connective tissue disorder was significantly associated with increased risk of AVR/root. Of 130 patients without connective tissue disorder, bicuspid aortic valve, aortic root aneurysm or intimal root tear, the rate of valve preservation was 65/65 (100%), 25/29 (86.2%), and 22/40 (55%) for those presenting with mild, moderate, and severe AI, respectively. The degree of preoperative AI, bicuspid valve morphology, size of the aortic root, and connective tissue disorder significantly correlate with the failure of aortic valve preservation in patients with ATAD. The vast majority of tricuspid valves in patients without connective tissue disorder or aortic root pathology can be salvaged.

Likelihood of Aortic Valve Preservation During Repair of Acute Type A Aortic Dissection

We sought risk factors for replacement of the aortic valve with or without the root (AVR/root) in the setting of acute type A aortic dissection (ATAD) repair. All ATAD repairs at our institution from January 2005 to June 2018 were reviewed. Baseline characteristics were recorded. For patients with aortic valve preservation we documented the degree of aortic insufficiency (AI) postoperatively and on subsequent echocardiograms when available. Logistic regression was used to determine the association between preoperative characteristics and the odds ratio of AVR/root. A total of 206 patients underwent repair of ATAD. Thirty-four were excluded for no documented AI grading. Forty-six underwent AVR/root during repair of the ATAD (including 40 root replacements). Of 126 that did not undergo AVR/root, 42 (33.33%) had follow-up echocardiograms at a median of 68 months postoperatively and 2 required reintervention for valve insufficiency. Increase in degree of AI, bicuspid valve morphology, size of the aortic root, and connective tissue disorder were significantly associated with increased risk of AVR/root. Of 130 patients without connective tissue disorder, bicuspid aortic valve, aortic root aneurysm, or intimal root tear, the rate of valve preservation was 65/65 (100%), 25/29 (86.2%), and 22/40 (55%) for those presenting with mild, moderate, and severe AI, respectively. Degree of preoperative AI, bicuspid valve morphology, size of the aortic root, and connective tissue disorder significantly correlate with failure of aortic valve preservation in patients with ATAD. The vast majority of tricuspid valves in patients without connective tissue disorder or aortic root pathology can be salvaged.

Recurrent aortic insufficiency after emergency surgery for acute type A aortic dissection with aortic root preservation

ObjectivePatients with acute type A aortic dissection demonstrate a wide range of aortic insufficiency. Outcomes after valve resuspension and root repair are not well studied in the long term. We evaluated the long-term effects of preoperative aortic insufficiency in patients undergoing emergency root-preserving surgery for acute type A aortic dissection. MethodsFrom 2002 to 2017, 558 of 776 patients with acute type A aortic dissection underwent native aortic valve resuspension and root reconstruction. Patients were stratified into 4 groups by preoperative aortic insufficiency grade (n = 539): aortic insufficiency less than 2+ (n = 348), aortic insufficiency = 2+ (n = 72), aortic insufficiency = 3+ (n = 49), and aortic insufficiency = 4+ (n = 70). Multivariable ordinal longitudinal mixed effects and multi-state transition models were used to assess risk factors for recurrent aortic insufficiency. ResultsThe prevalence of cardiogenic shock in patients presenting with preoperative aortic insufficiency less than 2+, 2+, 3+, and 4+ was 53 of 348 (15.2%), 12 of 72 (16.7%), 10 of 49 (20.4%), and 24 of 70 (34.3%), respectively (P = .002). Postoperatively, 94.0% of patients had aortic insufficiency 1+ or less at discharge. Operative mortality was 34 of 348 (9.8%), 10 of 72 (13.9%), 6 of 49 (12.2%), and 12 of 70 (17.1%) (P = .303). In an ordinal mixed effects model, preoperative aortic insufficiency was associated with more severe postoperative aortic insufficiency. The multi-state transition model demonstrated that severe aortic insufficiency was associated with progression from no to mild aortic insufficiency (hazard ratio, 2.14; 95% confidence interval, 1.35-3.38), and progression from mild to moderate aortic insufficiency (hazard ratio, 5.70; 95% confidence interval, 1.88-17.30). ConclusionsPreoperative aortic insufficiency is an important predictor of recurrent aortic insufficiency in patients undergoing valve resuspension with root reconstruction for emergency acute type A aortic dissection repair. Increased echocardiographic surveillance for recurrent aortic insufficiency may be warranted in this cohort.

Development of De Novo Aortic Insufficiency in Patients with HeartMate 3

Aortic insufficiency (AI) is common following continuous flow left ventricular assist device (CFLVAD) and is associated with morbidity and mortality. This study aims to assess the incidence of de novo AI in HeartMate 3 (HM 3) LVAD recipients and compare the outcomes with HeartMate II (HM II) patients. A retrospective review was conducted of clinical characteristics and serial echocardiograms (1 month, 6 months, and 1 year post implant) of 151 HM 3 patients implanted between Nov. 2014 and March 2019, as well as of 270 HM II patients implanted between April 2004 and Dec. 2015 at our center. Patients (n=30) were excluded from analysis for a history of aortic valve (AV) surgery, concomitant AV surgery with LVAD implant, or more than trace preoperative AI left untreated. De novo AI was defined as more than mild AI. In the HM 3 cohort, mean age was 58 ± 12 and 84% were male. 74% received HM 3 as destination therapy. Incidence and degree of de novo AI in each group is summarized in Figure 1. 4 patients were readmitted due to significant AI and heart failure symptoms. Cumulative incidence curves showed that the probability of de novo AI at 1 year was 8.4% in the HM 3 cohort vs. 13% in the HM II cohort (Figure 2, p=0.29). In both cohorts, patients who had AV opening on echocardiogram at 1 month post implant were significantly less likely to develop de novo AI (100% freedom from de novo AI at 1 year for HM 3 with open AV vs. 84% for HM 3 with closed AV, 97% for HM II with open AV vs. 76% for HM II with closed AV). The incidence of de novo AI is low and comparable between HM 3 and HM II patients at our center. AV opening at 1 month post implant appears to be protective of this complication.