Valve Repair For Aortic Insufficiency Research Articles

Outcomes of aortic valve-sparing root replacement with cusp repair in connective tissue disease

BackgroundAlthough, valve sparing is commonly performed in patients with Marfan syndrome, feasibility and results of cusp repair for aortic insufficiency have not been studied. AimTo report on the outcomes and durability of aortic cusp repair in valve sparing in patients with Marfan syndrome. MethodsAll consecutive adult patients with Marfan syndrome who underwent remodelling and annuloplasty with aortic valve repair for aortic insufficiency between May 2005 and December 2020 were included. Patients with Marfan syndrome treated for aortic aneurysm, but without aortic insufficiency, were excluded. Data were collected prospectively and reviewed retrospectively from the Aorticvalve repair International Registry (AVIATOR). ResultsDuring the study period, 71 patients with Marfan syndrome were referred to surgery. Fifty-five patients with connective tissue disease and aortic insufficiency with aorta aneurysm were treated: 46 underwent aortic valve repair and nine underwent aortic valve replacement (five mechanical aortic valve replacements and four biological aortic valve replacements). The mean age was 42.9±15.4 years, and the mean EuroScore II was 2.5±2.2. No patient died, and no patient had significant aortic insufficiency (grade≥II) at discharge. The 5-year survival rate estimate was 94.4%, which seems statistically similar to that of the age- and sex-matched general population. At 5 years, freedom from reoperation was 94.6%, and the incidence of infective endocarditis was 2.6%. No valve thrombosis, aortic dissection, major bleeding events, thromboembolic events (stroke) or myocardial infarctions were noted during follow-up. ConclusionRemodelling and aortic valve repair showed excellent durability at 5 years, even in connective tissue disorders.

Aortic Valve Repair for Aortic Insufficiency Due to Cusp Prolapse

Aortic Valve Repair for Aortic Insufficiency Due to Cusp Prolapse

Early results of geometric ring annuloplasty for bicuspid aortic valve repair during aortic aneurysm surgery.

ObjectivesGeometric ring annuloplasty has shown promise during bicuspid aortic valve repair for aortic insufficiency. This study examined early outcomes of bicuspid aortic valve repair associated with proximal aortic aneurysm replacement.MethodsFrom September 2017 to November, 2021, 127 patients underwent bicuspid aortic valve repair with concomitant proximal aneurysm reconstruction. Patient age was 50.6 ± 12.7 years (mean ± standard deviation), male gender was 83%, New York Heart Association Class was 2 (1-2) (median [interquartile range]), and preoperative aortic insufficiency grade was 3 (2-4). Ascending aortic diameter was 50 (46-54) mm, and all patients had ascending aortic replacement. Forty patients had sinus diameters greater than 45 mm, prompting remodeling root procedures. A total of 105 patients had Sievers type 1 valves, 3 patients had type 0, and 7 patients had type 2. A total of 118 patients had primarily right/left fusion, 8 patients had right/nonfusion, and 1 patient had left/nonfusion. Leaflet reconstruction used central leaflet plication and cleft closure, with limited ultrasonic decalcification in 31 patients.ResultsRing size was 23 (21-23) mm, and 26 of 40 root procedures were selective nonfused sinus replacements. Aortic clamp time was 139 (112-170) minutes, and bypass time was 178 (138-217) minutes. Postrepair aortic insufficiency grade was 0 (0-0) (P < .0001), and mean valve gradient was 10 (7-14) mm Hg. No early and 1 late mortality occurred. Four patients required reoperation for bleeding, and 4 patients required pacemakers. At a mean follow-up of 20 months (maximal 93), there were no valve-related complications, 5 late repair failures prompting valve replacement, and 1 death due to Coronavirus Disease 2019.ConclusionsGeometric ring annuloplasty for bicuspid aortic valve repair with proximal aortic aneurysm reconstruction is safe and associated with good early outcomes. Further experience and follow-up will help inform long-term durability.

Aortic Valve Repair for Aortic Insufficiency or Dilatation: Technical Evolution and Long-term Outcomes

Aortic valve repair (AVR) is an attractive alternative to valve replacement for the treatment of aortic valve insufficiency. Here we report on the midterm outcomes after AVR for aortic valve insufficiency with an emphasis on durability of repair. Between 1996 and 2017, 560 consecutive patients (mean age, 57 ± 16 years) underwent various AVR procedures on tricuspid (n= 415, 74%) and bicuspid (n= 145, 26%) aortic valves. In 313 patients (56%) the David procedure was performed, whereas in 247 patients (44%) cusp repair without aortic root procedure was conducted. Concomitant procedures were coronary artery bypass grafting in 82 patients (15%) and mitral valve repair in 47 patients (8%). Clinical and echocardiographic follow-up was complete in 97% of patients. Mean follow-up was 6.3 ± 4.6 years. Thirty-day mortality was 1.4% (n= 8). Late mortality was observed in 132 patients with cardiovascular events accounting for mortality in 13 patients: Survival at 10 years was 70%. Reoperation on the aortic valve was performed on 39 patients for recurrent insufficiency, isolated in 25, or combined with valve stenosis in 5 patients; endocarditis accounted for reoperation in 9 patients (0.2% per patient-year). Freedom from reoperation was 88% at 10 years. Cumulative linearized incidence of all valve-related complications was 2% per patient per year. AVR for insufficiency is a durable procedure with low valve-related morbidity and mortality in the midterm.

Mid-term outcomes of valve-sparing root reimplantation with leaflet repair.

Valve repair for aortic insufficiency (AI) requires a tailored surgical approach determined by the leaflet and aortic disease. In this study, we used a repair-oriented system for the classification of AI, and we elucidated long-term outcomes of aortic root reimplantation with this classification system. From 1999 to 2018, a total of 197 patients underwent elective reimplantation (mean age: 52.7 ± 17.7 years; 80% male). The aortic valve was tricuspid in 143 patients, bicuspid in 51 patients and quadricuspid in 3 patients. A total of 93 patients had type I AI (aortic dilatation), 57 patients had type II AI (cusp prolapse) and 47 patients had type III AI (restrictive). In total, 104 of the 264 patients (39%) had more than 1 identified mechanism. In-hospital mortality was 0.5% (1/197). Mid-term follow-up (mean follow-up duration: 5.5 years) revealed a late mortality rate of 4.2% (9/197). Aortic valve reoperation was performed on 16 patients (8.0%). Rates of freedom from aortic valve replacement and freedom from aortic valve-related events at 10 years of follow-up were 87.0 ± 4.0% and 60.6 ± 6.0%, respectively; patients with type Ib AI (98.3 ± 1.7%; 80.7 ± 7.5%) had better outcomes than patients with type III AI (59.6 ± 15.6%; 42.2 ± 13.1%, P = 0.01). In patients with types II and III AI who had bicuspid aortic valves, rates of freedom from aortic valve-related events at 5 years of follow-up were 95.2 ± 4.7% and 71.7 ± 9.1%, respectively (P = 0.03). This repair-oriented system for classifying AI could help to predict the durable aortic valve repair techniques. Patient selection according to the classification is particularly important for long-term durability. B190050.

Bicuspid Aortic Valve Repair for Aortic Insufficiency Without Aortic Root Aneurysm: Does Preoperative Annular Diameter Matter for Long-term Durability?

Bicuspid Aortic Valve Repair for Aortic Insufficiency Without Aortic Root Aneurysm: Does Preoperative Annular Diameter Matter for Long-term Durability?

Hemodynamic outcomes of geometric ring annuloplasty for aortic valve repair: A 4-center pilot trial

A geometric annuloplasty ring could improve efficacy and stability of aortic valve repair. Toward this goal, a 1-piece 3-dimensional titanium annuloplasty ring with Dacron covering was developed and tested successfully in animals. The purpose of this study was to define hemodynamic outcomes with this device used as the annuloplasty component of human aortic valve repair. In a 4-center pilot trial with informed consent, 16 patients underwent aortic valve repair for aortic insufficiency, with the annuloplasty device sutured into the annulus beneath the leaflets. Preoperative annular diameter averaged 26.5 ± 2.0 (mean ± standard deviation) mm, and average ring size was 22.3 ± 1.2 mm. After annuloplasty, leaflet defects were easy to identify, and 14 of 16 patients (88%) required leaflet plication and/or autologous pericardial reconstruction for leaflet defects. Three patients had ascending aortic replacement, and 2 had remodeling root replacement. One had ultrasonic leaflet decalcification and another tricuspid valve annuloplasty. Follow-up data were from site-specific studies at the 6-month postoperative time point. There were no in-hospital mortalities or major complications. Preoperative aortic insufficiency grade (0-4 scale) was 3.6 ± 1.0 and fell to 1.0 ± 0.8 at 6 months (P < .0001). New York Heart Association class fell from 2.5 ± 0.5 to 1.1 ± 0.3 (P < .0001). Postrepair valve area was 2.7 ± 0.2 cm(2), and 6-month mean systolic gradient was 11.3 ± 3.3 mm Hg. Left ventricular end-diastolic diameter and ejection fraction both normalized (both P < .0001). Geometric ring annuloplasty facilitated aortic valve repair, allowing more precise reconstruction of leaflet defects. Aortic insufficiency reduction and systolic gradients were excellent, and expansion of valve reconstruction into broader categories of aortic valve disease seems indicated.

Aortic Valve Repair for Aortic Insufficiency: A Review

AORTIC INSUFFICIENCY (AI) refers to the backward leaking of blood through the aortic valve (AV) during diastole. AI can be treated with many techniques that repair or replace the AV and modify the structural dimensions of the aortic root and ascending aorta. Based on the anatomy of an individual patient, a combination of surgical approaches may be used to repair an AI.

Aortic valve repair for active infective endocarditis

Aortic valve repair for active infective endocarditis

662 Effect of Left ventricular size and function on outcome following aortic valve repair for aortic insufficiency

BackgroundLeft ventricular (LV) dilation and reduced LV function are known predictors of poor long-term outcome following aortic valve (AV) replacement for aortic insufficiency (AI). We examined their impact on long-term outcome following AV repair.MethodsSince 1995, 300 patients with significant AI (> = 2+) with or without ascending aortic pathology underwent AV repair. Mean LV end diastolic (LVEDD) and end-systolic (LVESD) diameters were 60 ± 9 mm and 41 ± 10 mm respectively and 13% had reduced LV function. Valve repair included aortic root replacement in 42% patients and cusp repair in 68%. Cox Models were used to analyze failure-time data. The primary endpoint was prospectively defined as a composite of death, AV reoperation, or recurrent AI (> = 2+).ResultsOverall survival was 88 ± 3% at 8 years. During follow-up, 30 patients (10%) developed severe recurrent AI (>2+) and 22 (7.3%) underwent AV reoperation. Patients with preoperative LV dysfunction, and LV dilatation (Fig 1A) had increased risk of the composite endpoint. Multivariable analysis demonstrated that preoperative LVEDD (Hazard Ratio: 1.07 [1.04 - 1.11], P< 0.001) and LVESD (HR - 1.06 [1.03 - 1.10], p65 (Fig 1B) and LVESD>45.ConclusionLV dilatation is an important risk factor following AV repair. Valve repair prior to LV dilatation (LVEDD < 65 mm) is associated with improved long-term outcome. This finding may have implications for the timing of surgery in patients with AI amenable for valve repair. BackgroundLeft ventricular (LV) dilation and reduced LV function are known predictors of poor long-term outcome following aortic valve (AV) replacement for aortic insufficiency (AI). We examined their impact on long-term outcome following AV repair. Left ventricular (LV) dilation and reduced LV function are known predictors of poor long-term outcome following aortic valve (AV) replacement for aortic insufficiency (AI). We examined their impact on long-term outcome following AV repair. MethodsSince 1995, 300 patients with significant AI (> = 2+) with or without ascending aortic pathology underwent AV repair. Mean LV end diastolic (LVEDD) and end-systolic (LVESD) diameters were 60 ± 9 mm and 41 ± 10 mm respectively and 13% had reduced LV function. Valve repair included aortic root replacement in 42% patients and cusp repair in 68%. Cox Models were used to analyze failure-time data. The primary endpoint was prospectively defined as a composite of death, AV reoperation, or recurrent AI (> = 2+). Since 1995, 300 patients with significant AI (> = 2+) with or without ascending aortic pathology underwent AV repair. Mean LV end diastolic (LVEDD) and end-systolic (LVESD) diameters were 60 ± 9 mm and 41 ± 10 mm respectively and 13% had reduced LV function. Valve repair included aortic root replacement in 42% patients and cusp repair in 68%. Cox Models were used to analyze failure-time data. The primary endpoint was prospectively defined as a composite of death, AV reoperation, or recurrent AI (> = 2+). ResultsOverall survival was 88 ± 3% at 8 years. During follow-up, 30 patients (10%) developed severe recurrent AI (>2+) and 22 (7.3%) underwent AV reoperation. Patients with preoperative LV dysfunction, and LV dilatation (Fig 1A) had increased risk of the composite endpoint. Multivariable analysis demonstrated that preoperative LVEDD (Hazard Ratio: 1.07 [1.04 - 1.11], P< 0.001) and LVESD (HR - 1.06 [1.03 - 1.10], p65 (Fig 1B) and LVESD>45. Overall survival was 88 ± 3% at 8 years. During follow-up, 30 patients (10%) developed severe recurrent AI (>2+) and 22 (7.3%) underwent AV reoperation. Patients with preoperative LV dysfunction, and LV dilatation (Fig 1A) had increased risk of the composite endpoint. Multivariable analysis demonstrated that preoperative LVEDD (Hazard Ratio: 1.07 [1.04 - 1.11], P< 0.001) and LVESD (HR - 1.06 [1.03 - 1.10], p65 (Fig 1B) and LVESD>45. ConclusionLV dilatation is an important risk factor following AV repair. Valve repair prior to LV dilatation (LVEDD < 65 mm) is associated with improved long-term outcome. This finding may have implications for the timing of surgery in patients with AI amenable for valve repair. LV dilatation is an important risk factor following AV repair. Valve repair prior to LV dilatation (LVEDD < 65 mm) is associated with improved long-term outcome. This finding may have implications for the timing of surgery in patients with AI amenable for valve repair.

A Case of Successful Valve Repair for Aortic Insufficiency Associated with Discrete Subaortic Stenosis

Discrete subaortic stenosis (DSS) is an uncommon form of left ventricular outflow tract obstruction especially in adulthood. Moreover, aortic regurgitation (AR), which is a common sequence of DSS, requiring surgical correction is extremely rare. We report the case of a 33-year old man who had severe DSS accompanied with moderate aortic insufficiency. He underwent successful surgery including relief of DSS and aortic valve repair. Although careful follow-up is mandatory for recurrent AR and DSS, our approach was thought to be feasible for a young adult patient with DSS complicated with AR.

Repair-oriented classification of aortic insufficiency: Impact on surgical techniques and clinical outcomes

Valve repair for aortic insufficiency requires a tailored surgical approach determined by the leaflet and aortic disease. Over the past decade, we have developed a functional classification of AI, which guides repair strategy and can predict outcome. In this study, we analyze our experience with a systematic approach to aortic valve repair. From 1996 to 2007, 264 patients underwent elective aortic valve repair for aortic insufficiency (mean age - 54 +/- 16 years; 79% male). AV was tricuspid in 171 patients bicuspid in 90 and quadricuspid in 3. One hundred fifty three patients had type I dysfunction (aortic dilatation), 134 had type II (cusp prolapse), and 40 had type III (restrictive). Thirty six percent (96/264) of the patients had more than one identified mechanism. In-hospital mortality was 1.1% (3/264). Six patients experienced early repair failure; 3 underwent re-repair. Functional classification predicted the necessary repair techniques in 82-100% of patients, with adjunctive techniques being employed in up to 35% of patients. Mid-term follow up (median [interquartile range]: 47 [29-73] months) revealed a late mortality rate of 4.2% (11/261, 10 cardiac). Five year overall survival was 95 +/- 3%. Ten patients underwent aortic valve reoperation (1 re-repair). Freedoms from recurrent Al (>2+) and from AV reoperation at 5 years was 88 +/- 3% and 92 +/- 4% respectively and patients with type I (82 +/- 9%; 93 +/- 5%) or II (95 +/- 5%; 94 +/- 6%) had better outcomes compared to type III (76 +/- 17%; 84 +/- 13%). Aortic valve repair is an acceptable therapeutic option for patients with aortic insufficiency. This functional classification allows a systematic approach to the repair of Al and can help to predict the surgical techniques required as well as the durability of repair. Restrictive cusp motion (type III), due to fibrosis or calcification, is an important predictor for recurrent Al following AV repair.

Aortic valve repair for aortic insufficiency in adults: a contemporary review and comparison with replacement techniques

I recently read the review article by Carr and Savage [1], which focuses on the aortic valve repair (not the aortic valvesparing replacement) and its late outcome involving different techniques for patients with different etiologies. They should be commended for this work and I thank them for drawing attention to the aortic valve repair, which has received considerably less attention than mitral or tricuspid repairs in cardiac surgery. However, I believe that early and late outcomes after the repair should be tabulated and identified according to the etiology of the aortic valve disease. In their review, many articles containing 50% or more patients with rheumatic disease are included for review to compare postoperative early and late outcomes with valve replacements or Ross procedure. On the other hand, they admitted that patients with rheumatic disease have an increased incidence of recurrence after repair in the conclusion. It is not fair to include cases of rheumatic etiology in the repair group and compare its outcome with the replacement group. Readers should be aware of this inconsistency in this review to better understand the present outcome after aortic valve repair. Another important point which needs correction or clarification is the analysis of reported article cited in the reference. In their analysis, number of patients receiving aortic valve repair in Shafer et al.’s [2] article is 156 (Table 1). However, by carefully reading the article, Shafer et al. reported 68 patients who underwent aortic valve repair + valve-preserving surgery and 88 patients who underwent only valve-preserving surgery. Also in Table 1, the authors (Carr and Savage) showed that the percentage of leaflet plication or triangular resection in Izumoto et al.’s [3] report is 76%. However, if one carefully reads the article, the percentage of such procedure is far less than 76%. By roughly analyzing this Table 1, I do believe that the tables in their review or the

Aortic valve repair for aortic insufficiency in adults: a contemporary review and comparison with replacement techniques.

In evaluating the goal of aortic valve preservation, there have been 11 reports of large series of aortic valve repair for aortic insufficiency in adults published in recent years. We sought to analyze the validity of these methods and compare them to published results for bioprosthetic valves, pulmonary autografts, and aortic homografts. From 1990 to 2002, 761 adult aortic valve repairs were reported. Perioperative morbidity ranged from 3.6 to 23% (mean 14%), early mortality 0-8% (mean 3.6%), and late mortality 0-8% (mean 2.8%). The 5- and 10-year freedom from reoperation rates for repair were 89 and 64%. Although early results are good, long-term analysis suggests that, as a group, the durability of repair is unclear. Patients with rheumatic valvular disease appear to have an increased incidence of recurrence and repair failure. Although suture line dehiscence continues to be both an early and late complication with repair, the long-term morbidity and mortality is low and valve repair may be an option in carefully selected patients. However, the inability to break down the results by techniques does not allow for a definitive conclusion. Further subanalysis is necessary as larger series are reported. Proponents must attempt to separate successful from unsuccessful techniques. Aortic valve repair is a technique in evolution.

Valve repair for aortic insufficiency: surgical classification and techniques

Valve repair for aortic insufficiency may provide an alternative to aortic valve replacement in selected patients. This repair could be an attempt at permanent correction or palliation to allow the aortic annulus to grow and avoid the use of anticoagulation. Based upon a five-year experience, we proposed a classification according to valvular anatomy which could be a guide to patient and procedure selection. Between September 1989 and February 1995, 44 consecutive patients underwent aortic valvuloplasty for aortic incompetence at our institution. Patients' ages ranged from 19 months to 76 years with a mean of 33 years. The etiology of aortic incompetence was congenital in 30 patients, degenerative in 7 patients, rheumatic in 5 patients, and infective endocarditis in 2. Aortic valve lesions were classified into three different types: type I, aortic annular dilation (8 patients); type II, excessive aortic leaflet tissue (12 patients); and type III, restricted leaflet motion with or without deficient leaflet tissue (24 patients). Type I needed commissural plication in 7 patients; and aortic annuloplasty, which was simple in 6 patients, and pericardial-augmented in 2. Type II necessitated midleaflet excision in 11 patients and leaflet plication in 7. Type III required leaflet extension in 19 patients, leaflet replacement in 1 patient, aortic valve commissurotomy in 13 patients augmentation commissurorrhaphy in 2, leaflet shaving in 4, and repair of leaflet perforation in 2. Postoperative echocardiography revealed a significant decrease in the degree of aortic incompetence. Mean follow-up was 2.6 +/- 1.4 years. There was no mortality. Patients improved as is evident by NYHA functional class postoperatively. Eight of the first 13 patients (18%) needed reoperation. Three of these reoperations were bail-out procedures, and 3 patients (7%) who underwent the leaflet extension technique were reoperated upon 19 months to 3 years later. Presently, 23 patients are without anticoagulation, 11 take aspirin and 2 receive coumadin for combined mitral procedures. Aortic valve repair provides a low risk option with satisfactory intermediate-term results for the treatment of aortic insufficiency in appropriately selected patients. Patient and procedure selection may be based upon the echocardiographic anatomy of the aortic valve, and a comparative risk benefit appraisal with valve replacement.

Heart valve surgery.

Progress in valve repair and replacement continued over the past year. Aortic valve repair for aortic insufficiency appears promising, and aortic decalcification may still be a useful alternative in certain cases of aortic stenosis. Mitral valve repair, well accepted for myxomatous valves, presents a challenge in ischemic disease. Balloon mitral valvotomy offers significant short-term hemodynamic improvement, but needs to be properly compared with surgical treatment of mitral stenosis. Although aortic valve replacement with homografts and pulmonary autografts yields excellent results, enthusiasm for the stentless porcine xenograft is increasing. Clinical results reported for the Carpentier-Edwards pericardial valve (Baxter Healthcare Corp., Edwards Div., Santa Ana, CA) and the Bjork-Shiley monostrut valve (Shiley Inc., Irvine, CA) are excellent. Acute endocarditis continues to be a challenging problem but early aggressive debridement appears to offer patients the best chance of cure, regardless of what valve replacement is used.