Subcoronary Technique Research Articles

Intermediate-term Outcomes Following a Case Series of Reoperations for Medtronic Freestyle Stentless Aortic Valves

BackgroundData are limited on long-term outcomes in patients who have undergone a reoperation following failure of a stentless aortic valve. MethodsBetween 2006 and 2016, a retrospective analysis was performed on 24 patients who underwent open aortic valve replacement surgery for a failed stentless aortic valve prosthesis at Health Sciences North, Sudbury, Ontario, Canada. The primary outcome was a low mortality rate from cardiac-related deaths after 5 years. ResultsAll patients underwent insertion of a Medtronic Freestyle bioprosthesis (Minneapolis, MN) implanted using the modified subcoronary technique for their initial operation. The interval from the first operation to the stentless redo surgery ranged from 6 to 13 years. Aortic valve reoperation was performed for structural valve deterioration in 96% (n = 23) of the cases. Reoperations involved a removal of the stented valve leaflets and standard aortic valve replacement within the stentless casing in 20% (n = 5) of the cases, with the remaining cases requiring complete removal of the stentless prosthesis and aortic valve replacement. In those in whom a complete removal of the stentless valve was possible (n = 19), no disruption of the native aortic root occurred, with a 0% rate of conversion to a Bentall procedure. No intraoperative mortality occurred. The 30-day and 10-year operative mortality rates were 4% and 16%, respectively. ConclusionsRedo surgery for failing stentless valves can be done with relatively low risk and with acceptable long-term outcomes without resorting to root-replacement techniques.

The Ross sub-coronary technique

The Ross sub-coronary technique

The Ross Sub-Coronary Technique

The Ross Sub-Coronary Technique

Subcoronary Technique for Orthotopic Implantation of Aortic Scaffold Reinforced with Polytetrafluoroethylene Strips in Sheep: A pilot Study

Over the time, numerous studies have been reported describing successful pulmonary valve replacement, either with xenografts or allografts, performed in sheep model. In contrast, comparable results have not been achieved yet for aortic valve replacement in orthotopic position, which involves a more difficult surgical technique, high hemodynamic demands for the implanted valve and poor survival of animals undergoing this kind of surgery. To our knowledge, in Romania, these were the first orthotopic allogeneic aortic root implantations using the subcoronary technique, carried out by our team. We established feasible perioperative, anesthetic and surgical protocols, which will be used in future studies to evaluate the in vivo functional performances of decellularized valves compared with autologous adipose derived stem cells seeded valves. Therefore, a unique research core was created, which is currently the only center of this kind in our country, by joining a multidisciplinary team consisting of biomedical engineers, cardiovascular surgeons, anesthesiologists, cardiologists, pathologists, microbiologists and veterinarians, who will continue the research activity in the field of tissue engineering and translate experimental results into clinical activity.

Long-term assessment of the Ross procedure in adults: Clinical and echocardiographic follow-up at 20 years

IntroductionThe Ross procedure is an alternative to standard aortic valve (AV) replacement in young and middle-aged patients. However, durability and incidence of reoperation remain a concern for most cardiac surgeons. Our aim was to assess very long-term clinical and echocardiographic outcomes of the Ross procedure. MethodsWe conducted a single-center retrospective analysis of 56 consecutive adult patients who underwent the Ross procedure. Mean age at surgery was 44±12 years (range, 16-65 years) and 55% were male. Clinical endpoints included overall mortality and the need for valve reoperation due to graft failure. The echocardiographic endpoint was the presence of any graft deterioration. Median clinical follow-up was 20 years (1120 patient/years). ResultsIndications for surgery were dominant aortic stenosis in 50% and isolated aortic regurgitation in 21%. Concomitant mitral valve repair was performed in 21% and a subcoronary technique was most commonly used (86%). Overall long-term survival was 91%, 80% and 77% at 15, 20 and 24 years, respectively. The survival rate was similar to the age- and gender-matched general population (p=0.44). During the follow-up period, freedom from graft reoperation was 80%. Eleven patients (31%) developed moderate AV regurgitation, three (8.6%) developed moderate pulmonary regurgitation and one (2.9%) presented moderate pulmonary stenosis. ConclusionThe Ross procedure, mostly using a subcoronary approach, proved to have good clinical and hemodynamic results, with low reoperation rates in long-term follow-up. Moderate autograft regurgitation was a frequent finding but had no significant clinical impact.

Ross procedure: is the root replacement technique superior to the sub-coronary implantation technique? Long-term results.

There is controversy over the use of the Ross procedure with regard to the sub-coronary and root replacement technique and its long-term durability. A systematic review of the literature may provide insight into the outcomes of these two surgical subvariants. A systematic review of reports between 1967 and February 2013 on sub-coronary and root replacement Ross procedures was undertaken. Twenty-four articles were included and divided into (i) sub-coronary technique and (ii) root replacement technique. The 10-year survival rate for a mixed-patient population in the sub-coronary procedure was 87.3% with a 95% confidence interval (CI) of 79.7-93.4 and 89.1% (95% CI, 85.3-92.1) in the root replacement technique category. For adults, it was 94 vs 95.3% (CI, 88.9-98.1) and in the paediatric series it was 90 vs 92.7% (CI, 86.9-96.0), respectively. Freedom from reoperation at 10 years was, in the mixed population, 83.3% (95% CI, 69.9-93.4) and 93.3% (95% CI, 89.4-95.9) for sub-coronary versus root replacement technique, respectively. In adults, it was 98 vs 91.2% (95% CI, 82.4-295.8), and in the paediatric series 93.3 vs 92.0% (95% CI, 86.1-96.5) for sub-coronary versus root replacement technique, respectively. The Ross procedure arguably has satisfactory results over 5 and 10 years for both adults and children. The results do not support the advantages of the sub-coronary technique over the root replacement technique. Root replacement was of benefit to patients undergoing reoperations on neoaorta and for long-term survival in mixed series.

Bioprosthetic Valve Durability After Stentless Aortic Valve Replacement: The Effect of Implantation Technique

The Freestyle stentless bioprosthesis (FSB) (Medtronic Inc, Minneapolis, MN) is implanted using 2 techniques-subcoronary or aortic root replacement. Our objective was to determine whether the implantation technique had an impact on late reoperation for structural valve deterioration (SVD). Between 1993 and 2013, 531 patients underwent aortic valve replacement (AVR) or aortic root reconstruction with an FSB. The implantation technique was subcoronary in 430 patients (group S) and root replacement in 101 patients (group R). Median follow-up was 10.8 years for group S patients and 10.1 years for group R patients. The follow-up was complete in all patients. Mean age was 68.2 years in group S and 65.2 in group R (p= 0.001). In-hospital mortality was 3.5% and 5.0% in group S and group R, respectively (p= 0.56). Late reoperation was required in 60 (14.5%) hospital survivors in group S and 8 (8.3%) hospital survivors in group R. There were 36 reoperations in group S and 3 in group R for SVD. Freedom from reoperation for SVD was 94.6% and 76.7% at 10 and 15 years, respectively, in group S, and98.9% and 88.1% at 10 and 15 years, respectively, forgroup R (p= 0.04). The subcoronary technique was anindependent risk factor for late reoperation for SVD (p= 0.002). Implantation technique was not independently associated with in-hospital and long-term mortality. The Freestyle bioprosthesis implanted as a root replacement was associated with less reoperation for SVD over the long term compared with the subcoronary technique. However, the method of implantation has no influence on early and long-term survival.

The Ross procedure: suitable for everyone?

In 1967, Donald Ross transferred the patient’s own pulmonary valve into the aortic root. Although results of this technique were encouraging, the Ross procedure did not gain widespread popularity until the late 1980s when surgeons started to implant the pulmonary autograft as a freestanding full root replacement with reimplantation of the coronary arteries. However, frequent dilatation of the pulmonary autograft was observed using the freestanding full root replacement technique. In contrast, the original subcoronary implantation technique and aortic root inclusion technique prevented dilatation in the long-term. Through advancing know-how in aortic root surgery and confidence, the Ross procedure has also been used in combined procedures and complex clinical presentations with good long-term results, which encourage continual use. However, the Ross procedure is a complex operation; careful patient selection and experience of the surgeon are mandatory requirements to achieve satisfactory results.

Long-term outcomes of the Ross procedure in adults with severe aortic stenosis: single-centre experience with 20 years of follow-up†

The optimal prosthesis option for aortic valve replacement in adult patients<60 years of age with severe aortic stenosis (AS) remains controversial. The objective was to determine the long-term outcomes of the Ross procedure in this population. Between 1990 and 2013, 276 patients aged 18 years and above (mean 40.3±10.6) underwent an elective Ross procedure. Among them, 221 patients had predominant severe AS; these patients form the study group. The Ross procedure was performed either by aortic root replacement (n=190; 86%) or the subcoronary technique (n=31; 14%). There were 169 patients with bicuspid valves and 33 redo operations including previous aortic valve repair (n=6) and replacement (n=9) for severe AS. Demographic, preoperative, postoperative and longitudinal clinical and echocardiographic data were collected prospectively. The median and mean follow-up were 11.4 years (range: 1-20.1 years) and 10.1±5.9 years, respectively. The follow-up was complete in all patients. Kaplan-Meier actuarial survival analysis was performed to assess long-term survival, freedom from reoperation for autograft and/or homograft failure and freedom from autograft valve insufficiency. Cox regression risk analysis was performed to identify factors associated with autograft or homograft reoperations. The perioperative mortality rate was 0.9% (n=2). The incidence rate of early reoperation for bleeding was 5.9%. The actuarial survival rate at 10 and 15 years following surgery was 92.1 and 90.5%, respectively. Ross-related reoperations occurred in 21 patients during follow-up: autograft dysfunction (n=9), homograft dysfunction (n=6) and both (n=6). The rate of freedom from Ross-related reoperation was 94.7 and 87.7% at 10 and 15 years, respectively. The rate of freedom from reoperation for autograft failure was 97.6 and 91.5%, the rate of freedom from reoperation for homograft failure was 95.7 and 90.8%, and the rate of freedom from moderate or severe autograft regurgitation was 94.1 and 85.6% at 10 and 15 years, respectively. Compared with available aortic bioprosthetic alternatives in young adults with severe AS, the Ross procedure provides an excellent long-term option for patients with predominant severe AS who seek a durable operation without anticoagulation.

Long-term results of Freestyle stentless bioprosthesis in the aortic position: A single-center prospective cohort of 500 patients

Stentless xenograft bioprostheses may be the future valve of choice for aortic valve replacement. The study aim was to investigate the long-term clinical outcome after aortic valve replacement with the Medtronic Freestyle bioprosthesis (Medtronic Inc, Minneapolis, Minn). Between April 1997 and November 2004, a total of 500 patients (mean age, 74.5±9.6 years; 52% were male) underwent aortic valve replacement with a Freestyle bioprosthesis, without population selection. The surgical procedure used a modified subcoronary technique in 479 patients and a complete root replacement in 21 patients, conducted with mini-extracorporeal circulation. Concomitant procedures included coronary artery bypass grafting in 122 patients (24%) and mitral valve repair/replacement in 11 patients. The mean cardiopulmonary bypass time was 98±26 minutes, and total aortic crossclamp time was 77±19 minutes. Operative mortality was 5.2%. The median follow-up time was 104.8±5.7 months. During this period, there were 224 deaths (n=122 cardiovascular and n=102 noncardiovascular deaths). The actuarial survivals from cardiovascular and valve-related mortality were 67%±3% and 70%±4%, respectively, at 10 years. Freedom from structural valve deterioration at 10 years was 94%±2%. The linearized structural valve deterioration incidence was 0.6% per patient/year. Multivariate Cox regression analysis revealed that older age, impaired renal function, and coronary artery disease were independent predictors of cardiovascular death. In the subgroup of patients aged less than 65 years at implantation (n=45), the actuarial cardiovascular survival was 83%±8% and freedom from structural valve deterioration was 89%±6% at 10 years. The use of the Freestyle bioprosthesis for aortic valve replacement resulted in good long-term cardiovascular survival and freedom from structural valve deterioration in this cohort regardless of age at implantation.

Surgical Repair of Atrio-Oesophageal Fistula Secondary to Transcatheter Ablation for Atrial Fibrillation: A Case Report and Literature Review

other prosthesis types. Over 6000 individual patients were included in the selected case series’. Mean patient age ranged from 64.0 to 76.0 years. 48.1% of patients were in New York Heart Association class 3–4 pre-operatively; the majority (75.7%) of cases used the subcoronary implantation technique. Operativemortality ranged from 1.8% to 9.6%, and five-year actuarial survival ranged from 71 3.0% to greater than 90.0%. Post-operative neurological event and prosthetic endocarditis rates ranged from 0% to 6.5% and 0.7% to 2.0% (respectively). Discussion: Despite a lack of randomised studies, in those identified the FSB performed comparably against alternative prosthesis options regarding inhospital mortality, long-term survival and reduction in left ventricular mass index. Included case series demonstrated robust post-operative outcomes in both the short and long-term also.With longer-term clinical and echocardiographic follow-up of the FSB, additional outcomes will assist in confirming its place in aortic valve and root surgery.

Clinical outcome of redo operation on aortic root

With the increasing use of biologic conduits or bioprosthetic valve, the number of patients who require redo operation on aortic root increased. In the past 22 years, 14 patients underwent redo operation on aortic root. The mean age was 61.9 ± 14.8 years. Previous operations were full root replacement with stentless valve (n = 4), aortic root replacement with subcoronary technique (n = 3) and Bentall operation (n = 7). The operation interval was 5.4 ± 6.4 years. Indication for redo operation included structural valve deterioration (n = 6), prosthetic valve endocarditis (n = 4), perivalvular leakage (n = 2), dilatation of sinus of Valsalva (n = 1) and dehiscence of proximal anastomosis line (n = 1). Mean follow-up period was 5.3 ± 5.2 years. Present operations were full root replacement with stentless valve (n = 5) and Bentall operation (n = 9). There was one in-hospital death (7.1 %) caused by arrhythmia. Postoperative complications included implantation of permanent pacemaker (n = 3), arrhythmia (n = 2) and re-intubation (n = 1). The 5-year survival was 92.9 ± 6.9%. Freedom from redo aortic operation at 5 years was 100%. Redo operation on aortic root can be performed with acceptable in-hospital mortality and good late survival.

A simple technique for marking the aortic annulus during the implantation of a stentless aortic bioprosthesis

Figure 1: Clips usually used for harvesting of the internal thoracic artery are placed on the stitches of the first plan of the stentless Medtronic Freestyle® bioprosthesis (in that case, using the sub-coronary technique). They are not in contact with blood and are situated between the two aortic walls. Figure 2: Chest X-ray with an arrow showing the clips placed all around the aortic annulus. TAVI can be easily performed, even if no calcification is present.

Reoperations on the pulmonary autograft and pulmonary homograft after the Ross procedure: An update on the German Dutch Ross Registry

Reinterventions after the Ross procedure are a concern for patients and treating physicians. The scope of the present report was to provide an update on the reinterventions observed in the large patient population of the German-Dutch Ross Registry. From 1988 to 2011, 2023 patients (age, 39.05 ± 16.5 years; male patients, 1502; adults, 1642) underwent a Ross procedure in 13 centers. The mean follow-up was 7.1 ± 4.6 years (range, 0-22 years; 13,168 patient-years). In the adult population, 120 autograft reinterventions in 113 patients (1.03%/patient-year) and 76 homograft reinterventions in 67 patients (0.65%/patient-year) and, in the pediatric population, 14 autograft reinterventions in 13 patients (0.91%/patient-year) and 42 homograft reinterventions in 31 patients (2.72%/patient-year) were observed. Of the autograft and homograft reinterventions, 17.9% and 21.2% were performed because of endocarditis, respectively. The subcoronary technique in the adult population resulted in significantly superior autograft durability (freedom from autograft reintervention: 97% at 10 years and 91% at 12 years; P<.001). The root replacement technique without root reinforcement (hazard ratio, 2.4; 95% confidence interval, 1.4-4.1) and the presence of pure aortic insufficiency preoperatively (hazard ratio, 2.3; 95% confidence interval, 1.5-3.5) were statistically significant predictors for a shorter time to reoperation. The center volume had a significant influence on the long-term results. The freedom from homograft reoperation for the adults and pediatric population was 97% and 87% at 5 years and 93% and 79% at 12 years, respectively (P<.001), with younger recipient and donor age being significant predictors of a shorter time to homograft reoperation. The autograft principle remains a valid option for young patients requiring aortic valve replacement. The risk of reoperation depends largely on the surgical technique used and the preoperative hemodynamics. Center experience and expertise also influence the long-term results. Adequate endocarditis prophylaxis might further reduce the need for reoperation.

Dehiscence of Freestyle aortic valve visualized by real-time three-dimensional transoesophageal echocardiography and dual-source computed tomography: a rare cause of aortic regurgitation

A 54-year-old man was admitted because of acute decompensated heart failure. Ten years ago, he underwent implantation of a 27 mm Freestyle aortic root stentless bioprosthesis (Medtronic Inc., Minneapolis, Minnesota) with a subcoronary technique for severe aortic regurgitation (AR) due to the bicuspid valve, combined with mitral valve repair for moderate mitral regurgitation (MR) due to anterior leaflet prolapse. …

An alternative subcoronary implantation technique decreases the risk of complete heart block after stentless aortic valve replacement

Context:Stentless aortic valve prostheses have excellent hemodynamic profiles, but may be associated with an increased postoperative heart block when compared to conventional prostheses.Aims:To assess the effect of an alternative subcoronary implantation technique on postoperative complete heart block (CHB) and permanent pacemaker implantation (PPI) following aortic valve replacement (AVR) with stentless tissue valves.Settings and Design:A total of 130 consecutive patients undergoing AVR with stentless tissue valves by a single surgeon were studied retrospectively.Materials and Methods:A stentless tissue valve was implanted into 80 patients using the conventional modified subcoronary implantation technique, and 50 patients received a stentless tissue valve by an alternative subcoronary technique in which the inflow suture line is raised at the level of right-non coronary commissure. Data were collected at the time of hospital discharge and at 6–12 months postoperatively.Statistical Analysis Used:Independent samples t-test was used to compare continuous variables, and categorical variables were compared with the chi-square test.Results:Use of this new method reduced postoperative CHB (4.0% vs. 16.3%, P = 0.033), with fewer patients requiring PPI in the early postoperative period (6.0% vs. 18.8%, P = 0.041). Echocardiographic examination showed no differences in the effective orifice area, peak and mean aortic valve gradients, or left ventricular mass index between groups. Trivial or mild aortic regurgitation was found in 3.9% of patients with the conventional modified technique and 4.0% of patients undergoing the alternative technique, during follow-up (P > 0.05).Conclusions:Compared to the conventional subcoronary implantation technique, the alternative subcoronary implantation technique reduces the incidence of new CHB and the requirement of PPI following AVR with stentless tissue valves while preserving mid-term hemodynamic function.

Pulmonary Homografts for Aortic Valve Replacement: Long-term Comparison with Aortic Grafts

The use of homografts for aortic valve replacement (AVR) is an alternative to mechanical or biological valve prostheses, especially in younger patients. This retrospective comparative study evaluated our single-center long-term results, with a focus on the different origins of the homografts. Since 1992, 366 adult patients have undergone AVR with homografts at our center. We compared 320 homografts of aortic origin and 46 homografts of pulmonary origin. The grafts were implanted via either a subcoronary technique or the root replacement technique. We performed a multivariate analysis to identify independent factors that influence survival. Freedom from reintervention and survival rates were calculated as cumulative events according to the Kaplan-Meier method, and differences were tested with the log-rank test. Overall mortality within 1 year was 6.5% (21/320) in the aortic graft group and 17.4% (8/46) in the pulmonary graft group. In the pulmonary graft group, 4 patients died from valve-related complications, 1 patient died after additional heterotopic heart transplantation, and 1 patient who entered with a primary higher risk died from a prosthesis infection. Two patients died from non-valve-related causes. During the long-term follow-up, the 15-year survival rate was 79.9% for patients in the aortic graft group and 68.7% for patients in the pulmonary graft group (P = .049). The rate of freedom from reoperation was 77.7% in the aortic graft group and 57.4% in the pulmonary graft group (P < .001). The reasons for homograft explantation were graft infections (aortic graft group, 5.0%; pulmonary graft group, 6.5%) and degeneration (aortic graft group, 7.5%; pulmonary graft group, 32.6%). Our study demonstrated superior rates of survival and freedom from reintervention after AVR with aortic homografts. Implantation with a pulmonary graft was associated with a higher risk of redo surgery, owing to earlier degenerative alterations.

A Modified Technique for Pulmonary Valve Replacement with a Homograft

We present a modified technique for replacement of the pulmonary valve with a pulmonary homograft. The principles of this technique are similar to the "scalloped subcoronary technique" for aortic valve replacement with a homograft. The advantages of using this technique in the pulmonary position are briefly discussed.

In vivo functional performance and structural maturation of decellularised allogenic aortic valves in the subcoronary position☆☆☆

Successful animal and clinical implantation of decellularised heart valves has been performed in the pulmonary position. Comparable results have not yet been achieved for the aortic position with the high haemodynamic demands of the systemic circulation and the challenging implantation procedure. Allogenic aortic valves (n=10) were decellularised using detergents (decellularised aortic valves (dAoVs)). Five prostheses were analysed for decellularisation quality and scaffold preservation. Five valves were orthotopically implanted in juvenile sheep in a subcoronary technique. After 5 months, echocardiography, immunohistology, histology, electron microscopy and western blot (WB) were used for analysis. All animals survived the follow-up with increased body weight (38.8 ± 2.8kg vs 56.0 ± 2.6kg, p<0.001). After implantation, three dAoVs showed negligible and two others minor insufficiency (I), which remained unchanged at explantation. Effective orifice area increased slightly (1.1 ± 0.2cm(2) vs 1.6 ± 0.3cm(2), p=0.051). Explanted dAoVs (n=4) showed excellent macroscopy with minor soft-tissue nodules observed at the free cusp margins of only one dAoV. No valve showed any signs of thrombosis or calcification. On microscopic evaluation, the cusp architecture was preserved with an almost complete endothelial repopulation as confirmed by vimentin(+)/von Willebrand factor (vWF(+))-staining, WB of endothelial markers (eNOS/vWF) and scanning electron microscopy (SEM). Partial interstitial reseeding with vimentin(+)/alpha-smooth muscle (αsm(+))-cells was noted. Quantitative measurement of collagen-IV, collagen-I, laminin and elastin (WB) demonstrated preserved scaffold composition as compared to native tissue. The dAoVs showed excellent functional outcome at 5 months in a subcoronary model of juvenile sheep. Advanced endothelial and nascent interstitial repopulation, with preserved structural integrity under the high-shear-stress milieu of the aortic valve, encourage further long-term studies.

The Ross Procedure Performed in the Subcoronary Technique: A Single Center Experience of 501 Cases

The Ross Procedure Performed in the Subcoronary Technique: A Single Center Experience of 501 Cases