Repair Of Aortic Root Aneurysms Research Articles

Differences in Aortic Histopathology in Patients Undergoing Valve Reimplantation Surgery for Various Clinical Syndromes.

Objectives The study aims to investigate aortic histopathologic differences among patients undergoing aortic valve reimplantation, suggest different mechanisms of aortic root aneurysm pathogenesis, and identify factors associated with long-term success of reimplantation. Methods From 2006 to 2017, 568 adults who underwent reimplantation for repair of aortic root aneurysm, including patients with tricuspid aortic valves with no connective tissue disease (TAV/NoCTD, n = 314/568; 55.3%), bicuspid aortic valves (BAVs, n = 86/568; 15.1%), or connective tissue disease (CTD, n = 177/568; 31.2%), were compiled into three comparison groups. Patients with both BAV and CTD ( n = 9/568; 1.6%) were omitted to increase study power. Patient records were analyzed retrospectively, focusing on pathology reports, which were available for 98.42% of patients, and were classified based on their descriptions of aortic tissue samples, primarily from the noncoronary sinus. Mean follow-up time available for patients was 2.97 years. Results Aortitis, medial fibrosis, and smooth muscle loss were more common histopathologic findings in patients with TAV/NoCTD than in patients with BAV and CTD ( p < 0.05). Cystic medial degeneration was most often found in patients with CTD, then TAV/NoCTD, and least in BAV ( p < 0.01). Increases in mucopolysaccharides were found more often in the BAV group than in the TAV/NoCTD and CTD groups ( p < 0.01). There were no differences in the frequency of elastic laminae fragmentation/loss across these three groups. Among all patients, 1.97% ( n = 11/559) had an unplanned reintervention on the aortic valve after reimplantation, but no significant demographic or histopathologic differences were identified. Conclusion Despite some common histopathologic features among patients undergoing aortic valve reimplantation, there were enough distinguishing features among aortic tissue samples of TAV/NoCTD, BAV, and CTD patients to suggest that these groups develop root aneurysms by different mechanisms. No histopathologic features were able to predict the need for late reintervention on the aortic valve.

Aortic root aneurysm repair in a neonate with Loeys-Dietz syndrome.

Loeys-Dietz syndrome is a connective tissue disorder known to cause aggressive aortopathy in paediatric patients, but it is extremely rare for cardiovascular events to present during infancy. We report the first successful aortic repair in a neonate with LDS presenting in extremis with an early onset, massive aortic aneurysm.

Regurgitant Bicuspid Aortopathy: Is Valve-Sparing Root Replacement Equivalent to Bentall Procedure?

Repair of aortic root aneurysms with nonstenotic bicuspid valves (NS-BAVs) is achieved either with valve-sparing root replacement (VSRR) or conventional Bentall procedure (ROOT). Procedural and long-term outcomes comparing these 2 techniques are sparse and need investigation. From March 2004 to January 2019, 158 patients with an aortic root aneurysm and NS-BAV underwent VSRR (n= 78, 49.3%) or ROOT (n= 80, 50.6%). VSRR involved optional aortic valve repair (n= 47, 60%), and ROOT was performed with bioprosthetic (81.3%) or mechanical valve replacement (18.7%). Procedural and postoperative outcomes were obtained, and univariate and Kaplan-Meier analyses were performed. VSRR patients were younger (42.7 ± 12.0 years of age) than ROOT (54.8 ± 13.6 years of age) (P < .001). Cardiopulmonary bypass (CPB) and cross-clamp duration were longer in VSRR (CPB: 228.0 ± 39.1 minutes; cross-clamp: 200.1 ± 36.2 minutes) compared with ROOT (CPB: 199.5 ± 55 minutes; cross-clamp: 170.3 ± 39.5 minutes) (P < .001). Postoperative stroke, renal failure, pneumonia, and reoperation for bleeding were similar, but postoperative atrial and ventricular arrhythmias was lower in VSRR (15% vs 42%; P < .001). Length of stay and 30-day mortality were similar. At discharge, none had greater than trivial aortic insufficiency. Long-term 10-year survival and incidence of moderate-severe aortic insufficiency, aortic stenosis, and reoperation were equivalent between groups. Surgery for aortopathy associated with NS-BAV is safe and effective with either VSRR or ROOT. Despite its complexity, VSRR should be considered in the surgical treatment of this population.

Evaluation of aortic valve in valve sparing root replacement: Reimplantation versus noncoronary sinus replacement

BackgroundValve sparing aortic root replacement (VSRR) had been popularized in the last decades because preservation of the native valve allows for better hemodynamics, better left ventricular performance, lesser risk of endocarditis and avoidance of lifelong anticoagulation. Two basic types of VSRR techniques are used: reimplantation of the aortic valve (Tirone David) and remodeling of the aortic root(Yacoub). We compared the David reimplantation technique versus one or two sinus replacement in repair of aortic root aneurysm or dissection associated with aortic regurge. Patients & MethodsFifty patients were divided into two groups: Group I (25 patients) undergone David reimplantation technique, Group II (25 patients) undergone supracoronary with one or two sinus replacement. ResultsThere were two deaths (8%) within 30 days in each group. Postoperative significant regurge in Group I occurred in 1 case (4.3%) and in 2 cases (8.6%) in Group II with no significant difference. Cross clamp time was significantly shorter in Group II; 137 ± 37.0 min versus 177 ± 33.0 min in Group I. Significant bleeding occurred in 7 cases (28%) in Group I which was significantly higher than Group II; 1 case (4%). ConclusionReplacement of one or two sinuses is not inferior to reimplantation technique regarding early survival and correction of aortic regurge. Noncoronary sinus replacement provided better results than reimplantation technique regarding postoperative bleeding and cross clamp time.

Aortic-root aneurysm repair: how to deal with an abnormal circumflex artery from the right coronary sinus

Aortic-root aneurysm repair: how to deal with an abnormal circumflex artery from the right coronary sinus

Valve-Sparing Repair of Aortic Root Aneurysms: An Update on the Florida Sleeve

Aortic valve-sparing reimplantation remains an effective technique for repair of aortic root aneurysms. Studies indicate that the Florida Sleeve procedure is dimensionally stable and durable in the early postoperative period; however, our technique has evolved. We describe a 10-year institutional experience and the technical update of the Florida Sleeve repair for root aneurysms.

Abstract 9355: Mitral Valve Disease in Marfan Syndrome Patients Undergoing Aortic Root Replacement

Background: The primary cardiac manifestations of the Marfan syndrome (MFS) include aortic root dilation and mitral valve prolapse (MVP). There are only scant data describing MV disease in MFS patients who undergo aortic root replacement. Methods: We retrospectively studied 239 patients (90 female; mean age 34 y) with MFS enrolled in a prospective multicenter registry. All patients were referred for repair of aortic root aneurysms with either composite graft aortic valve replacement (AVR, n=59) or an aortic valve-sparing procedure (AVS, n=180). MVP and mitral regurgitation (MR) severity was evaluated by echocardiography preoperatively and during follow-up (postoperatively, 6 months, and 1, 2, and 3 years after surgery). The severity of MR was graded as none, trivial (0), mild (1), moderate (2), moderate to severe (3), or severe (4). Preoperative echocardiography identified MVP in 166 (69%) patients without previous MV intervention. Results: Forty-one (25%) of 166 patients with MVP received AVR, and 125 (75%) received AVS, with similar proportions of patients with preoperative MR grade &gt;2 in the two groups ( p =0.7). Thirty-three patients (20%) underwent concomitant MV intervention: 29 repairs and 4 replacements (15 patients (45%) had MR &gt;2, 11 (33%) had MR=2, and 7 had MR ≤1). All patients with MR &gt;2 underwent a MV procedure. One patient following MV repair required MV replacement on postoperative day 16 after developing grade 4 MR. No other patient required MV reintervention during follow-up (mean clinical follow-up, 30±9 months). Echocardiography performed 21±13 (±1 SD) months postoperatively revealed MR &gt;2 in only 1 of 158 patients. There were 1 early death (bleeding) and 2 late deaths (multi-organ failure and unknown cause); all deaths occurred in patients with concomitant MV surgery. Conclusions: MVP is present in 69% of patients with MFS undergoing aortic root replacement; 20% of patients with MVP underwent a concomitant MV procedure. Short-term results suggest that a simultaneous MV procedure in patients with MR &gt;2 is reasonable because operative risk was not increased and subsequent MV procedures were rare. More follow-up is needed to learn if prophylactic MV intervention at the time of aortic surgery might benefit patients with MR ≤2.

Improved outcome with composite graft versus homograft root replacement for children with aortic root aneurysms

Review of surgical repair of aortic root aneurysms using composite graft or homograft in children. A consecutive series of 34 children (mean age 10.8+/-5.4 years) who underwent elective aortic root replacement using composite graft or homograft from 1987 to 2003 (mean follow-up 5.7+/-3.7 years). Preoperatively, the aortic annulus and aortic root average z-scores were 4.1+/-2.2 and 9.4+/-4.7, respectively. Composite graft root replacement was performed in 22 patients, and cryopreserved aortic homograft root replacement in 12 patients. There was one perioperative death in the homograft group due to sudden cardiovascular collapse. There was one late death in the composite graft group due to acute aortic dissection, and two late deaths in the homograft root replacement group, one at 7 months postoperatively due to coronary artery thrombosis and one due to severe chronic myocardial dysfunction 5 years postoperatively. One patient who initially had a homograft died due to mechanical valve thrombosis following reoperative composite graft replacement. Five patients had reoperations at a median of 7.1 years after initial surgery. One patient in the composite graft group underwent arch replacement. There were no graft related reoperations after composite graft root replacement, but 4 patients in the homograft group had reoperative composite graft replacement. Predictors of reoperation included age at surgery, lower weight, and longer ICU time (P<0.05). In children with aortic root aneurysms, reoperation is more common after homograft root replacement than composite graft replacement. Composite graft root replacement provides more stable repair of the aortic root.

Composite aortic root replacement with a bovine pericardial valve conduit

In order to offer selected patients undergoing composite aortic root replacement the advantages of a tissue valve, we have constructed conduits intraoperatively by suturing a stented bovine pericardial valve (Edwards Lifesciences LLC, Irvine, CA) inside of a Dacron tube graft (Boston Scientific Corp, Natick, MA). The conduit is quickly made from readily available materials, is easily implanted, and can accommodate any of the anatomic situations encountered in repair of aortic root aneurysms. It is particularly suitable for patients 65 years of age and older.

Aortic root replacement in 271 Marfan patients: a 24-year experience

Background. The introduction of composite graft repair of aortic root aneurysm by Hugh Bentall in 1968 promised Marfan patients the choice for a normal life expectancy. We performed our first Bentall composite graft procedure in 1976 and herein report our 24-year experience with 271 Marfan patients. Methods. Between September 1976 and August 2000, 232 Marfan patients had a composite graft replacement of the aortic root, 15 patients received a homograft, and 24 had a valve-sparing procedure. Results. Two hundred thirty-five Marfan patients underwent elective aortic root replacement with no 30-day mortality. Two early deaths occurred among 36 patients who underwent urgent or emergent operation. Eighty-three percent of patients in this series are currently alive. The actuarial freedom from thromboembolism, endocarditis, and reoperation on the residual aorta 20 years postoperatively was 93%, 90%, and 74%. Twenty-four patients have undergone valve-sparing procedures with encouraging results. Conclusions. Elective aortic root replacement for Marfan patients can be performed with low operative risk. Elective repair before the aortic root reaches 6 cm in diameter is recommended to minimize risk of dissection and rupture.

Combined use of aprotinin and a heparin-bonded cardiopulmonary bypass system for aortic aneurysm repair

S URGICAL repair of an ascending aortic aneurysm involving the aortic root presents a challenge for the surgeon, anesthesiologist, and perfusionist. Hemorrhage is an important indicator for mortality after repair of annuloaortic ectasia, l?and when a patient refuses all blood products, complications of hemorrhage would likely increase the risks. Hemorrhage during repair of aortic root aneurysm can be caused by the surgical anastomoses, systemic heparinizatlon, exposure to the cardlopulmonary bypass (CPB) circuit, or the prosthetic graft itself) The impairment in hemostasls associated with CPB remains unclear but hkely involves a combination of a reduction m platelet adhesiveness, complement achvation, kaltikrein/ klnin activation, a sUmulation of the fibrinolytic system, and dilution. 4 Aprotmin, a serine protease inhibitor, has been shown to preserve platelet adhesive receptors (Gplb), inhabit contact activation of the kallikrein system, and inhibit plasmin-lnduced fibrmolysIs. When used in conjunction with heparln, aprotinin prevents thrombln formation through inhibmon of the intrinsic clotting cascade. 5 The effectiveness of aprotmin in reducing perloperative blood loss and amount of transfused blood products during cardiac surgery has been demonstrated. T M The combinanon of heparin-bonded perfusion systems and reduced systemic heparinlzation for CPB has been reported 12-i4 Reported advantages of heparin-bonded perfusion systems include reduced actwation of the complement and coagulation systems and improved platelet function caused by the Improved blocompatibility of a heparin-bonded material, both leading to reduced penoperatlve bleeding. 13-16 A drawback in the use of a heparinbonded system is that because of the continuous air-toblood interface associated with roller pump suction, shed mediastlnal blood and vented blood must be returned to a cell-saving device for washing instead of directly into the CPB circuit. In cases involving extensive suctlonmng and venting and excessive surgical bleeding, washing and autotransfusion of suctioned blood may result in a tremendous loss of plasma and platelets, negating the benefits of reduced systemic heparinlzation. Because of this patient's religious behefs, and the nature of her disease process, a heparin-bonded perfusion system for CPB was used in conjunction with full systemic heparinlzatlon and aprotinln administration.

Surgical repair of aortic root aneurysms in 280 patients

Bentall's technique for repair of annuloaortic ectasia has been associated with postoperative bleeding and with false aneurysms at the anastomotic site between the coronary orifices and valve-containing graft. To reduce the incidence of these complications, we modified the Bentall procedure, using a simplified technique to implant the graft and to create a fistula between the closed perigraft space and right atrium to control bleeding. A continuous suture of monofilament polypropylene was used to implant the prosthetic valve ring and to anastomose the coronary orifices to the Dacron fabric. In some instances, a brief period of hypothermic circulatory arrest was needed to perform the distal aortic anastomosis. Among 562 patients undergoing operation for aneurysm of the ascending aorta between January 1, 1980, and February 28,1990, 280 underwent graft replacement with a valve-containing composite conduit. Most (82%) had annuloaortic ectasia. In 267, we performed a classic Bentall procedure with direct anastomosis between the coronary orifices and fabric graft. The remaining 13 patients underwent other procedures for coronary connection. Early mortality was 5.0%. Reoperation for bleeding was needed in 13.2% of patients who underwent operation before we used the right atrial fistula technique and in 4.4% after we began to use the technique ( p = 0.044). Actuarial survival was 71% at 5 years and 65% at 7 years. For hospital survivors, it was 76% at 5 years and 70% at 7 years. During follow-up, only 9 patients have required reoperation. A false aneurysm at the coronary anastomosis, which was associated with prosthetic valve endocarditis, developed in 1 patient. No permanent fistulas have developed. Thus, by using simplified methods to implant the graft and to control postoperative bleeding, the Bentall technique can be performed successfully with excellent early and late results.