Valve-sparing Operations Research Articles

Implications of Left Atrial Size in Rheumatic Mitral Valve Disease Undergoing Mitral Valve Replacement

and also a lethal injury with 85% of patients dying at the scene of the injury. This is only the second reported case of survival following combined aortic transection and intrapericardial IVC injury. Expedient surgical intervention, the appropriate use of clamshell incision and the ability to rapidly institute cardiopulmonary bypass helped to improve this gentleman’s chance of surviving an invariably fatal injury. doi:10.1016/j.hlc.2011.08.056 2011 Poster Presentation/Panel 18 Valve Sparing Aortic Root Surgery in Bicuspid Aortic Valve: A Systematic Review Hamid Mollahajian1,2,∗, Ratnasari Padang2,3, MohammadRahnavardi 1,2,3, TristanD. Yan1, PaulG. Bannon1,2,3 1 The Baird Institute for Applied Heart and Lung Surgical Research, Sydney, Australia 2 Faculty of Medicine, The University of Sydney, Sydney, Australia 3 Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia Introduction: Bicuspid aortic valve (BAV) is the most common congenital heart disease, often associated with an intrinsic aortopathy resulting in dilatation of ascending aorta and aortic root. Aortic valve sparing operation ( a o v t t T r o

Invited Commentary

In the present series including 101 patients who were scheduled to receive aortic valve-sparing aortic root replacement according to David's reimplantation technique, the authors identified 16 cases (15%) that met the criteria of aortic root repair failure defined as (1) intraoperative conversion to Bentall's procedure, (2) reoperation because of aortic regurgitation, and (3) aortic regurgitation of moderate degree or more at follow-up [1]. The authors have to be congratulated for their honest report on failure after aortic valve-sparing operations.

Tetralogy of Fallot: prediction of outcome in the mid‐second trimester of pregnancy

To evaluate the usefulness of fetal echocardiography in the mid-second trimester in predicting postnatal outcome of tetralogy of Fallot (ToF), focusing on the need for early intervention (EI) and surgery type: pulmonary valve-sparing surgery (PVSS) versus placement of transannular patch (TAP). Assessment of cardiac morphological and functional parameters in 23 live-born fetuses with isolated ToF was performed at 19 to 22 and 34 to 38 weeks. Comparisons were made between outcome groups (EI vs non-EI and PVSS vs TAP). EI was considered as requirement either of palliative procedure or corrective surgery before three months. Overall survival was 96%. EI was required in 32% of cases and TAP in 50%. At 19 to 22 weeks, a pulmonary valve peak systolic velocity (PVPSV) ≥87.5 cm/s predicted EI with 100% sensitivity and 93.3% specificity (p < 0.01). At 34 to 38 weeks, the size of the pulmonary valve, pulmonary valve/aortic valve and main pulmonary artery/ascending aorta were significantly different, but the PVPSV again yielded the best performance: all cases undergoing EI and/or TAP were selected using cut-off of ≥144.5 cm/s. The postnatal outcome of fetuses with ToF may be established using PVPSV from the mid-second trimester. This may be useful in providing the most appropriate perinatal management and accurate parental counselling.

607 Aortic cusp prolapse repair: Effect of surgical technique on leaflet dynamics and stress

Cusp prolapse correction is frequently required during aortic valve sparing and repair surgery. While a number of surgical techniques have been proposed to correct cusp prolapse, their effects on leaflet dynamics and stress remain unknown. We compared three surgical techniques for varying degrees of cusp prolapse correction and examined their effects on leaflet dynamics and stress.

A New Simple and Objective Method for Graft Sizing in Valve-Sparing Root Replacement Using the Reimplantation Technique

The methods of graft sizing in valve-sparing surgery are criticized for their complexity and subjectivity in application. We propose a simple method for graft sizing in valve-sparing root replacement using the reimplantation technique. Practically, the height of the commissure between the noncoronary cusp and the left coronary cusp give the size of the graft. This new method of graft sizing was successfully applied in the last 27 consecutive patients with good immediate results. Graft sizing with this objective and reproducible simple method results in restoration of normal aortic valve geometry and function.

Combined valve-sparing root replacement and total arch replacement with frozen elephant trunk

We report a case of simultaneous repair of an extensive thoracic aortic aneurysm from the aortic root to the distal aortic arch. A 54-year-old male had annuloaortic ectasia and a transverse aortic and distal arch aneurysm. Aneurysms of the descending aorta and the abdominal aorta were also demonstrated. The patient underwent aortic valve-sparing root reconstruction, replacement of the aortic arch and placement of a frozen elephant trunk stent-graft concomitantly through a median sternotomy incision. Because a complicated procedure was necessary, root reconstruction was performed first and coronary perfusion was resumed. This case suggests that the surgical procedure should be determined on the bases of the situation of thoracic aortic aneurysm and the general condition of the patient. Treatment for extensive diseased aorta from the aortic root to the distal aortic arch is a surgical challenge. Although single-stage repair is one of the options for this condition, it is very invasive. Total arch replacement with the frozen elephant trunk technique is efficacious to exclude distal arch aneurysm or descending aortic aneurysm through median sternotomy. An aortic valve-sparing operation was developed to preserve the native aortic valve function in order to improve the patient's quality of life. We herein report a case of concomitant total arch replacement using a frozen elephant trunk and aortic valve-sparing operation for extensive thoracic aortic aneurysm.

Modeling leaflet correction techniques in aortic valve repair: A finite element study

In aortic valve sparing surgery, cusp prolapse is a common cause of residual aortic insufficiency. To correct cusp pathology, native leaflets of the valve frequently require adjustment which can be performed using a variety of described correction techniques, such as central or commissural plication, or resuspension of the leaflet free margin. The practical question then arises of determining which surgical technique provides the best valve performance with the most physiologic coaptation. To answer this question, we created a new finite element model with the ability to simulate physiologic function in normal valves, and aortic insufficiency due to leaflet prolapse in asymmetric, diseased or sub-optimally repaired valves. The existing leaflet correction techniques were simulated in a controlled situation, and the performance of the repaired valve was quantified in terms of maximum leaflets stress, valve orifice area, valve opening and closing characteristics as well as total coaptation area in diastole. On the one hand, the existing leaflet correction techniques were shown not to adversely affect the dynamic properties of the repaired valves. On the other hand, leaflet resuspension appeared as the best technique compared to central or commissural leaflet plication. It was the only method able to achieve symmetric competence and fix an individual leaflet prolapse while simultaneously restoring normal values for mechanical stress, valve orifice area and coaptation area.

Aortic Valve Sparing Operations

Aortic valve sparing operations were developed to preserve the aortic valve in patients with ascending aortic aneurysm and aortic insufficiency or patients with aortic root aneurysm. There are 2 types of aortic valve sparing operations, remodeling of the aortic root and reimplantation of the aortic valve. The author believes that remodeling of the aortic root is more appropriate for older patients with ascending aortic aneurysm, dilated aortic sinuses, and normal aortic annulus, whereas reimplantation of the aortic valve is more appropriate for young patients with aortic root aneurysm in whom dilation of the aortic annulus is commonly associated. Although remodeling of the aortic root has been extensively used in patients with aortic root aneurysm, the long-term results are somewhat inferior to reimplantation in most series. The late results of aortic valve sparing operations have been excellent, and these operations have become an important addition to the surgical armamentarium to treat patients with proximal aortic aneurysms.

Aortic valve-sparing operations in aortic root aneurysms: remodeling or reimplantation?

A best evidence topic was written according to a structured protocol. The question addressed was whether the reimplantation (David) technique or the remodeling (Yacoub) technique provides the optimum event free survival in patients with an aortic root aneurysm suitable for an aortic valve-sparing operation. In total, 392 papers were found using the reported search criteria, of which 14 papers provided the best evidence to answer the clinical question. A total of 1338 patients (Yacoub technique in 606 and David technique in 732) from 13 centres were included. In most series, cardiopulmonary bypass time and aortic cross-clamp time were longer for the David technique compared to the Yacoub technique. Early mortality was comparable between the two techniques (0-6.9% for the Yacoub technique and 0-6% for the David technique). There is a tendency for a higher freedom from significant long-term aortic insufficiency in the David group than the Yacoub group, which does not necessarily result in a higher reoperation rate in the Yacoub group. In the largest series reported, freedom from a moderate-to-severe aortic insufficiency at 12 years was 82.6 ± 6.2% in the Yacoub and 91.0 ± 3.8% in the David group (P=0.035). Freedom from reoperation at the same time point was 90.4 ± 4.7% in the Yacoub group and 97.4 ± 2.2% in the David group (P=0.09). In another series, freedom from reoperation at a follow-up time of about four years was 89 ± 4% in the Yacoub group and 98 ± 2% in the David group. Although some authors merely preferred the Yacoub technique for a bicuspid aortic valve, the accumulated evidence in the current review indicates comparable results for both techniques in a bicuspid aortic valve. Current evidence is in favour of the David rather than the Yacoub technique in pathologies such as Marfan syndrome, acute type A aortic dissection, and excessive annular dilatation that may impair aortic root integrity. Careful selection of patients for each technique and successful restoration of normal cusp geometry are the keys to success in aortic valve-sparing operations.

Long-term results after aortic valve-sparing operation (David I)

Aortic valve-sparing David procedure has gained broad acceptance. However, few long-term results have been published. We present our results. More than 450 David procedures have been performed in our institution so far. Of these, 126 patients were operated between July 1993 and December 2000. Median age was 57 (8-83) years and 46 (36.5%) were female. As many as 26 (20.6%) had Marfan syndrome, 21 (16.7%) had acute aortic dissection type A (AADA) and 67 (53.2%) had additional procedures. There were six (4.8%) deaths in 30 post-operative period (POD), four of whom had AADA. In the follow-up, there were 32 (25.4%) late deaths, 11 (34.4%) of these were caused by cardiac or underlying disease or op-related. As many as 15 (11.9%) patients were re-operated; six (40%) were Marfan patients and two (13.3%) had early endocarditis. Follow-up echocardiography of 76 (60.3%) event-free patients showed valve insufficiency (AI)≤AI I° in 68 (89.5%) and grade II in 7 (9.2%) patients. Leaflet degeneration due to proposed leaflet contact with the straight Dacron graft was not observed. A total of 36 (47.4%) patients were in New York Heart Association (NYHA) class I, 33 (43.4%) in NYHA II, and five (6.6%) were in class III. During the entire follow-up of 790 patient-years, there was no stroke or major bleeding. Survival at 1, 5 and 10 years was 93%, 85% and 70%, respectively. Freedom from valve replacement at 1, 5 and 10 years was 96%, 91% and 87%, respectively. Regardless of the underlying pathology, valve-sparing David I procedure has acceptable long-term results. Valve-related complications such as stroke or major bleeding is exceedingly low.

Staged repair of pectus excavatum during an aortic valve–sparing operation

hemidiaphragm raise at one stage occurred somemonths after cessation of that drug. Likewise, the timing and brevity of exposure to clofazimine makes it an unlikely culprit. We postulate that in this case of MRS intermittent diaphragmatic paralysis of unknown etiology may have been an unusual extracranial neuropathy. We suggest that the diagnosis be considered in other patients with peripheral neuropathies in the context of granulomatous cheilitis.

Half-Leaflet Suspension With a Thin Gore-Tex Suture for Aortic Leaflet Prolapse

The treatment of aortic root dilatation accompanied by a leaking valve requires a multimodal approach involving root reimplantation or remodeling with tailoring of the sinotubular junction or valvular apparatus, or both. We report a patient with annuloaortic ectasia with a leaking valve that was successfully treated by performing aortic valve repair and root reimplantation. The operation was performed by placing a thin Gore-Tex CV7 suture (W. L. Gore and Assoc, Flagstaff, AZ) halfway along the prolapsed right coronary leaflet to suspend the leaflet. By using this surgical technique, we easily repaired the prolapsed leaflet by meticulously adjusting the length of the edge of the diseased leaflet.

Finite element analysis of aortic root dilation: a new procedure to reproduce pathology based on experimental data

Sinotubular junction dilation is one of the most frequent pathologies associated with aortic root incompetence. Hence, we create a finite element model considering the whole root geometry; then, starting from healthy valve models and referring to measures of pathological valves reported in the literature, we reproduce the pathology of the aortic root by imposing appropriate boundary conditions. After evaluating the virtual pathological process, we are able to correlate dimensions of non-functional valves with dimensions of competent valves. Such a relation could be helpful in recreating a competent aortic root and, in particular, it could provide useful information in advance in aortic valve sparing surgery.

Is repair of the aortic root without downsizing of the annulus justifiable?

Valve-sparing aortic root surgery is gaining increased interest; however, it remains unclear if down-sizing the annulus is indicated. The study was conducted to evaluate the long-term results after aortic repair based on patient-tailored restoration of root anatomy rather than valve downsizing.

Excellent results after valve sparing replacement of the aortic root at up to five years of follow-up

Objectives: Aortic valve sparing surgery has been recognized as a viable alternative to composite grafting in patients with aortic regurgitation (AR) due to root enlargement. While short-term results are encouraging, outcomes at longer follow-up warrant investigation especially in patients with connective tissue disorders or in the presence of aortic valve abnormalities.

Reimplantation Versus Remodeling: A Meta-Analysis

Reimplantation and remodeling procedure are two different techniques for valve-sparing aortic root surgery. A number of comparative series have been published but, to date, there has been no meta-analysis comparing outcomes following the two techniques. This meta-analysis was performed in accordance with the Cochrane Handbook for Systematic Reviews. A public domain database (MEDLINE) was searched to identify relevant series. Pooled risk ratios (RR) were calculated using fixed effects models for early (30-day) mortality, late deaths, and reoperation related to moderate or severe aortic insufficiency (AI) during follow-up. The search identified seven eligible series, totaling 672 patients (367 reimplantation patents). There was no significant difference in early (30-day) mortality (pooled RR 1.06; 95% CI 0.36 to 3.10; p = 0.92) and late deaths (pooled RR 0.57; 95% CI 0.18 to 1.87; p = 0.36) between reimplantation and remodeling groups. However, reimplantation technique has less chance for reoperation related to moderate or severe AI during follow-up (pooled RR 0.46; 95% CI 0.23 to 0.92; p = 0.03). Comparing with remodeling, reimplantation technique has less chance for reoperation related to moderate or severe AI during long-term follow-up.

How I Do Aortic Valve Sparing Operations to Treat Aortic Root Aneurysm

How I Do Aortic Valve Sparing Operations to Treat Aortic Root Aneurysm

Análise do tratamento cirúrgico da raiz da aorta com o tubo valvulado e com a preservação da valva aórtica

Comparative analysis of early and late results of aortic root reconstruction with aortic valve sparing operations and the composite mechanical valve conduit replacement. From November 2002 to September 2009, 164 consecutive patients with mean age 54 ± 15 years, 115 male, underwent the aortic root reconstruction (125 mechanical valve conduit replacements and 39 valve sparing operations). Sixteen percent of patients had Marfan syndrome and 4.3% had bicuspid aortic valve. One hundred and forty-four patients (88%) were followed for a mean period of 41.1 ± 20.8 months. The hospital mortality was 4.9%, 5.6% in operations with valved conduits and 2.6% in the valve sparing procedures (P <0.05). There was no difference neither in survival (95% CI = 86% - 96%, P= 0.1) nor in reoperation-free survival (95% CI = 85% - 90%, P = 0.29). The survival free of complications such as bleeding, thromboembolism and endocarditis were favorable to the valve sparing operations, respectively (95% CI = 70% - 95%, P = 0.001), (95% CI = 82% - 95% P = 0.03) and (95% CI = 81% - 95%, P = 0.03). Multivariate analysis showed that creatinine greater than 1.4 mg/dl, Cabrol operation and renal dialysis were predictors of mortality, respectively, with occurrence chance of 6 (95% CI = 1.8 - 19.5, P = 0.003), 12 (95% CI = 3 - 49.7, P = 0.0004) and 16 (95% CI = 3.6 - 71.3, P = 0.0002). The aortic root reconstruction has a low early and late mortality, high survival free of complications and low need for reoperation. During the late follow-up, valve sparing aortic root reconstructions presented fewer incidences of bleeding, thromboembolic events and endocarditis.

Three-Dimensional Computer-Aided Design-Based Geometric Modeling of a New Trileaflet Aortic Valve

Our objective was to design a new trileaflet aortic valve using computer-aided design (CAD). Quantification of aortic valve geometries is essential in understanding normal and pathological valvular function and eventually in the design of valves. We have designed a new tissue valve model to investigate its suitability in aortic valve replacement. Steps involved in three-dimensional CAD-based geometric modeling of a trileaflet aortic valve and the effects of different component dimensions on the mechanical behavior of valve are presented in this article. Conceptual designing of individual components was used to build the total geometric model. A new geometric model of a trileaflet aortic valve was designed. This may be of great interest to designers of new prosthetic heart valve models, as well as to surgeons involved in valve-sparing surgery.

Methods of pseudosinus creation in an aortic valve-sparing operation for aneurysmal disease.

Methods of pseudosinus creation in an aortic valve-sparing operation for aneurysmal disease.