Valve-sparing Aortic Root Reimplantation Research Articles

Short and mid-term outcomes of valve-sparing, aortic root reimplantation (David’s procedure)

BackgroundIn the current study, we aimed to report the short- and mid-term outcomes of patients undergoing valve-sparing aortic root reimplantation (VSARR) and our center’s experience with the procedure.MethodsForty patients with aortic root aneurysms underwent VSARR at our center from 2010 until 2022. We retrospectively reviewed the medical records of these patients and extracted the relevant data. After carefully examining the aortic valve, the surgeon decided to perform Bentall or David’s procedure during the operation.ResultsThe study population comprised 31 (77.5%) men and nine (22.5%) women, with a mean age of 55.35 ± 15.40. One patient developed hemodynamic instability post-surgery in the hospital and died from multi-organ failure. Another patient had severe AI in the intraoperative echocardiography, and aortic valve replacement with a prosthetic graft was performed during the same operation. In pre-operation echocardiography, 25 (62.5%) patients had severe, nine (22.5%) had moderate, and six (15%) had mild AI. In the in-hospital post-operation follow-up echo, AI was improved, and no patients had severe AI (P < 0.001). Only eight patients had moderate AI in post-one-year follow-up echo exams, while the rest had mild AI.ConclusionDavid’s procedure showed excellent mid-term results in our center, with only one in-hospital mortality.

Outcomes of Aortic Valve Repair with valve-sparing aortic root reimplantation &amp; maintenance of commissural orientation.

Outcomes of Aortic Valve Repair with valve-sparing aortic root reimplantation &amp; maintenance of commissural orientation.

Mitral Valve Repair Is Effective When Performed With Valve-Sparing Aortic Root Replacement

BackgroundConcurrent aortic and mitral valve repair presents specific technical challenges to surgeons. Here we evaluate the outcomes of patients undergoing combined valve-sparing aortic root reimplantation and mitral valve repair. MethodsWe performed a retrospective review of patients at our center between 2006 and 2021 who underwent concomitant valve-sparing aortic root replacement and mitral valve repair. Patient characteristics, including preoperative and postoperative valve function, and operative outcomes were analyzed. ResultsBetween 2006 and 2021, 14 patients underwent valve-sparing aortic root replacement with concurrent mitral valve repair. Mean age of the patients at operation was 39 ± 20 years. Almost half of the patients (6/14) had Marfan disease. The primary indication for operation in all patients was aortic root dilation. Preoperatively, all patients (14/14) had moderate to severe mitral regurgitation, and half (7/14) had moderate to severe aortic regurgitation. Patients underwent mitral annuloplasty alone (9/14) or had concurrent leaflet repair (5/14). The median length of intubation was 0 day (interquartile range, 0-1 day), and median length of stay was 7 days (interquartile range, 6-10 days). At average follow-up of 6.8 ± 4.2 years, 13 of 14 patients had none to trace aortic and mitral regurgitation. One patient required reoperation for late recurrence of aortic and mitral regurgitation. There was no early or late cardiovascular mortality. ConclusionsMitral valve repair can be performed safely with excellent short-term and long-term results in selected patients undergoing valve-sparing aortic root reimplantation. For durable bivalvular repair to be achieved, specific technical considerations should be adhered to.

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.

Remote results of Florida Sleeve technique in patients with ascending aortic aneurysms and aortic insufficiency.

The aim of our investigation was to assess the remote results of valve-sparing aortic root reimplantation into the graft (Florida Sleeve technique) compared with reimplantation of the aortic valve into the graft (David technique) during surgical correction of ascending aortic aneurysms accompanied by concomitant aortic insufficiency. Our single-centre, blind, prospective, randomized study carried out from 2011 to 2015 included a total of 64 patients with ascending aortic aneurysms and aortic insufficiency. The patients were randomized into 2 groups: group I - aortic root reimplantation according to the Florida Sleeve technique (FS group) and group II - reimplantation of the aortic valve according to the T. David technique in David I modification (D group). The groups did not statistically differ by the baseline clinical profile. The overall 7-year survival for the FS group and D group amounted to 83% and 85.6%, respectively (p=0.98). Assessing the competing risks of mortality related to cardiovascular or other causes revealed no differences. Freedom from prosthetic repair of the aortic valve in the remote follow-up period amounted to 92.8% and 85.8% for the FS group and D group, respectively (p=0.4). According to the obtained findings, the technique of a valve-sparing operation is not a predictor of either lethality (RR 0.98 (95% CI 0.23-4.15), p=0.98) or prosthetic repair of the aortic valve (RR 2.03 (95% CI 0.40-14.63), p=0.40) in the remote period of follow up. Aortic root reimplantation inside the prosthesis according to the Florida Sleeve technique makes it possible to simplify and accelerate the procedure of aortic root reconstruction in patients with aortic root aneurysms and concomitant aortic insufficiency, demonstrating long-term results comparable with those of the David technique.

Early and long-term results of aortic valve sparing aortic root reimplantation surgery for bicuspid and tricuspid aortic valves

To evaluate early and long-term clinical outcomes following aortic valve sparing aortic root reimplantation surgery in patients with leaking bicuspid and tricuspid aortic valves. The study consisted of 92 consecutive adult patients (tricuspid aortic valve group = 63 and bicuspid aortic valve group = 29) who underwent aortic valve sparing aortic root reimplantation surgery with or without aortic cusp repair for dilatation of the aortic root and/or aortic valve regurgitation at our institution from April 2004 to October 2016. Clinical outcomes were investigated using Kaplan-Meier and log-rank tests between groups. The follow-up was 100% complete with a mean time of 5.3 ± 3.3 years. The 30-day in-hospital mortality was 3.1% in tricuspid aortic valve group and 3.4% in bicuspid aortic valve group patients. The overall survival rates at 10 years did not differ between bicuspid aortic valve and tricuspid aortic valve patient groups (96.6 ± 3.3% vs. 90.3 ± 4.2%, p = 0.3). Freedom from recurrent aortic valve regurgitation (>2+) at 10 years was 90.5 ± 4.1% in tricuspid aortic valve group and 75.7 ± 8.7% in bicuspid aortic valve group (p = 0.06). Freedom from aortic valve reoperation at 10 years was 100% in tricuspid aortic valve group and 83.9 ± 7.4% in bicuspid aortic valve group (p = 0.002). Aortic valve sparing aortic root reimplantation surgery is a safe and efficient technique, providing acceptable long-term survival with low rates of valve-related complications in both tricuspid aortic valve and bicuspid aortic valve patient groups. However, aortic valve reoperation rates at 10 years follow-up were higher in bicuspid aortic valve group patients compared to tricuspid aortic valve group patients.

Minimally invasive valve-sparing aortic root reimplantation

Valve-sparing aortic root reimplantation is the technique of choice in appropriately selected patients with aortic root aneurysms. Valve-sparing operations require durable restoration of the structural and functional integrity of the aortic root and valve. These procedures are seldom performed in a minimally invasive fashion. We describe a systematic approach to minimally invasive valve-sparing aortic root reimplantation.

Minimally invasive valve-sparing aortic root reimplantation in a tricuspid aortic valve

Minimally invasive valve-sparing aortic root reimplantation in a tricuspid aortic valve

Mid-Term Results of Valve-Sparing Aortic Root Replacement in Patients With Expanded Indications

The mid-term results of valve-sparing aortic root reimplantation (VSRR) for various indications were investigated. From 2000 to 2013, 183 consecutive patients undergoing VSRR were enrolled. Expanded indications, defined as a patient on the marginal operative indication, included age 65 years or older (n = 33), age 15 years or younger (n = 4), acute type A aortic dissection (AAAD) (n = 21), aortitis (n = 8), reoperative root replacement (n = 11), cusp prolapse (n = 67), large aortoventricular junction of greater than 28 mm (AVJ) (n = 42), preoperative severe aortic regurgitation (AR) (n = 89), left ventricular ejection fraction 0.40 or less (n = 12), LV dilation (n = 66), New York Heart Association class III or greater (n = 5), need for total arch replacement (n = 29), and concomitant mitral valve repair (n = 12). The overall survival at 5 years was 96.6%. Freedom from greater than mild AR and reoperation at 5 years was 85.8% and 92.9%, respectively. Cox proportional hazard model revealed that AAAD, cusp prolapse, AVJ 28 mm or greater, and operation before 2009 were at risk for late AR recurrence (p = 0.015, p = 0.0041, p = 0.032, and p = 0.014, respectively). After 2009, freedom from late AR in the cusp prolapse group improved (p = 0.055, versus control). Both freedom from recurrent AR and reoperation were worse as the number of expanded indications increased (log-rank trend p = 0.00017 and p = 0.00067, respectively). Surgical outcomes of VSRR in these patient cohorts were satisfactory with some room for improvement in patients with cusp prolapse. Although the indications for VSRR are being expanded, a larger number of expanded indications were associated with poor outcomes in terms of longevity of valve function.

Long-term outcome after the original and simple modified technique of valve-sparing aortic root reimplantation in Marfan-based population, David V University of Tokyo modification

BackgroundIn valve-sparing aortic root replacement (VSARR), how to reproduce Valsalva sinus has been an issue. In the original David V procedure, they put plication stitches at sinotubular junction level, although the reefing effect is limited and distal graft remains larger than native. Other modified techniques are two-grafts technique and ready-made Valsalva graft. However, the former needs graft–graft anastomosis and may not be cost-effective, while in the latter, the shape of sinus is fixed and minor adjustment is difficult. David V University of Tokyo modification (David V-UT) is our original solution to that, creating pseudosinus with one straight graft by longitudinal size-reduction running sutures above each pseudosinus. The purpose of the present study is to investigate long-term outcome of David V-UT. MethodsWe analyzed 59 David V-UT patients from February 2004 to February 2013 and long-term outcomes were investigated by Kaplan–Meier methods. Risk factors for adverse events “death or recurrent aortic insufficiency (AI) with or without aortic valve reoperation” were analyzed by using Cox proportional hazard models. ResultsMean age was 33.1±14.5 years, and 38 patients (64%) were male. Marfan syndrome (MFS) accounts for 47 patients (80%). Only one patient was with bicuspid aortic valve. No in-hospital mortality was observed. Mean follow-up was 4.9±2.4 years. Estimated survival was 94.0±3.4% at 5 years. Freedoms from aortic valve reoperation and recurrent AI greater than mild were 95.7±3.0% and 88.9±4.7% at 5 years, respectively. In Cox proportional hazard analysis, preoperative AI greater than mild and Z score of annular diameter were significant risks for adverse events (p=0.027 and 0.045, hazard ratio 6.084 and 1.432, 95% C.I. 1.225–30.21 and 1.008–2.035, respectively). ConclusionsEven in Marfan-characterized population, David V-UT provided satisfactory long-term outcome, comparable to other VSARR modifications. It is simple but can freely reproduce trilobed sinus with one straight graft.

Valve Sparing Aortic Root Re-implantation (David V Procedure): Early and Midterms Results of Our Clinic

PP-405 Replacement procedures in patients with aortic root dilatation became more important with increasing information about the dynamic nature and physiology of the aortic root. Especially, valve sparing aortic root replacement and reimplantation procedures are more preferred in normal valve

Early results of a novel technique for ring-reinforced aortic valve and root restoration†

Surgery for aortic root aneurysm without valve stenosis is increasingly being transformed from the Bentall procedure to valve-sparing aortic root remodelling or reimplantation. In this report, a new repair option is explored, with full functional 'restoration' of the aortic root complex using a geometric annuloplasty ring, leaflet repair, and sinus/ascending aortic replacement with a Valsalva graft. The geometric annuloplasty ring restores elliptical annular shape and size in patients with tri-leaflet aortic insufficiency (AI). The ring mounts the three valve commissures on 10° outwardly flaring posts, and facilitates required leaflet procedures. In clinical application, the device has been effective in achieving stable AI reduction with low valve gradients. In this report, 6 patients with aortic root aneurysms and moderate/severe AI were managed with valve repair using the annuloplasty device and leaflet reconstruction, and then concomitant sinus and ascending aortic graft replacement with coronary implantation. In the 6 initial root aneurysm patients, there were no in-hospital mortalities, procedural conversions, or valve-related complications. Preoperative AI grade was 2-4 and fell to 0-1 postoperatively. Post-repair mean systolic gradients ranged from 7 to 12 mmHg, and all patients had stable intermediate-term valve function. Aortic root restoration using a geometric annuloplasty ring and Valsalva graft may be the most physiological method of aortic valve repair and root replacement. Even with severe leaflet derangements, valve sparing can be achieved with good competence and potentially stable long-term results. This technique could assist in extending valve sparing into most categories of aortic root disease. Patients were managed as part of a Phase I (ClinicalTrials.gov Identifier: NCT01400841), supported by BioStable Science and Engineering (BSE), Austin, TX, USA; www.biostable-s-e.com.

Valve-sparing aortic root reimplantation and cusp repair in bicuspid aortic valve: with aortic insufficiency and root aneurysm.

The text of this manuscript describes the surgical techniques demonstrated in our video, “Valve-sparing aortic root reimplantation in bicuspid aortic valve: with aortic insufficiency (AI) and root aneurysm” (Video 1). Video 1 Valve-sparing aortic root reimplantation and cusp repair in bicuspid aortic valve: with aortic insufficiency and root aneurysm This video shows our approach to valve-sparing aortic root reimplantation in bicuspid aortic valve (BAV) presenting with proximal dilation and eccentric aortic valve insufficiency. Understanding the aortic insufficiency classification system as conceived by the Brussels group under the direction of Gebrine El Khoury and published by Boodhwani et al. is important. This video is our approach to the combination type Ib/II BAV. This is the most common presentation and represents aortic root dilation with cusp prolapse. The anatomy of the classically repairable type Ib/II BAV is characterized by lack of signification leaflet calcification, presence of eccentric AI, and dilated proximal aorta with sinotubular junction (STJ) effacement. Note that the actual sinus segment is mildly dilated only. The main concepts of bicuspid aortic valve repair and root reimplantation are as follows: (I) leaflet/cusp free margin equalization, (II) annular stabilization and annular reduction, (III) raphe release (IV) optimization of the leaflet coaptation height to ensure elevation of this height above the annular plane, and (V) root reimplantation and coronary button reconstruction.

Extensive aneurysms of sinuses of Valsalva precluding valve sparing aortic root reimplantation (David procedure)

A 55-year-old female noticed worsening exertional dyspnoea for two years. She was born with cleft palate and profound deafness. Significant physical findings included dysmorphism with micrognathia and acrocephaly and congenital deafness. Transthoracic echocardiogram revealed aneurysms involving the right and the non-coronary sinuses of Valsalva. Despite that, the native aortic valve retained preserved geometry. Computed tomography (CT)-scan demonstrated multiple aneurysms arising from all three sinuses of Valsalva. This displaced the right ventricle (RV) caudally and indented the RV outflow tract. A valve-sparing root reimplantation was planned. However, intraoperatively the root aneurysms were found to be very extensive such that no healthy tissue remained along the insertion lines of the aortic valve leaflets. The aortic annulus was not dilated (2 cm) and the left ventricular outlow tract was not involved in the disease process. Consequently, despite the presence of macroscopically normal leaflets and relatively undisturbed annular geometry, we were unable to reimplant the native aortic valve and proceeded to a modified Bentall procedure. Histologically, significant medial degeneration with loss of elastin and muscle was identified in the aortic sinus wall. Similar changes were also found affecting the native leaflets coupled with increased fibrous thickening.

Aortic root surgery in septuagenarians: impact of different surgical techniques

BackgroundTo evaluate the impact and safety of different surgical techniques for aortic root replacement (ARR) on early and late morbidity and mortality in septuagenarians undergoing ARR.MethodsNinety-five patients (73.8 ± 3.2 years) were operated and divided into three groups according to the aortic root procedure; MECH-group (n = 51) patients with a mechanical composite graft, BIO-group (n = 22) patients with a customized biological composite graft, and REIMPL-group (n = 22) patients with a valve sparing aortic root reimplantation (David I). In 42.1% (40/95) of these patients the aortic arch was replaced. Follow-up was completed in 95.2% (79/83) of in-hospital survivors.ResultsHospital mortality was 12.6% (12/95) in the entire population (MECH. 15.7% (8/51), BIO 19.7% (4/22), REIMPL 0% (0/22); p = 0.004). Two patients died intraoperatively. The most frequent postoperative complications were prolonged mechanical ventilation ((>48 h) in 16.8% (16/93) (MECH. 7% (7/51), BIO 36.4% (8/22), REIMPL 4.5% (1/22); p = 0.013) and rethoracotomy for postoperative bleeding in 12.6% (12/95) (MECH. 12% (6/51), BIO 22.7% (5/22), REIMPL 4.5% (1/22); p = 0.19). Nineteen late deaths (22.9%) (19/83) (MECH 34.8% (15/43), BIO 16.7% (3/18), REIMPL 4.5% (1/22); p = 0.012) occurred during a mean follow-up of 41 ± 42 months (MECH 48 ± 48 months, BIO 25 ± 37 months, REIMPL 40 ± 28 months, p = 0.028). Postoperative NYHA class decreased significantly (p = 0.017) and performance status (p = 0.027) increased for the entire group compared to preoperative values.ConclusionOur data indicate that valve sparing aortic root reimplantation is safe and effective in septuagenarians, and is associated with low early and late morbidity and mortality.

Valve-Sparing Operation for Aortic Root Aneurysm Late After Mustard Procedure

The aortic valve reimplantation technique leads to excellent clinical outcome in patients with aortic valve incompetence and aneurysms of the ascending aorta. This technique is now applied for aneurysms of ascending aorta, aortic dissection type A, and even dilatation of pulmonary autograft after the Ross operation. We report a case of aortic root dilatation late after a Mustard operation for transposition of the great arteries that was successfully managed by valve-sparing aortic root reimplantation.

A simple modification of ‘David-V’ aortic root reimplantation

Valve-sparing aortic root reimplantation with creation of Dacron graft pseudosinuses is a popular and promising surgical choice for annuloaortic ectasia or ascending aortic aneurysm. We have developed a simple modification of the David-V technique, which facilitates free adjustment of the size of the new aortic annulus and the pseudosinus of each patient, as well as the creation of pseudosinuses of excellent shape, with only one Dacron graft.

Outcome of valve sparing aortic root reimplantation for various indications during eleven years

Outcome of valve sparing aortic root reimplantation for various indications during eleven years

Impact of preoperative aortic root diameter on long-term aortic valve function after valve sparing aortic root reimplantation.

Valve sparing aortic root reimplantation technique in patients with aortic root aneurysm have shown excellent mid-term results. In conjunction with the diameter of the aortic root the mechanical leaflet stress increase, which might have an impact on long-term aortic valve function after valve sparing aortic root reimplantation. From July 1993 to October 2001, 168 patients with aortic root aneurysm underwent valve sparing aortic root reimplantation. Patients with type A aortic dissection were excluded. Thus, 123 patients were analyzed. We identified 47 patients with an preoperative aortic root diameter exceeding 60 mm (group A), 58 patients with an diameter between 50 and 60 mm (group B), and 18 patients with a diameter less than 50 mm (group C). The groups were compared regarding mortality, long-term survival, freedom from reoperation, freedom from severe and moderate aortic valve insufficiency (AI), and postoperative morbidity. Mean follow-up (group A 43+/-26 months, group B 40+/-25 months, group C 23+/-19 months; group C versus group A, P=0.005; group C versus group B, P=0.011) was shorter in group C. Perioperative mortality (group A 2.2%, group B 1.9%, group C 5.2%; P=ns) was comparable between the groups with each one patient. The 3-year survival for group A was 98+/-2%, for group B 96+/-3%, and for group C 100+/-0% (P=ns). Freedom from reoperation for group A was 98+/-2%, for group B 96+/-3%, and for group C 88+/-8% (P=ns). Four patients developed severe or moderate AI, thus freedom from severe and moderate AI for group A was 100+/-0%, for group B 88+/-8%, and for group C 94+/-5% (P=ns). During follow-up no thromboembolic or bleeding events were noticed. Our data show that the preoperative diameter of the aortic root has no impact on the longevity of the repair. Thus, the reimplantation technique can be recommended for all patients presenting with an aortic root aneurysm and normal leaflets regardless of the aortic root diameter.

Aortic root reimplantation for successful repair of an insufficient pulmonary autograft valve after the Ross procedure

J Thorac Cardiovasc Surg 2002;124:1048-9