Reduction Aortoplasty Research Articles

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.

Anaesthesia for Thoracic Aortic Disease: Series of Four Cases

Thoracic aortic diseases involving the thoracic aorta, from the ascending aorta, the aortic arch to the descending aorta, can present in the form of aneurysms, dissection, tear and coarctation which usually lead to various complications, requiring surgical intervention. The same can be addressed surgically by ascending aorta replacement or reduction aortoplasty with/without Aortic Valve Replacement (AVR). The anaesthetic implications might vary depending on the pathology of the thoracic aortic disease which can be acute or chronic and, silent or symptomatic. Anaesthetic management of four patients (1 female and 3 males) with varied thoracic aortic diseases have been described in the series, including bicuspid aortic valve with severe aortic stenosis, Ischaemic Heart Disease (IHD) with severe Aortic Regurgitation (AR) with ascending aortic aneurysm, ascending aortic dilatation in a known Takayasu arteritis patient and coarctation of aorta with atrial septal defect. These patients underwent aortoplasty with or without aortic root replacement. Full cardiopulmonary bypass with Deep Hypothermic Circulatory Arrest (DHCA) at 16-20°C was the technique used for these procedures as it prevents stroke and ensures cognitive function. This technique had no additional cannulas, less chances of intimal injury or embolisation and clear surgical fields. During the process of rewarming, Inj. nitroglycerine was started which reduced preload, conserving the myocardium against ischaemic injuries. These patients were successfully managed perioperatively and were discharged with good outcomes postoperatively

P24 The Serious Danger of Using Reduction Aortoplasty With External Wrapping to Treat Ascending Aortic Aneurysms

There are multiple surgical methods in use internationally to treat ascending aortic aneurysms. One such controversial technique is the use of reduction aortoplasty with external wrapping. We present a case which highlights the grave dangers of using external wrapping to treat ascending aortic aneurysms.

Aortic Valve replacement with Reduction Aortoplasty with Mesh Prosthesis in 75 years old with Sever aortic Regurgitation with Aortic Aneurysm

Although classic and standard procedure for patients with ascending Aorta aneurysm with Sever aortic Regurgitation is Bentall surgery but in some selected cases this complex surgery was not performed with different reason like advanced age and coexisting comorbidity involving renal and hepatic and lung Function. In our cases 75 years old man with chronic renal failure ( Cr= 3.2 ) who was known case of sever aortic Regurgitation and Ascending Aortic Aneurysm with 5.5 diameter.replacement of Aortic Valve with Biologic Prosthesis Aortic Valve and Reduction Aortoplasty with Mesh prosthesis was done successfully with good result with early follow up.

Surgical repair of the moderately dilated ascending aorta combined with bicuspid aortic valve replacement

Background: Ascending aortic (AA) dilatation is common in patients with bicuspid aortic valve (BAV). In BAV replacement, surgery of the AA is indicated in the case if AA diameter exceeds 45 mm. Aortic valve replacement combined with an AA intervention is associated with increased risk of complications. The feasibility of the reduction ascending aortoplasty for correction of the dilated AA remains disputable.Aim: To analyze the results of BAV surgical replacement with simultaneous surgical correction of the borderline AA dilatation (45-50 mm) by the reduction aortoplasty (RAP) or supracoronary AA replacement (SPR).Materials and methods: This single center prospective non-randomized study included 53 patients with significant BAV stenosis and AA dilatation (45-50 mm), divided into 2 groups: BAV surgical replacement combined with RAP AA replacement (group 1, 36 patients) and BAV replacement with SPR (group 2, 17 patients). There were no significant differences between the patients of the two groups in their characteristics of the underlying disease, complications and comorbidities.Results: Hospital mortality was 0%. No between-group differences in the early postoperative course were found. At later term, 44 (81.5%) patients were assessed; median (dispersion) of the follow-up was 36 (25; 50) months. Two patients from the group 2 died during the follow-up. The long-term survival was better in the group 1 (p = 0.028). No differences in the combined adverse event rate were observed between the groups (p = 0.633). The median (dispersion) of the AA absolute increment and the rate of dilatation after RAP were 1.0 (0.0; 3.0) mm and 0.24 (0.00; 0.95) mm/year, respectively. The predictor of AA increment rate ≥ 2 mm/year was the baseline blood pressure level (odds ratio 1.321, 95% confidence interval 1.050-1.662; p=0.017). The threshold preoperative blood pressure value for the increased risk of the long-term AA expansion rate was 138 mmHg.Conclusion: The efficacy and safety of RAP and SRP combined with BAV replacement in AA borderline dilatation are similar. Combined BAV surgery and RAP is effective and safe in patients with systolic blood pressure level ≤ 135 mmHg. Combined BAV replacement with SRP seems reasonable in patients with arterial hypertension.

Koroner Arter Baypas Greftleme ile Off-Pump Küçültücü Aortoplasti: 3 Olgu

Koroner Arter Baypas Greftleme ile Off-Pump Küçültücü Aortoplasti: 3 Olgu

Long-Term Results Following Pericardial Patch Augmentation for Incompetent Bicuspid Aortic Valves: A Single Center Experience

Many techniques for repair of bicuspid aortic valves have been described and long-term results differ considerably. The current study evaluates our institutional results using the pericardial patch augmentation technique with the aim of increasing coaptation height. From November 2002 through April 2015, 103 consecutive patients underwent aortic valve repair using pericardial patch augmentation for incompetent bicuspid aortic valve. Of them 26 were referred with an aortic valve regurgitation grade 1+ or 2+ and were excluded from the current report. The remaining 77 patients with a mean age of 42 ± 14 years and aortic valve regurgitation grade of 3+ or higher were included in this retrospective single-center study. The main step of operative technique is the partial correction of leaflet prolapse by leaflet plication and overcorrection of coaptation height augmenting the fused leaflet with an autologous pericardial patch. In 45 patients (58%) an isolated aortic valve repair was performed. The ascending aorta was dilated in 32 cases (42%), and the following procedures were used for correction: reduction aortoplasty (19 patients), the David procedure (11 patients), and ascending aortic replacement (2 patients). Long-term results were evaluated by echocardiography and standardized questionnaire. Mean follow-up was 4.9 ± 4.6 years. There was no perioperative or 90-day mortality. Survival at 5 and 10 years was 96.1% and 93.5%, respectively. Freedom from reoperation at 5 and 10 years was 94.8% and 93.5%, respectively. At the latest echocardiographic follow-up, 94% of patients had none to trivial aortic regurgitation and 6% showed aortic regurgitation greater than or equal to 2°. Mean aortic gradients were 12.6 ± 9 mm Hg. One patients developed endocarditis 1 year after the procedure. There were no perioperative or long-term major neurologic events. The pericardial patch augmentation technique provides reliable long-term competence of reconstructed bicuspid aortic valves and results in a low reoperation rate, with other valve related complications being rare.

PP-110 Reduction Aortoplasty for Ascending Aortic Aneurysm: Midterm Results

PP-110 Reduction Aortoplasty for Ascending Aortic Aneurysm: Midterm Results

Successful use of reduction aortoplasty in patients undergoing aortic valve replacement with ascending aortic dilatation.

Ascending aortic dilatation is associated with bicuspid aortic valve disease. Some advocate replacing the ascending aorta in conjunction with aortic valve replacement. We adopted to perform ascending aortoplasty at the time of aortic valve replacement.

Mortality benefit after reinforced reduction aortoplasty for dilated ascending aorta. Meta-analysis

Mortality benefit after reinforced reduction aortoplasty for dilated ascending aorta. Meta-analysis

Midterm follow up in patients with reduction ascending aortoplasty.

BackgroundThe reduction ascending aortoplasty in patients with an aortic ectasia/dilatation is a common procedure during concomitant cardiac operations. Aim of the follow up study was the evaluation of possible re-dilatation and complications.MethodsFrom 1998 to 2010 124 patients (69% male; mean age 66.6 ± 12 ys) with ectasia of the ascending aortic who had no further indication for an aortic replacement, were included. The mean preoperative diameter of the ascending aorta was 4.2 ± 0.6 cm. The patients risk profile was moderate (mean EF 51% ± 11%, Euroscore 4.2 ± 2.1). To treat the dilatation of the ascending aorta, a longitudinal incision was performed and a strip of the aortic wall was resected. A reduction aortoplasty was carried out with a double-layered suture line using a 4/0 Prolene mattress suture with an additional 4/0 Prolene running suture. A follow up (rate 95%) was performed by echocardiography- and clinical examination.ResultsAll patients underwent reduction aortoplasty associated with a primary cardiac surgical procedure (AVR 63%, CABG 13%, other or combination 24%). The intrahospital mortality rate was 4%. Four aortic bleeding complications occurred. After a mean postoperative period of 57 ± 39 months, the ascending aortic diameter (3.6 ± 0.6 cm) was still significantly (P < 0.01) reduced. No postoperative aortic-related complications including aortic rupture, dissection and reoperation were observed. In 4 patients, the ascending aorta had re-dilated to the preoperative diameter.ConclusionReduction ascending aortoplasty without external wrapping is a safe procedure with acceptable midterm results in patients with asymptomatic dilatations and concomitant cardiac surgical procedures.

Aortoplasty for Management of the Dilated Distal Ascending Aorta During Proximal Aortic Reconstruction

When aneurysms of the ascending aorta extend into the arch, the conventional approach is replacement witha Dacron graft, including a distal beveled hemiarch anastomosis with the patient under hypothermic circulatory arrest. For certain cases, we propose an alternative strategy combining replacement of the proximal and middle segments of the ascending aorta with external wrapping aortoplasty for the distal segment. This "turtleneck" aortoplasty achieves successful complete repair of the ascending aorta without the risks associated with circulatory arrest.

Less invasive surgery of the proximal aorta

Results No conversion to full sternotomy was necessary. The aortic cross-clamp, cardiopulmonary bypass and operative times averaged 136 ± 20 min., 186 ± 36 min. and 327 ± 83 min., respectively. In eight patients, the right axillary artery was cannulated for establishing cardiopulmonary bypass; the others were cannulated centrally. All patients except one received a procedure on the ascending aorta, either replacement in 30 (58%) or reduction aortoplasty in 21 (40%). Aortic root replacement was additionally performed in 31 patients (60%), including David in 20 (38%) and Ross procedure in 6 (11.5%). The aortic arch was replaced either partially in 5 (10%) or totally in 3 (6%) patients, in moderate hypothermia employing antegrade cerebral perfusion. Additional procedures, included mitral valve repair in 15 (29%) patients and coronary grafting. Ventilation time, intensive care unit and hospital stay averaged 17 ± 12 hours, 2 ± 1, and 11 ± 9 days. Chest drainage was 470 ± 380 ml/24 hours. Permanent neurologic deficit did not occur. Wound dehiscence was observed in a single patient (2%). Thirty-day and hospital mortality were not observed. Conclusions Less invasive surgery on the aortic root, ascending aorta and aortic arch can be performed safely and reproducibly. Potential benefits include a minimized risk of wound dehiscence and reduced postoperative bleeding. The PUS does not compromise the quality of the operation.

Reduction aortoplasty supported by pericardial patch, early results and outcome at Queen Alia Heart Institute

Methods From 2006 till end of 2011, 37 patients with aneurysm of the ascending aorta without involvement of the aortic root underwent longitudinal reduction aortoplasty supported by pericardial patch which was sewed to the lateral wall of the ascending aorta by 5/0 prolene. The average age was 70.9 year ±4.2, females were 28 (75.7%), the average ejection fraction was 42.1%. The size of the ascending aorta was less than 55 mm in all patients; all patients underwent other cardiac procedure at the same time. 33 patients (89%) aortic valve replacement, 22 patients (59.5%) aortic valve replacement with CABG, 4 patients (11%) CABG alone, 7 patients (19%) were redo aortic valve replacement. Mean follow-up was 2 year.

Off pump reduction aortoplasty in ascending aortic aneurysm

Methods Three patients with a story of ascending aorta aneurysm were selected from October 2012 to December 2012. Trans thoracic echocardiography, angio CT scan and a coronarography were performed during the pre op evaluation. The surgical procedure was performed on beating heart in off pump using a low dose of heparin (5000 UI). A side clamp was used to plicate longitudinally the ascending aorta at the level of maximum dilatation from the sino tubular junction up to the troncus anonymous with controlled hypotension (70 mmHg).The plication was performed with a double layer of 3/0 prolene suture reinforced with two strips of Teflon along the plication. Furthermore, an opened longitudinally 32 mm Dacron tube was wrapped around the ascending aorta and sutured to the plication with a double 3/0 prolene suture.

Ascending Aortic Aneurysm Treatment With Linear Plication and External Wrapping Technique: Mid-Term Results

The aim of this study is to assess mid-term outcomes of reduction aortoplasty and wrapping technique which is an alternative method to replacement of the aorta in ascending aortic aneurysms. We aimed to show the efficacy of this technique especially when used for patients with increased perioperative mortality or morbidity due to their concomitant pathologies. From March 2009 to May 2011, 22 patients underwent reduction aortoplasty and wrapping for ascending aortic aneurysm. The study group consisted of 16 male and six female patients with a mean age of 68 ± 13.1 years. Linear plication with wrapping was performed as concomitant surgery in 20 patients and as a primary procedure in two patients. The diameter of the aorta was measured using a computed tomography scan 12 months after surgery and was compared with the preoperative value. Mean aortic clamp and cardiopulmonary bypass times were 91.0 ± 58.1 and 150.7 ± 80.9 minutes, respectively. Mortality was 9.1%. In no case was the postoperative death related to the aortoplasty procedure. The mean postoperative ascending diameter was 29.5 ± 1.04 mm (vs. preoperative 49.1 ± 4.1 mm, p < 0.001). Mean follow-up time was 17.2 ± 8.88 months. During the follow-up period we observed that there were no findings to suggest redilatation. Linear plication with external wrapping is a therapeutic option with promising mid-term results, in carefully selected, high surgical risk patients with an ascending aortic aneurysm.

Should the ascending aorta be replaced less frequently in patients with bicuspid aortic valve disease?

I read with interest the recent article by Girdauskas et al. [1] concerning the risk of late aortic events after aortic valve replacement in bicuspid aortic valve (BAV) patients with ascending aortic dilatation. The risk of late aortic events was low in their study group, with a freedom from adverse events of 95% at 10 years and 93% at 15 years, and freedom from aortic interventions of 97 and 94%, respectively. The authors note that the actual followup with serial aortic imaging, either computed tomography or magnetic resonance angiography, was only 23%, however. Thus, their paper may seriously underestimate the actual need for reoperation in the study cohort. Furthermore, the method of followup was telephone interview rather than formal testing or evaluation. What is the actual rate of progression of aortic dilatation in the study population? How many of the patients now have asymptomatic and undiagnosed aortic aneurysms >5 cm? If one estimates a modest, particularly for BAV patients, progression of the aortic diameter at 0.5 mm per year, then in 11.5 years (the mean follow-up) the approximate growth will be 5.75 mm. If the aortic diameter starts at 45 mm, then in 11.5 years the diameter will be 50.75 mm. Thus, it is likely that at 11.5 years, patients would just begin developing clinically relevant aortic aneurysms with resultant aortic complications and surgical referrals. This article highlights an important and controversial area in aortic surgery. The current guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) recommend repair of the aortic root or replacement of the ascending aorta if the diameter of the aortic root or ascending aorta is >4.5 cm, for patients with BAV undergoing AVR [2]. This is a Class I, level C recommendation based on several supportive reports, including the study by one of the authors, Borger et al. [3]. More recently, Dr Svensson’s group [4] has also provided support for ‘proactive’ repair of the ascending aorta in BAV patients undergoing AVR with an aortic size >4.5 cm, although the rates of late aortic complications in both the valve alone and the valve-aorta surgical groups were both similarly low. The present authors state that of the 18 BAV patients in Dr Borger’s 2004 study who developed an ascending aortic aneurysm requiring redo surgery, there were 11/18 (61%) who underwent aortic valve replacement for structural valve deterioration. The authors also note that ‘it may be difficult to retrospectively determine patients who underwent replacement of the ascending aorta as the principal reason for their reoperation’ [1]. However, in Dr Borger’s 2004 study, the average size of the ascending aorta for the 18 patients requiring reoperation was 58 ± 9 mm [3]. Thus, the majority of the 18 BAV patients do meet ACC/AHA guideline criteria for replacement of the ascending aorta at the threshold of 5.0 cm [2], whether or not one considers this as a ‘primary’ or ‘secondary’ reason. Are the authors, including Dr Borger, now recommending that the guidelines be changed and that we operate on the ascending aorta less frequently in patients with BAV? If so, what threshold of aortic size would the authors recommend? Finally, there have been a few small studies that advocate reduction aortoplasty to treat mild to moderate dilatation of the ascending aorta in patients with BAV [5]. This approach is controversial and arguably unsettling, as it would assume the connective tissue abnormalities found in the aortic wall of BAV patients emanate from primarily a haemodynamic, as opposed to a genetic, etiology. The lead author’s recent review summarizes quite thoroughly the genetic vs haemodynamic argument, vis-a-vis, BAV [6]. Based on their recent data, would the authors advocate reduction aortoplasty for BAV patients with aortic sizes 4.5–5.0 cmwho undergo AVR?

Reply to Lee

Reply to Lee

Modified reduction aortoplasty with external reinforcement of the ascending aortic aneurysm caused by giant cell arteritis treated as polymyalgia rheumatica

A 74-year-old Japanese woman was referred to our hospital for surgical repair of an ascending aortic aneurysm and severe aortic valve regurgitation. She had received low dose steroid treatment for 6 years due to a diagnosis of the polymyalgia rheumatica (PMR), and no signs of inflammation were detected serologically. Modified reduction aortoplasty with external prosthetic support of the ascending aorta was performed following uneventful aortic valve replacement under cardiopulmonary bypass. The macroscopic view of the ascending aortic wall showed the diffuse spotty medial defects. The pathological interpretation of the aneurysmal wall was giant cell arteritis (GCA). Because PMR is intimately associated with GCA, physicians should be aware of the development of thoracic aortic aneurysm even in the course of PMR. Reduction aortoplasty is simple and may not be precluded from the treatment option for the aortic dilatation associated with giant cell arteritis.

Long-term follow-up of reduction ascending aortoplasty with autologous partial wrapping: for which patient is waistcoat aortoplasty best suited?

The aim of this study was to assess the early and long-term outcomes of a previously introduced technique of reduction aortoplasty for asymmetric ascending aortic dilatation. Different indication criteria for reduction ascending aortoplasty have been previously adopted by others, thus another purpose was to identify the patient profile for whom this approach may be best suited. Between January 2001 and December 2010, reduction ascending aortoplasty with "waistcoat technique" was performed in 156 patients (mean age 62 ± 12 years, 61% male) with asymmetric dilatation of the ascending aorta (prevailing at the convexity of the supracoronary tract). Eighty-seven patients had a tricuspid aortic valve (TAV), 69 a bicuspid aortic valve (BAV). Aortoplasty was associated to aortic valve replacement in 60% cases. Preoperative, intraoperative, early postoperative and follow-up data were analysed. Comparisons were performed between groups of valve morphology (TAV versus BAV) and subgroups of baseline valve function. In patients with a follow-up time >1 year the annual growth of the ascending tract was calculated and compared between subgroups. The independent predictors of growth velocity were assessed by multivariable linear regression analysis. Mean cross-clamp and cardiopulmonary bypass times were 39 ± 18 and 69 ± 29 min, respectively. Hospital death was 1.9%. In no case, postoperative death or any early complication was causally related to the aortoplasty procedure. The mean postoperative ascending diameter was 3.1 ± 0.3 (versus preoperative 5.2 ± 0.8 cm, P < 0.001). Mean follow-up time was 4 ± 2.5 years (maximum 10 years): 7-year survival was 95 ± 2%; 7-year freedom from aortic events 94 ± 4%. Redilatation (ascending diameter exceeding 4.5 cm) occurred in two patients, acute dissection in one: all three preoperatively had significant aortic regurgitation. The mean ascending aortic diameter at last follow-up was 3.4 ± 0.5 cm; median diameter progression was 0.4 mm/year, with no significant difference between TAV and BAV and no patient reaching 0.5 cm/year. With TAV, the only determinant of aortic growth rate was normal preoperative valve function (P = 0.04); with BAV, the degree of regurgitation at preoperative echocardiography (P = 0.001). Waistcoat aortoplasty proved a safe and durable treatment for patients with asymmetric non-syndromic non-familial ascending aorta dilatation. The technique showed its best durability in aortic stenosis patients and in patients with normofunctional BAV.