Technique Of Aortic Root Replacement Research Articles

Virtual Reality Computed Tomography Evaluation - Anatomy and Clinical Implications for Valve-Sparing Aortic Root Replacement.

Three-dimensional aortic root evaluation using virtual reality (VR) techniques for valve-sparing aortic root replacement (VSARR) preparation has not yet been implemented, so we demonstrated VR computed tomography (VR-CT) and assessed its utility for VSARR.Methods and Results: We enrolled 72 patients who underwent multidetector CT before elective VSARR for annuloaortic ectasia with tricuspid aortic valve. The geometries of their aortic roots were measured with a VR-CT workstation. The mean values of geometric height (GH), free margin length (FML), and commissural height (CH) were 17.2±2.4 mm, 36.0±5.2 mm, and 24.0±4.3 mm, respectively. The right coronary/noncoronary CH was significantly greater than the left coronary/right coronary and left coronary/noncoronary CH. The left coronary cusp had the shortest FML, intercommissural distances (ICD), and smallest central angle. Although the right coronary cusp had the largest values for FML, ICD, and central angle, the right coronary cusp had the lowest GH and EH. The VR-CT measurements strongly correlated with intraoperative alternatives, especially with mean GH (R2=0.75) and left coronary/noncoronary CH (R2=0.79). Furthermore, mean GH was observed to be significantly different among the selected graft size groups; therefore, the preoperative mean GH could play a significant role in graft sizing. VR-CT evaluation allows a thorough understanding of aortic root anatomy, which could facilitate VSAAR.

Completion Bentall procedure for a huge aortic root pseudoaneurysm after surgery for acute aortic dissection: A case report

A 56-year-old man with a history of emergency ascending aortic and aortic valve replacement for acute type A aortic dissection 6 months previously developed a huge pseudoaneurysm arising from the sinus of Valsalva due to recurrent aortic root dissection. The patient urgently underwent the completion Bentall procedure with coronary artery reconstruction using interposing grafts. During surgery, the non-coronary sinus of Valsalva was repeatedly dissected and ruptured, where surgical glue was applied in the previous operation. The 25-mm REGENT mechanical valve® from the previous operation was left in place, and 2-0 bladed mattress sutures were circumferentially placed in the sewing ring of the prosthesis. A 28-mm Valsalva graft® was cut at the middle of its skirt portion, through which these sutures were passed and tied, and was seated to completely cover the valve cuff. The completion Bentall procedure is considered a feasible technique for reoperative aortic root replacement in patients with a prosthetic aortic valve following acute type A aortic dissection repair. It is important to accurately measure the outer diameter of the prosthetic valve to ensure proper fit of the graft and to minimize the risk of bleeding.

Long-term experience of the modified David V re-implantation technique for valve-sparing aortic root replacement.

The modified David V technique is one of the valve-sparing aortic root replacement (V-SARR) techniques, which is an alternative to traditional composite valve graft root replacement techniques. We aimed to analyse our long-term experience with the modified David V re-implantation technique for the treatment of aortic root aneurysm and significant aortic valve insufficiency. From March 2009 to November 2021 the modified David V re-implantation technique, one of the V-SARR techniques, was performed on 48 patients in our centre. The results were analysed retrospectively. Two different-sized grafts were used in all patients. The grafts used in the proximal position were larger than the distal grafts. We performed both intra-operative and post-procedural transoesophageal echocardiography on each patient. All patients were followed by means of transthoracic echocardiography. The mean follow-up period was 5.7 ± 3.1 years. The mean age of this cohort was 56.3 ± 14.3 years (24-79) and the majority were men (75%). The mean aortic root diameter was 5.1 ± 0.6 cm. The mean diameter for the assending aorta was 5.4 ± 2.1 cm. The in-hospital mortality rate was 4.2% (n = 2). One patient needed aortic valve replacement in the early postoperative period. Two (4.2%) patients died in the early postoperative period and four (8.3%) died in the late postoperative period. Overall survival was 91 ± 4 and 86 ± 5% at one and five years, respectively. Aortic valve insufficiency was at moderate levels postoperatively. Freedom from moderate to severe residual aortic insufficiency was 89.6% at 10 years. None of the patients needed late re-operation of the aortic valve postoperatively. Freedom from valve re-operation was 100% at the end of the follow up. Our study shows that the David V technique is associated with excellent long-term durability, a remarkably low rate of valve-related complications, and it protects the re-implanted native aortic valve from a second operation. Additionally this technique could be safely implemented in patients with a bicuspid aortic valve and acute type A aortic dissection without leaflet deformity.

Valve-Sparing Aortic Root Replacement Technique: Valsalva Graft versus Two Straight Tubular Grafts.

There are many variations in valve-sparing aortic root replacement techniques. Our aim is to determine the impact of the graft on mid-term outcomes: Valsalva graft vs. two straight tubular grafts. From 2004 to 2020, 332 patients underwent valve-sparing aortic root replacement with either a Valsalva graft (Valsalva group: n = 270) or two straight tubular grafts (two-graft group: n = 62). Data were obtained through chart review and the National Death Index. Primary outcomes were mid-term survival and freedom from reoperation. The preoperative characteristics of the groups were similar, but the two-graft group had more type A dissections (32% vs. 19%) and emergent operations (26% vs. 15%) and was younger (45 vs. 50 years). Intraoperatively, the groups were similar, but the two-graft group had longer cross-clamp (245 vs. 215 minutes) and cardiopulmonary bypass times (284 vs. 255 minutes). Postoperative complications including reoperation for bleeding, stroke, pacemaker implantation, and renal failure were slightly more frequent in the Valsalva group, but the differences were not significant. Operative mortality was similar between the Valsalva and two-graft groups (0.7% vs. 0%). Five-year survival in the two-graft group was 100% compared to 96% in the Valsalva group (p=0.56). Five-year freedom from reoperation in the two-graft group was 100% compared to 93% in the Valsalva group (p=0.29). The Valsalva and two-graft techniques both have excellent short- and mid-term outcomes. The two-graft technique might have slightly better survival and freedom from reoperation, but a larger sample size and longer follow-up are needed to determine if these advantages are significant.

Mid-term outcomes of an alternative remodelling technique for aortic root replacement without coronary ostial mobilisation or reimplantation

BackgroundWe compare the early and late outcomes of a modified aortic root remodelling (ARR) technique for aortic root replacement without mobilisation or reimplantation of the coronary ostia, with those of the modified Bentall-de Bono procedure.MethodsA retrospective observational study was performed comprising 181 consecutive patients who underwent aortic root replacement with a modified Bentall-de Bono procedure (104 patients) or ARR (77 patients) between January 2013 and December 2019. Primary endpoints included hospital mortality and late survival. Secondary endpoints included incidence of post-operative complications and freedom from late re-operation.ResultsARR procedures were performed with shorter cross-clamp times and comparable cardiopulmonary bypass times to modified Bentall-de Bono procedures. The incidence of early post-complications was comparable between groups. 30-day mortality was numerically lower with ARR than the modified Bentall-de Bono procedure. Over 7-year follow-up, 4 patients (3.8%) required repeat aortic surgery after a modified Bentall-de Bono procedure, and none after ARR. Long-term mortality after ARR and after modified Bentall-de Bono procedures was 17.1% and 22.7%, respectively. The cumulative incidence of reintervention on the aortic root/valve was 3.2% after a modified Bentall-de Bono procedure and 0% after ARR. When adjusted for other independent risk factors, late mortality was not influenced by the procedure performed, although competing risk adjusted for age showed that the modified Bentall-de Bono procedure was associated with an increased risk of aortic root/aortic valve re-operation.ConclusionsThe modified ARR technique is associated with reduced myocardial ischaemia time, lower post-operative mortality and aortic re-intervention rates compared to a modified Bentall-de Bono procedure. It may be considered a safe and feasible procedure for aortic root/ascending aortic replacement offering good long-term outcomes.

Modified composite-graft technique for aortic root replacement.

This report describes a novel modification of a self-assembled composite graft to replace the aortic root and left ventricular outflow tract (LVOT). This technique enables the implantation of a larger valve than conventional ways and simultaneous reconstruction of LVOT. This technique comprises Inspiris Resilia aortic valve and Gelweave Valsalva graft. By placing the valve in the sinus portion of the graft, the bioprosthesis that is 1mm smaller than the graft can be accommodated, providing a proper length of the collar for LVOT reconstruction. This technique is useful for patients who require redo-aortic root replacement and have restricted LVOT.

Aortic root replacement in severe left ventricular dysfunction: The added value of beating-heart surgery.

There are limits to the use of cardioplegic arrest during complex cardiac surgical procedures, especially in patients with severe left ventricular dysfunction. In the current report, we graphically present the detailed surgical strategy and technique for beating-heart aortic root replacement with concomitant coronary bypass grafting, for patients otherwise deemed inoperable. With support of cardiopulmonary bypass (CPB), beating-heart bypass surgery is realized, after which the bypass grafts can selectively be connected to the CPB, preserving coronary flow. Then, on the beating and perfused heart, a complex procedure such as aortic root replacement can be performed, without jeopardizing postoperative cardiac function. However, several important caveats and remarks regarding the use of beating-heart surgery should be considered, including: coronary perfusion verification and maintenance, temperature management, and prevention of air embolisms. By use of this strategy, risks associated with cardioplegic arrest are minimized, while it circumvents the potential need for long-term postoperative extracorporeal membrane oxygenation.

Outcomes after ROSS procedure with pulmonary autograft reinforcement using reimplantation technique

Pulmonary autograft reinforcement to prevent dilatation and subsequent neo-aortic valve regurgitation was reported. However, the late functional outcome of the native pulmonary valve inside a rigid Dacron conduit requires to be documented. We aimed to assess the results of modified Ross procedure associated with autograft reinforcement reimplantation technique. Outcomes of 61 consecutive patients who underwent Ross procedure with reinforcement between 2009 and 2021 were analyzed. Majority of cases has presented with mono or bicuspid aortic valve ( n = 52; 85%), predominant aortic valve regurgitation ( n = 47; 77%) and dilatation (> 30 mm) of the ascending aorta ( n = 33; 54%). Forty-seven patients (77%) had prior aortic valve procedure including 38 surgical repair (62%) and 9 balloon dilatation (15%). Pulmonary autograft was reimplanted in a Dacron conduit of a median diameter = 25.6 mm (ranges: 20–30) using Tirone David's valve sparing aortic root replacement technique. No death occurred. Median age at procedure was 16.8 years (range: 6–38). Two patients (3%) required early neo-Aortic root revision, one other was reoperated later on resulting in neo-aortic valve replacement in 3 (4.9% IC 95% [0.34%; 12.7%]) because of respectively infective endocarditis, left ventricular false aneurysm and leaflet perforation. Six patients required right ventricular outflow conduit replacement including one percutaneous replacement. At mean 66 ± 50.5 months postoperatively, the survival rate with freedom from reintervention was 83% [71.9; 93.5] and the deterioration of the initial neo-Aortic valve function (regurgitation or stenosis) was not observed ( Fig. 1 ). Autograft reinforcement by means of reimplantation technique allowed to extend the indications for Ross procedure to all patients requiring Aortic valve replacement and prevented neo-Aortic root dilatation. Failures were early and rare, and late controls confirmed the stability of the neo-aortic valve function in follow-up.

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.

Valve-sparing root replacement after the Ross procedure

ObjectivesThe Ross procedure is a preferred treatment for infants and children with aortic valve disease. Progressive neoaortic root dilation and neoaortic insufficiency can occur after the Ross procedure, and because of the young age of these patients, valve-sparing aortic root replacement procedures have advantages compared with the Bentall procedure. The aim of this study is to describe our experience with different techniques of aortic valve-sparing root replacement in this unique cohort of patients. MethodsPatients undergoing valve-sparing aortic root replacement with a history of the Ross procedure between January 2001 and March 2021 were identified. A retrospective chart review was performed, and clinical characteristics of these patients were analyzed. The results of different types of valve-sparing aortic root replacement were also compared. ResultsForty-two patients who had previously undergone a Ross procedure in childhood presented for reintervention for neoaortic root or valve pathology. Seventeen of these patients were considered for valve-sparing aortic root replacement but underwent bioprosthetic or mechanical valve replacement, and 25 patients underwent successful valve-sparing aortic root replacement. Patients who underwent valve-sparing aortic root replacement received a traditional aortic root remodeling procedure with or without suture annuloplasty (Yacoub technique, group 1, n = 7), an aortic root reimplantation procedure (David technique, group 2, n = 11), or a modified root remodeling procedure that also used a geometric annuloplasty ring (group 3, n = 7). Patient demographics and comorbidities were similar between groups. Mean follow-up for these 3 cohorts was 14 years, 4 years, and 1 year, respectively. Overall survival was good, with 1 early death due to hemorrhage in group 2 and 1 death due to malignancy in group 1. Eight patients (7 in group 1; 1 in group 2) required subsequent aortic valve replacements due to neoaortic insufficiency, whereas none in group 3 have required any reintervention. Overall, patients requiring valve replacement after valve-sparing aortic root replacement had lower grades of preoperative neoaortic insufficiency and higher grades of postoperative neoaortic insufficiency. Greater than mild postoperative neoaortic insufficiency was associated with the need for subsequent neoaortic valve replacement. ConclusionsValve-sparing aortic root replacement is safe in patients with a prior Ross procedure. Reimplantation offers superior durability compared with the traditional remodeling procedure. Greater than mild neoaortic insufficiency on postoperative echocardiogram should prompt additional attempts at valve repair. A modified remodeling procedure with geometric ring annuloplasty that is personalized to the patient's individual anatomy is safe with good short-term results, but longer follow-up is needed.

David Procedure for Valve-Sparing Aortic Root Replacement in a Marfan Syndrome Patient

Valve-sparing aortic root replacement (VSRR) is an established treatment method for aortic root dilatation and aortic valve insufficiency (AI). It was developed to restore the aortic valve functions in patients of aortic root aneurysms with morphologically normal aortic valve. We hereby present a case of 67 years, male, with aortic root aneurysm and severe aortic regurgitation who was treated successfully by David’s procedure for valve sparing aortic root replacement technique. Cardiovasc j 2022; 14(2): 185-190

Modified Bentall procedure: A 15-year single-center clinical experience.

Bentall procedure is a standard technique for complete aortic root replacement but a huge challenge is postoperative bleeding. Many modifications have been proposed and the "button technique" is commonly used. With a 15-year experience, this study was to evaluate outcomes of this modified Bentall procedure. A retrospective study was performed with all patients who underwent the Bentall procedure with a button technique between 2005 and 2020. Commercially available composite grafts were used in 38 patients and self-assembled composite graft was used in 74 patients. Safety outcome was postoperative complications and long-term outcomes included overall and reoperation-free survivals. Among 112 patients, the mean age was 46.3 years and 69.6% were men. Indications for the Bentall procedure were ascending aortic aneurysm and valve regurgitation (59.8%), aortic dissection (19.6%), Marfan syndrome (17%), and endocarditis (3.6%). Three patients (2.7%) died in hospital. During a median follow-up period of 42 months, 11 patients died and 7 patients required reoperation. Overall survival and reoperation-free survival were 86.1% and 83.4% at 5 years and 86.1% and 72.6% at 10 years, respectively. The Bentall procedure with a button technique is safe and effective for aortic root replacement. Further investigations are required to improve the feasibility and effectiveness of the procedure.

Ross procedure with pulmonary autograft reinforcement using reimplantation technique

Dilatation of the pulmonary autograft resulting in aortic valve regurgitation represents a common issue following Ross procedure with root replacement, in particular when performed beyond childhood. We present our early experience with modified Ross procedure associated with autograft reinforcement using reimplantation technique. Records of 59 consecutive patients who underwent Ross procedure with reinforcement between 2009 and 2021were analysed. Pulmonary autograft was reimplanted in a Dacron conduit of a median diameter = 26 mm (range: 20–30) using Tirone David's technique of valve sparing aortic root replacement (VSRR). Median age was 17 years (range: 6–38). Majority of cases has presented with mono or bicuspid aortic valve ( n = 50; 85%), predominant aortic valve regurgitation ( n = 38; 64%) and dilatation (> 30 mm) of the ascending aorta ( n = 32; 54%). Forty-six (78%) had at least one prior aortic valve procedure. No death occurred. Three patients required early procedure-related reoperation 8 others were reoperated on later resulting in 3 neo-aortic valve replacement all-over (5%). The mean duration of follow-up was 46 ± 12 months. Neither more than mild autograft regurgitation nor stenosis was observed. Mean diameters of the autograft annulus and sinotubular junction were respectively 24.8 ± 2.6 mm and 25.3 ± 2.1 mm at discharge and 25.3 ± 2.1 mm and 25.4 ± 2.7 mm at the last visit ( P = 0.06 and 0.08). Autograft reinforcement by means of reimplantation technique prevented neo-aortic root dilatation and allowed to extend the indications for Ross procedure to patients for whom the conventional Ross technique was qualified to be unsuitable. Early failure was rare (5%) and mid-term outcomes confirmed the stability of the neo-aortic valve function in follow-up.

How We Perform a David Procedure With an Upper Hemisternotomy Approach.

Valve-sparing aortic root replacement (David procedure) is the technique of choice in appropriately selected patients with aortic root aneurysms. These procedures are seldom performed in a minimally invasive fashion. We describe our systematic approach to the David procedure using an upper hemisternotomy (UHS). Methods: Our method involves a J-type UHS exiting the right third or fourth intercostal space. Ascending aortic and femoral venous cannulation are performed using the Seldinger technique under transesophageal echocardiographic guidance. Between August 2005 and August 2014, 27 patients underwent an isolated elective David procedure using a full sternotomy (FS). Sixteen underwent an isolated elective UHS David procedure from May 2015 to February 2019. Perioperative safety outcomes were compared between the 2 cohorts. Results: The UHS and FS David cohorts were primarily male (87.5% and 85.2%, respectively) and 51 and 50 years old on average, respectively. Custodiol-histidine-tryptophan-ketoglutarate cardioplegia (93.8% vs 37.0%, P < 0.001) and Cor-Knot (100% vs 0%, P < 0.001) were used significantly more in the UHS David cohort. There were no significant differences in cardiopulmonary bypass (200 [183-208] vs 212 [183-223] min, P = 0.309) and aortic cross-clamp (169 [155-179] vs 188 [155-199] min, P = 0.128) times in the UHS and FS cohorts. There were no instances of hospital or 30-day mortality in either cohort. Intensive care unit and hospital stays were comparable between the 2 cohorts. Conclusions: The David procedure via UHS is a safe and reproducible technique for aortic root replacement.

Fifteen-Year Outcomes Following Valve-Sparing Aortic Root Replacement in Elderly Patients

Valve-sparing aortic root replacement (VSRR) techniques have several advantages such as preservation of physiological haemodynamics of the native aortic valve and avoidance of prosthetic valve-related complications. However, VSRR procedures are generally performed in young patients and the long-term results in elderly patients (≥65 years) are scarce. Fifty-six (56) consecutive patients underwent VSRR surgery by a single surgeon at the current centre between January 2006 and December 2013; a modified "remodelling technique" was typically performed. The mean age was 58.86±12.5 years; Marfan syndrome and bicuspid aortic valve were both present in six patients (10.7%); 38 patients (67.8%) presented with greater than moderate aortic regurgitation; and 17 patients (30.4%) were in New York Heart Association (NYHA) class III before surgery. They were divided into two groups according to their ages receiving VSRR surgery: Group E (elderly patients aged ≥65 years, n=24) and Group Y (young patients aged <65 years, n=32). The primary outcomes were aortic valve-related reoperation, cardiovascular reoperation, all-cause mortality, and functional status. One (1) patient in Group E was converted to aortic valve replacement as a result of a failed aortic valve repair. No perioperative mortality was observed. The mean follow-up was 11.5±2.9 years. Aortic valve-related reoperation was noted in two patients of each group (one with endocarditis, one with severe aortic regurgitation). Cardiovascular reoperations were observed in three and six patients, and all-cause deaths in seven and two patients in Group E and Group Y, respectively. The 10-year freedom from aortic valve-related reoperation was estimated to be 91.7±5.6% and 92.7±5.0% (p=0.594), the 10-year freedom from cardiovascular reoperation was 86.4±7.3% and 81.1±7.7% (p=0.781), and the cumulative 10-year survival rates were 74.0±9.2% and 93.8±4.3% (p=0.018) in Group E and Group Y, respectively. During follow-up, 6.7% of patients were in NYHA class III and 6.4% of patients developed moderate-to-severe aortic regurgitation. Cox regression analysis failed to identify predictors for primary outcomes. Valve-sparing aortic root replacement can safely be performed in elderly patients with low early mortality and satisfactory long-term freedom from aortic valve-related and cardiovascular re-intervention.

Aneurysm of the aortic root and valve‑sparing aortic root replacement: long-term outcomes from a single Polish center.

Valve-sparing aortic root replacement (VSARR) techniques are an alternative to the classic Bentall procedure when aortic root aneurysm is not accompanied by aortic valve stenosis, and the regurgitant aortic valve is amenable to repair. The aim of the study was to assess long -term outcomes of valve sparing aortic root replacement using the David technique and the Yacoub technique. A total of 101 consecutive, elective VSARR procedures were performed from January 2010 to April 2020 including 52 David procedures (51.5%) and 49 Yacoub procedures (48.5%). We analyzed mortality, freedom from reoperation, and freedom from aortic valve regurgitation. The analysis was performed for the entire study cohort and for 2 subgroups: the David technique and the Yacoub technique. The mean (SD) age was 50.2 (16.1) years; 90 (89.1%) patients were male. The median (interquartile range [IQR]) EuroScore II was 3.7 (2.7‒5.8). At 1, 5, and 8 years after surgery, survival (SE) was 98% (3%), 91.8% (8%), and 91.8% (8%), respectively, whereas freedom from reoperation (SE) was 100%, 97% (3%), and 97% (3%), respectively. Follow‑up echocardiography performed at a median (IQR) of 18.7 (2.5‒36.7) months postsurgery revealed freedom from aortic valve regurgitation in 90.8% of patients. No significant differences in mortality, freedom from reoperation, and freedom from aortic valve regurgitation were noted between the David and Yacoub subgroups. VSARR is a safe and effective surgical technique in patients with aortic root aneurysm, as the associated mortality, reoperation rate, and aortic valve regurgitation recurrence are low.

Outcomes in techniques of valve sparing aortic root replacement: A systematic review and meta-analysis.

To compare clinical outcomes of reimplantation versus remodeling in patients undergoing valve-sparing aortic root replacement (VSRR) surgery. Electronic database search at PubMed, Scopus, Embase, Ovid, and Google scholar was performed from inception to January 2020. Primary outcomes were aortic valve(AV) reintervention and postoperative grade of aortic insufficiency (AI) while secondary outcomes were 30-day mortality, reoperation for bleeding, and operative times. A total of 21 articles met the inclusion criteria. A total of 1283 patients had reimplantation while 1150 had remodeling. No difference in preoperative demographics was noted except reimplantation patients were younger (48 ± 16 vs. 56 ± 15 years; p < .00001). The cardiopulmonary bypass and aortic cross-clamp times were shorter in the remodeling cohort (168 ± 38 vs. 150 ± 37 min; p = .0001 and 133 ± 31 vs. 112 ± 30 min; p = .0002, respectively). No difference in concomitant total arch surgery (14% in reimplantation vs. 15% in remodeling; p = .53). Postoperatively, there were similar stroke rates (3% in both cohorts; p = .54), rates of reoperation for bleeding (9% in reimplantation vs. 12% in remodeling; p = .88), and 30-day mortality (3% in reimplantation vs. 4% in remodeling; p = .96). No difference in early AV reintervention (1% in reimplantation vs. 2% in remodeling; p = .07), and late AV reintervention (4% in reimplantation vs. 7% in remodeling; p = .07). The AI of +2 grade was significantly lower in the reimplantation cohort (5% vs. 8%; p = .01). Our study shows comparable clinical outcomes between both techniques. The practice of each technique is largely center and surgeon dependent. Larger sample size cohorts with minimal confounding factors are required to confirm the above findings.

Concomitant Aortic Root Replacement With Anterior Konno Annular Enlargement

The need for concomitant aortic annular enlargement and aortic root replacement may be necessary in situations of multilevel left ventricular outflow tract obstruction and/or prior aortic or aortic valve surgery, particularly in the setting of congenital heart disease. It can be extremely tedious and fraught with numerous complications. Major challenges include bleeding in difficult-to-reach areas and the potential need for subsequent operations. This article describes a technique of concomitant aortic annular enlargement and aortic root replacement that minimizes the risk of significant blood loss and facilitates future surgery should it be necessary.

Solo Smart stentless bioprosthesis for extensive aortic annular defects caused by infective endocarditis.

The optimal valve and prosthesis in patients with aortic valve infective endocarditis with annular abscess is controversial. If extensive annular defects occur after debridement, standard techniques are difficult; more complex aortic root replacement (ARR) or aortic valve translocation technique are inevitable. The Solo Smart stentless bioprosthesis is specially designed for supra-annular implantation without annular stitches. Nineteen patients with active aortic valve infective endocarditis underwent aortic valve replacement in the past 3 years. Of these, we performed aortic valve replacement using the Solo Smart valve in four patients with extensive annular destruction and complex aortic root pathologies requiring reconstruction. Although more than two-thirds of the annular structure was missing after radical debridement of infected tissues, supra-annular aortic valve replacement with the Solo Smart valve could be performed successfully in all four patients. All patients are doing well without prosthetic valve dysfunction and/or recurrent infection. The supra-annular aortic valve replacement using the Solo Smart valve is considered to be a useful alternative to standard aortic valve replacement in patients complicated with extensive annular defect. It is a simple and technically less demanding alternative to ARR or aortic valve translocation technique.

A novel device for technical standardization of valve-sparing aortic root reimplantation.

Among valve-sparing aortic root replacement techniques developed for the treatment of aortic root aneurysms and aortic insufficiency, the reimplantation technique (the David procedure) has proved to provide excellent outcomes in experienced hands. However, it involves certain challenges in technical standardization, particularly for graft sizing, which is still far from standardization. A novel device was developed to facilitate and provide all the measurements in high precision and accuracy required for the David procedure. The device allows easy, rapid, and accurate acquisition of the patient"s data and appropriate configuration of the aortic valve, irrespective of the surgeon's subjective evaluations. This all-in-one device provides all the major parameters including graft size, effective height, graft preparation, and simulation of the aortic coaptation. The device was successfully tested on a Devotini aortic root simulator and on a bovine heart ex vivo. The device proposed herein to be used for reimplantation has one explicit advantage: all valve geometry to be reconstructed and repaired can be simulated on the device with all its elements, in particular, the commissures and the cusps. Thus, all that is necessary can be clearly visualized in a manner whatever the configuration the surgeon prefers, particularly the creation of the effective height.