Aortic Valve Reimplantation Research Articles

Surgical Approaches for Aortic Root Aneurysm: A Comparative Analysis of the David and Yacoub Techniques

Introduction: This paper compares the David and Yacoub procedures for valve-sparing aortic root replacement, two leading techniques for treating aortic root aneurysms while preserving the native aortic valve. Both methods aim to avoid prosthetic valve replacement and the need for lifelong anticoagulation. Material and Methods: We reviewed the technical nuances, clinical outcomes, and long-term durability of each technique, incorporating findings from recent and historical studies. Also, we'd like to present two case reports from our clinic showing the application of the David procedure. Results: The David procedure involves complete excision of the aortic root and reimplantation of the native aortic valve within a Dacron graft. It offers superior long-term durability and lower reoperation rates, particularly in younger patients and those with connective tissue disorders. In contrast, the Yacoub procedure entails partial root resection and remodeling with preservation of the sinuses of Valsalva, making it a viable option for older patients or those with isolated root dilation. Conclusions: Both the David and Yacoub procedures are advanced techniques for aortic root replacement, each with unique advantages and challenges. The David procedure, with its excellent durability, has consistently delivered successful outcomes. It is especially beneficial for younger patients and those with connective tissue disorders, supporting its role as a preferred approach for long-term outcomes in this population.

Creation of aortic regurgitation model on isolated porcine heart and aortic valve-sparing root replacement using a new device for aortic valve cusps positioning

Valve-sparing surgery in ascending aortic and root aneurysms combined with aortic regurgitation (AR) is a relevant and actively developing trend. The ways to improve these operations are the development of new devices to simplify and standardize valve-sparing procedures using animal models and testing in experiment. Objective. To review experimental methods of aortic root aneurysm and AR modeling, as well as devices simplifying aortic valve-sparing root replacement, including a new device for positioning of aortic valve (AV) cusps during valve-sparing root replacement with AV reimplantation (David procedure), which we have developed. Materials and methods. The components of the developed device were manufactured by three-dimensional printing with preliminary modeling in the parametric environment of computer-aided design with the open source code FreeCAD 0.20.1. The possibility of David procedure on the isolated swine aortic root in the experiment using the new device was evaluated. Results. During the experiments we performed aortic root replacement with AV reimplantation on the isolated porcine aortic root. We noted that the developed device provides good exposure of the surgical correction zone and reduces the probability of damage to the aortic root structures, especially to the AV cusps, in the process of reimplantation. The device eliminates the necessity to use assistants during the main stage of intervention, which reduces the probability of operator-associated complications. Conclusion. Standardization and simplification of reimplantation of AV cusps into the vascular graft during aortic root replacement with the help of the device developed by us is achieved by performing trial positioning of AV cusps and hydraulic tests at different positions of the cusps, which simplifies the search for the optimal point of coaptation and allows to keep the found best position of the cusps until their anchoring inside the graft. The directions of further research are improvement of the design of the developed device, experimental studies with evaluation of the result of valve-sparing surgery under conditions of pulsating fluid flow, testing of the technology on large laboratory animals.

Development of a device for assessment of aortic root parameters and positioning of aortic valve cusps during aortic valve-sparing root replacement

Background. A promising method of surgical treatment of aneurysms of the root and ascending aorta (AA) with unchanged aortic valve (AV) cusps is aortic valve-sparing root replacement (VSRR) with AV reimplantation (David procedure). To date, there are no clear indications to make a choice in favor of valve-replacing or valve-sparing intervention. The result of visual evaluation and the choice of treatment method based on the surgeon’s experience remains the main criteria. Objective. In the experiment to develop a prototype and method of application of the device for positioning of AV cusps, which will simplify and standardize aortic valve-sparing root replacement, improve the results and increase the reproducibility of these operations. Design and methods. Three-dimensional (3D) modeling of the device components was performed in the parametric open-source computer-aided design environment FreeCAD 0.20.1. Two-dimensional sketches were converted into three-dimensional models and exported as stl files for 3D printing. Solid components of the model were made of polylactic acid (PLA-plastic), elastic components were made of rubber-like photopolymer (Dropstil F556 10 shore A) also by 3D printing using SLA technology. Results. The device consists of 2 similar ring-sizers of variable diameter connected by three struts of variable length. In the upper part of each of the struts fastenings to the distal ring represents T-shaped cutouts for temporary locking of the suture-holders passed through the commissures of the AV cusps. For proximal locking of the aortic graft and the proximal ring-sizer, 3 U-shaped sutures are used, passed from inside to outside through the AV ring, the proximal part of the graft and taken in the tourniquets. The diameters of the ring-sizers can be varied between 25–40 mm by rotating a worm drive. A graft is placed on the inner side of the device, the suture-holders attached to the tops of the commissures are locked in the T-shaped notches in the upper parts of the struts. The device will allow changing the position of the coaptation point, coaptation square and performing hydraulic tests in different positions of the cusps, as well as variable diameters at the level of the AV ring and sinotubular junction (25–40 mm). When the target position of the coaptation point, coaptation area and satisfactory hydraulic test result are achieved, the cusps with commissures are locked inside the graft and the device is removed. Conclusion. A new device has been developed to facilitate, reproduce, and standardize VSRR. The results obtained will facilitate and accelerate the performance of VSRR, increase the reproducibility of the technique, and reduce the risks of complications.

Aortic valve performance after remodelling versus reimplantation in a propensity-matched comparison.

Both aortic root remodelling and aortic valve (AV) reimplantation have been used for valve-sparing root replacement in patients with aortic root aneurysm with or without aortic regurgitation. There is no clear evidence to support one technique over the another. This study aimed to compare remodelling with basal ring annuloplasty versus reimplantation on a multicentre level with the use of propensity-score matching. This was a retrospective international multicentre study of patients undergoing remodelling or reimplantation between 2010 and 2021. Twenty-three preoperative covariates (including root dimensions and valve characteristics) were used for propensity-score matching. Perioperative outcomes were analysed along with longer-term freedom from AV reoperation/reintervention and other major valve-related events. Throughout the study period, 297 patients underwent remodelling and 281 had reimplantation. Using propensity-score matching, 112 pairs were selected and further compared. We did not find a statistically significant difference in perioperative outcomes between the matched groups. Patients after remodelling had significantly higher reintervention risk than after reimplantation over the median follow-up of 6 years (P = 0.016). The remodelling technique (P = 0.02), need for decalcification (P = 0.03) and degree of immediate postoperative AV regurgitation (P < 0.001) were defined as independent risk factors for later AV reintervention. After exclusion of patients with worse than mild AV regurgitation immediately after repair, both techniques functioned comparably (P = 0.089). AV reimplantation was associated with better valve function in longer-term postoperatively than remodelling. If optimal immediate repair outcome was achieved, both techniques provided comparable AV function.

Early and Short-term Outcomes of Adopting Aortic Valve Re-Implantation Technique Addressing DeBakey Type 1 Aortic Dissection

Early and Short-term Outcomes of Adopting Aortic Valve Re-Implantation Technique Addressing DeBakey Type 1 Aortic Dissection

ASSESSMENT OF PATIENTS' QUALITY OF LIFE AFTER DAVID SURGERY

Modern cardiac surgery increasingly requires rapid physical and mental rehabilitation of the patient. Today, more and more attention is paid to the peculiarities of psycho-emotional indicators in patients who are planned or have undergone surgical interventions. The quality of life of patients after David's operation for aneurysm of the root and ascending aorta remains unexplored. The aim: assessment of the quality of life of patients with aortic aneurysm who underwent David's valve-preserving operation. Materials and methods. From December 2015 to April 2023, 38 patients were operated on using the technique of aortic valve reimplantation with direct Dacron prosthesis "David" and 40 patients with prosthetic aortic valve and ascending aorta "Bentall operation". The mean age of patients was 46.97 ± 12.2 years in group 1 and 52.08 ± 12.08 in group 2, respectively. The share of men is 92.1% in group 1 and 97.5% in group 2. The average observation period is 31.89 ± 22.42 months. Results.Not a single fatal case was recorded within 30 days of the postoperative period. The percentage of survival after the observation period is 97.36% in group 1 and 92.5% in group 2. We analyzed the quality of life of all patients according to eight scales: physical functioning (PH), role functioning (RP), pain intensity (BP), general health (GH), vital activity (VT), social functioning (SF), emotional condition (RE) and mental health (MH). When analyzing patient questionnaires in the scale of physical functioning, we calculated a sufficiently high indicator, which was 94.59 ± 6.71% in group 1 and 79.5% ± 8.46% in group 2. On all other scales, there was also an advantage in the group patients who underwent David's operation. Conclusions. From the obtained results, it can be stated that patients after David's operation in the medium term have excellent physical and mental health indicators and are completely adapted to daily life compared to the results after Bentall's operation. David's valve-sparing operation, especially in isolated, planned situations, ensures normal functioning of the aortic valve with no regurgitation. This operation can be performed with very low rates of complications and postoperative mortality. Thus, in our center, all patients with aortic root aneurysms are potential candidates for valve-sparing operations.

Discussion to: Outcomes of aortic root replacement with tricuspid aortic valve reimplantation in patients with residual aortic regurgitation

Discussion to: Outcomes of aortic root replacement with tricuspid aortic valve reimplantation in patients with residual aortic regurgitation

Survival and repair durability in patients undergoing concomitant aortic valve reimplantation and mitral valve repair

The study objective was to determine repair durability and survival in patients with and without connective tissue disorders undergoing concomitant aortic valve reimplantation and mitral valve repair. From 2002 to 2019, 68 patients underwent concomitant aortic valve reimplantation and mitral valve repair, including 27 patients with Marfan syndrome (39.7%). Follow-up echocardiograms were analyzed using nonlinear multiphase mixed-effects cumulative logistic regression. The regurgitation grade over time was estimated by averaging patient-specific profiles. Survival and freedom from reoperation were estimated by the Kaplan-Meier method. At 7years, 11% of patients had aortic insufficiency greater than mild (severe in 2 patients). There was no difference in greater than mild aortic insufficiency between patients with or without Marfan syndrome (P=.37). Twenty percent of patients had progressed to mitral regurgitation greater than mild (severe in only 1 patient). The prevalence of recurrent mitral regurgitation was higher in those without Marfan syndrome, with greater than mild regurgitation increasing to 24% by 2years and remaining constant thereafter (P=.04). Freedom from reoperation on the aortic valve or mitral valve was 83% at 10years and did not differ between Marfan syndrome groups. There were no cases of perioperative mortality. Survival at 5 and 10years was 94% and 87%, respectively, without a difference between those with and without Marfan syndrome. Patients can undergo a total repair strategy using combined aortic valve reimplantation and mitral valve repair procedures with a low risk of mortality and complications, with favorable freedom from both residual valve regurgitation and reoperation.

Aortic Valve Reimplantation or Aortic Root Replacement With a Valved Conduit?

Aortic Valve Reimplantation or Aortic Root Replacement With a Valved Conduit?

Outcomes of aortic root replacement with tricuspid aortic valve reimplantation in patients with residual aortic regurgitation

To characterize residual aortic regurgitation (AR), identify its risk factors, and evaluate outcomes following aortic root replacement with aortic valve reimplantation. From 2002 to 2020, 756 patients with a tricuspid aortic valve underwent elective reimplantation for aortic root aneurysm. AR on transthoracic echocardiograms before hospital discharge was graded as mild or greater. Machine learning was used to identify risk factors for residual AR and subsequent aortic valve reoperation. Sixty-five patients (8.6%) had mild (58 [7.7%]) or moderate (7 [0.93%]) residual postoperative AR. They had more severe preoperative AR (38% vs 12%; P<.0001), thickened cusps (7.7% vs 2.2%; P=.008), aortic valve repair (38% vs 23%; P=.004), and multiple returns to cardiopulmonary bypass for additional repair (11% vs 3.3%; P=.003) than those without AR. Predictors of residual AR were severe preoperative AR, smaller aortic root graft, and concomitant cusp repair. At 10years, patients with versus without residual AR had more moderate or severe AR (48% vs 7.0%; P<.0001) and freedom from reoperation was worse (89% vs 98%; P<.0001). Residual AR was a risk factor for early reoperation. Concomitant coronary bypass, lower body mass index, and lower ejection fraction were risk factors for late reoperation. Ten-year survival was similar among patients with and without residual AR (97% vs 93%; P=.43). Residual AR after elective reimplantation of a tricuspid aortic valve for aortic root aneurysm is uncommon. Patients with severe preoperative AR and those who undergo valve repair have higher risk for residual AR, which can progress and increase risk of aortic valve reoperation.

Aortic valve cusp repair does not affect durability of modified aortic valve reimplantation for tricuspid aortic valves

During aortic valve reimplantation, cusp repair may be needed to produce a competent valve. We investigated whether the need for aortic valve cusp repair affects aortic valve reimplantation durability. Patients with tricuspid aortic valves who underwent aortic valve reimplantation from January 2002 to January 2020 at a single center were retrospectively analyzed. Propensity matching was used to compare outcomes between patients who did and did not require aortic valve cusp repair. Cusp repair was performed in 181 of 756 patients (24%). Patients who required cusp repair were more often male, were older, had more aortic valve regurgitation, and less often had connective tissue disease. Patients who underwent cusp repair had longer aortic clamp time (124 ± 43minutes vs 107 ± 36minutes, P=.001). In-hospital outcomes were similar between groups and with no operative deaths. A total of 98.3% of patients with cusp repair and 99.3% of patients without cusp repair had mild or less aortic regurgitation at discharge. The median follow-up was 3.9 and 3.2years for the cusp repair and no cusp repair groups, respectively. At 10years, estimated prevalence of moderate or more aortic regurgitation was 12% for patients with cusp repair and 7.0% for patients without cusp repair (P=.30). Mean aortic valve gradients were 6.2mm Hg and 8.0mm Hg, respectively (P=.01). Ten-year freedom from reoperation was 99% versus 99% (P=.64) in the matched cohort and 97% versus 97%, respectively (P=.30), in the unmatched cohort. Survival at 10years was 98% after cusp repair and 93% without cusp repair (P=.05). Aortic valve reimplantation for patients with tricuspid aortic valves has excellent long-term results. Need for aortic valve cusp repair does not affect long-term outcomes and should not deter surgeons from performing valve-sparing surgery.

Reimplantation of the aortic valve in patients with tricuspid aortic valve: the Toronto General Hospital experience.

Aortic valve sparing operations were introduced three decades ago but controversy remains regarding its appropriateness, reproducibility and durability. This article describes the long-term outcomes of patients who had reimplantation of the aortic valve. All patients who had reimplantation of a tricuspid aortic valve at Toronto General Hospital from 1989 through 2019 were selected for this study. Patients were followed prospectively with periodical clinical assessments and imaging of the heart and aorta. Four hundred and four patients were identified. The median age was 48.0 [interquartile range (IQR), 35.0-59.0] years and 310 (76.7%) were men. There were 150 patients with Marfan syndrome, 20 with Loeys-Dietz syndrome and 33 with acute or chronic aortic dissections. The median follow-up was 11.7 (IQR, 6.8-17.1) years. There were 55 patients alive and without reoperation at 20 years. The cumulative mortality at 20 years was 26.7% [95% confidence interval (CI): 20.6-34.2%], the cumulative incidence of reoperation on the aortic valve was 7.0% (95% CI: 4.0-12.2%) and the development of moderate or severe aortic insufficiency was 11.8% (95% CI: 8.5-16.5%). We could not identify variables associated with reoperation on the aortic valve or with the development of aortic insufficiency. New distal aortic dissections were common in patients with associated genetic syndromes. Reimplantation of the aortic valve in patients with tricuspid aortic valve provides excellent aortic valve function during the first two decades of follow-up. Distal aortic dissections are relatively common in patients with associated genetic syndromes.

Twenty-year experience of aortic valve reimplantation using the Valsalva graft: a successful technique with well-made device!

The introduction of the aortic valve (AV) reimplantation, also called David procedure, by David and Feindel in 1992 have placed a milestone for AV sparing [1]. This, one of the most 2 important valve-sparing aortic root replacement operations became the standard technique for patients with aortic root aneurysm with or without AV regurgitation with excellent short- and long-term results [2]. Over the years, the surgical technique of AV reimplantation has evolved significantly from the originally described technique aiming to mimic the anatomical form of the aortic root. Many modifications, including the ‘so-called’ David I–V operations, using different techniques such as plication stitches to create pseudo-/neo-sinuses [3, 4], 2 cylindrical grafts [5] or even special anatomically designed bulged grafts [6] have been described. In this issue of the European Journal of Cardiothoracic Surgery, Chirichilli et al. describe their 20-year-long experience with AV reimplantation using the Gelweave Valsalva graft Vascutek Ltd, Terumo Company (Renfrewshire, Scotland, UK) in 265 patients with aortic root aneurysm with or without AV regurgitation [7]. This device has been designed and invented by the senior author of the current article De Paulis [6] at the end of the last millennium and implemented in the routine practise at the beginning of 2000. The presented study belongs to the largest published cohorts describing AV reimplantation with this graft. The early- and long-term outcomes (mean of 7.1 years) are excellent. The overall survival at 15 years was 87.6 ± 3.4% and freedom from cardiac death was excellent and stable at 99.6 ± 0.4% up to 15 years. Freedom from recurrent AR ≥moderate and freedom from reoperation remained stable up to 15 years at 92.2 ± 2.1% and 95.9 ± 1.6%, respectively. In addition, the incidence of infective endocarditis, thromboembolism and haemorrhage was extremely low. Importantly, a clear message that can be derived from this paper is that David procedure using this particular graft is an excellent and durable option for the surgical treatment of the patients with aortic root aneurysm with or without AV regurgitation. The authors also report that long-term results might have improved after the implementation of routine performance of AV analysis with calliper.

Planning of graft size and 3D reconstruction using virtual reality technique in aortic valve reimplantation.

To evaluate applicability and feasibility of the virtual imaging technology for diagnosis and planning of the aortic valve sparing procedure. Pre-operative electrocardiography-gated computed tomography images of 12 adult patients with aortic root pathology were used for 3D reconstruction of the aortic root geometry. The structural analysis was conducted with focusing on spatial architecture of key aortic root structures such as the three commissures, intervalvular triangles (IVT), as well as on morphology of the aortic root base (AoB) and of the sinotubular junction (STJ). In all included patients, the 3D mapping of aortic root (AoR) morphology was successfully performed. The pre-operative diameter of the AoB was 30.6 ± 2.6 mm and of the STJ 46.5 ± 7.5 mm (p < 0.001). Based on measured AoB diameter, the mean size of prosthesis used was 28.3 ± 1.37 mm. The planar arrangement of the three commissures was similar to an equilateral triangle where the three commissures were at similar distance for each individual sinus with 39.8 ± 6.64 mm for right, 37.5 ± 7.10 mm for left, and 39.2 ± 7.52 mm for non-coronary sinus (p = 0.72) subsequently. The similar height of the three IVT's with 32.6 ± 5.87 mm for right, 33.6 ± 6.14 mm for anterior, and 31.7 ± 5.83 mm for left IVT (p = 0.73) was suggestive for all three commissures being positioned in the same plane. Consequently at reimplantation, the orientation of the three commissures followed the pattern of an equilateral triangle. The reconstructed images revealed a detailed 3D anatomy of the aortic root, with the spatial arrangement of the intervalvular triangles, planimetric orientation of the commissures, as well as determination of the AoB and STJ diameters. Obtained information was successfully applied to pre-operative surgical planning. The reimplantation technique, the height of the reimplanted intervalvular triangles, as well as their orientation are crucial for achieving adequate aortic valve function.

Twenty-year experience of aortic valve reimplantation using the Valsalva graft.

Over the past 20 years, valve-sparing aortic root replacement has aroused increasing interest because of a progressive attitude towards the preservation of natural tissue. Aortic reimplantation is the most used technique to spare the valve, allowing simultaneously aortic root replacement and aortic annular stabilization. The reimplantation into a graft with sinuses guarantees an optimal anatomic and functional reconstruction with established good results at 15 years. The aim of this study is to report the world longest follow-up (up to 20 years) of aortic valve reimplantation using the Valsalva graft. From February 2000 to December 2021, 265 consecutive patients with aortic root aneurysm received aortic valve reimplantation using the Valsalva graft. From 2018, leaflet plication with the routine use of calliper was performed. For each patient, we performed both intraoperative and post-procedural transoesophageal echocardiography. All patients were followed with clinical assessment and echocardiography. The mean duration of follow-up was 85 ± 63 months. The study cohort had a median age of 55 ± 18 and 87.2% were male. The aortic root aneurysm was associated to bicuspid aortic valve in 18.9% of patients and to Marfan syndrome in 10.6% of cases. 55.9% had an aortic regurgitation ≥ 2+. Overall survival at 15 was 87.6 ± 3.4. Freedom from cardiac death was stable at 99.6 ± 0.4 at 5, 10 and 15 years. Freedom from recurrent AR ≥3+ and freedom from reoperation remained stable at 10 and 15 years at 92.2 ± 2.1 and 95.9 ± 1.6, respectively. There was a minimal incidence of infective endocarditis (0.8%), thromboembolism (2.2%) and haemorrhage (2.0%). Six out of 7 patients requiring reoperation had surgery in the first period of our experience (last in 2004). Early suboptimal results had a negative effect on residual aortic regurgitation. Moreover, we hypothesized that the routine use of calliper may have contributed to a further improvement of the outcome, even if these data need to be confirmed by a longer follow-up. The first long-term follow-up after aortic valve reimplantation using the Valsalva graft demonstrated excellent results. These long-term results gradually improved with learning curve, remaining stable during the second decade of observation. The systematic use of calliper may have contributed to a further improvement of the outcome.

Aortic valve reimplantation in patients with connective tissue disorders: Are the leaflets durable?

The durability of reimplanted myxomatous aortic valves in root replacements for patients with connective tissue disorders (CTD) is unclear; therefore, we sought to evaluate the long-term resilience of these repairs. From January 1980 to January 2020, 214 patients with CTD and 645 without CTD underwent primary, elective aortic valve reimplantation operations at Cleveland Clinic. The CTD cohort included 164 (77%) with Marfan, 23 (11%) with Loeys-Dietz, and 7 (3.3%) with Ehlers-Danlos CTD. We accounted for differing patient characteristics between the groups by propensity score matching to compare outcomes, yielding 96 matched pairs. Longitudinal echocardiographic measures were compared using nonlinear mixed effects models. In the CTD cohort, there were no operative mortalities (30-day or in-hospital), 1 (0.47%) stroke, and 1 (0.47%) early in-hospital reoperation for valve dysfunction. Ten-year prevalence of no aortic regurgitation was 86%, mild 11%, and moderate 3%. Ten-year freedom from reoperation was 97%. In propensity matched cohorts, there were no significant differences in in-hospital outcomes, longitudinal aortic regurgitation and mean gradient, risk of reoperation on the aortic valve, or risk of late death. Aortic valve reimplantation is a durable operation in patients with CTD and root aneurysms. These patients do not experience early degeneration of their reimplanted aortic valves.

Surgical Options for Physiological Treatment of Aortic Root Dilatation Either Isolated or Associated with Aortic Valve Disease.

Patients affected by severe aortic root pathology require an operation to replace the dilated aortic root and repair or replace the aortic valve, which is very frequently involved in the disease. Among the surgical options available for aortic root replacement, the Bentall operation and the David aortic valve reimplantation procedure are the most commonly used by surgeons. This article provides an overview of the Bio-Bentall and David operations. It illustrates their surgical details and discusses the correct indications for both procedures to achieve excellent long-term outcomes. Finally, the authors present their experience with the physiologic treatment of aortic root pathology by using stentless Bio-conduits and David reimplantation in a cohort of patients with long-term follow-up. A comparative analysis of early and late results along with an evaluation of possible benefits and drawbacks related to each technique concluded that both procedures were effective in correcting the aortic root pathology, and the results were adequate and stable over time. Since hemodynamic performance was more improved after the David operation, it should be preferred, whenever feasible, in younger and active patients.

Reply to de Kerchove et al.: 'Rather addition than extension of Florida sleeve indications'.

We read the invited commentary by de Kerchove et al. entitled ‘Is extension of Florida Sleeve indications taking us in the right direction?’ [1] in reference to our work [2] with great interest. We thank the authors for their valuable comments. In fact, there is no uniform technique to perform aortic valve (AV) reimplantation. David [3] himself published variations up to David V. There is a vast body of technical development. In our department, we also implemented steps to create a sinus bulge to avoid retraction of the right coronary base and to adapt for the geometry of bicuspid AVs [4]. We have started using AV reimplantation in 1992 and over years only sporadically used the Florida sleeve technique. Performing more complex operations and treating elderly patients, we had a concern of prolonged clamp times especially when concomitant surgery was indicated. Another indication was borderline dilatation of the aortic root. The question is what to do with a young adult with myxomatous mitral valve disease and an aortic root of 40 mm diameter? This kind of wrapping of the root, nearly without any risk of bleeding, could be an acceptable prophylactic tool. In AV repair, one faces frequently dilated roots by far not reaching the current indication for the root replacement. The sleeve around the aorta provides potentially a stable geometry and eases the judgement for AV cusp repair.

High-precision computer segmentation of the aortic valve and aortic root

Background. Valve-sparing aortic root replacement with aortic valve reimplantation is a rapidly developing method of treatment of ascending aortic aneurysm. The improvement of the results of this method is inextricably linked with the understanding of the relationships between the initial functional and planimetric characteristics of the valvular-aortic complex, the technical aspects of the reimplantation procedure and the results obtained.Objective. To search and analyze previously little-studied factors — the planimetric characteristics of the aortic valve and the aortic root.Design and methods. High-precision assessment of the planimetry of the aortic flaps requires precision visualization methods and subsequent creation of virtual three-dimensional models. The creation of high-precision reconstructions became possible due to the introduction of specialized computer-aided design environments into clinical practice. Due to the technical complexity, none of the known methods has previously been used to accurately measure all the structures of the aortic root in a large group of patients. Simplification, acceleration of reconstruction construction, as well as scaling of this technique remain unresolved tasks.Results. The main result of this work is the development of an algorithm of segmentation of the aortic root and the construction of a high-precision three-dimensional model of the aortic valve, as well as the practical implementation of an algorithm for determining main planimetric parameters of the aortic root with the possibility of scaling to a large group of patients.Conclusion. The method makes it possible to construct a high-precision three-dimensional reconstruction of the internal structures of the aortic root within a few hours and is valuable both for determining the tactics and technical features of surgical treatment of the patient, and for studying the effect of the anatomy of the aortic root on the development of recurrence of aortic insufficiency after valve-sparing surgery.

Aortic valve reimplantation in patients with Marfan and other connective tissue syndromes: a success story for these patients!

After the introduction of aortic valve (AV) and root replacement (Bentall–De Bono procedure), survival changed dramatically for patients with AV and/or root pathologies, including patients with Marfan syndrome or other genetic connective tissue diseases (CTD) [1, 2]. Since the latter mentioned patients are presented for surgery at a very young age, mechanical prosthesis is generally chosen over the biological. The consequent need for life-long anticoagulation exposes the patients to the potential, sometimes severe complications accounting up to 5% per year [3]. Due to this fact, AV-sparing techniques have been evolving over the last 30 years. Especially, AV reimplantation, as described by David and Feindel in 1992, became the standard technique for valve-sparing aortic root replacement with excellent short- and long-term results, even in patients with Marfan syndrome or other CTD [2, 4, 5]. In this issue of the European Journal of Cardiothoracic Surgery, Gil et al. describe their experience with AV reimplantation (David operation) in 157 patients with Marfan syndrome (143 patients) and other CTD [6]. The presented cohort is one of the largest published yet. The early- and long-term outcomes (median of 7.3 years) are impressively good. Especially, survival at 10 and 15 years with 98% is excellent and not different to the general Spanish population for the same age and gender. Furthermore, reported freedom from greater than moderate aortic regurgitation and reintervention were 90% and 96% at 10 years, respectively. Importantly, all these patients were operated by the same cardiosurgical team. The clear message that can be derived from this article is that David operation is an excellent option for the surgical treatment of these patients. The authors also conclude these patients should be centralized in referral centres and operated by very experienced surgeons. Finally, based on these results, authors postulate the threshold for prophylactic surgery in CTD should be reviewed and lowered.