Valve-sparing Operations Research Articles

Total aortic root replacement versus valve-sparing surgery: providing a basis for comparison

Total aortic root replacement versus valve-sparing surgery: providing a basis for comparison

Aortic valve–sparing reimplantation for dilatation of the ascending aorta and aortic regurgitation late after repair of congenital heart disease

Aortic regurgitation resulting from progressive dilatation of the aortic root late after surgical correction of congenital heart disease is now widely recognized. We reviewed our experience with aortic valve-sparing operations to access the effectiveness of this approach. Three patients, aged 28, 31, and 32 years, had progressive dilatation of the ascending aorta and aortic regurgitation 25, 27, and 28 years, respectively, after surgical repair of complex congenital heart disease. At the time of reoperation, the maximum diameter of the aortic root ranged between 50 and 55 mm. All 3 patients survived the operation and were in New York Heart Association functional class II or less at a maximum of 9 years' follow-up. The most recent echocardiogram demonstrated mild or less aortic insufficiency with favorable systemic ventricular function. Aortic valve-sparing reimplantation is an effective treatment for aortic root dilatation and aortic regurgitation after corrective repair of complex congenital heart disease. This procedure leads to correction of aortic regurgitation, favorable durability of the native aortic valve, and excellent hemodynamics, avoiding a prosthetic valve and anticoagulation.

Aortic valve-sparing operations and aortic root replacement

The aortic root is a complex structure whose single components are of paramount importance in assuring proper functioning of the aortic valve. In fact, opening and closing behaviours of the aortic leaflets are regulated by the interaction of the various components of the aortic root as well as by the characteristics of blood flow. For many years, aortic root replacement has been considered as the standard option of surgical correction for aortic root aneurysm, regardless of the intrinsic and organic lesions of the valve cusps. The analysis of the normal anatomy and physiology of this peculiar structure is the basis for establishing the surgical transition, in selected cases, from aortic root replacement to aortic valve-sparing operation.

Remodeling or Reimplantation for Valve-Sparing Aortic Root Surgery?

Valve-sparing operations are gaining increasing acceptance; however, there is an ongoing discussion about the technique-specific indications. We present our experience with a follow-up of 123 months. Between July 1993 and July 2005, 164 consecutive patients were operated on using the remodeling (group A, n = 96) or reimplantation technique (group B, n = 68). Fifty-seven patients presented with acute type A dissection. Aortic regurgitation was present in 84%. Follow-up was 54.7 +/- 28 in group A and 48.4 +/- 37.3 months in group B. After urgent operations, 4 patients died in each group, but none died after elective surgery. Late mortality was 8% in group A and 4% in group B. Seven patients of group A and 1 in group B required reoperation. Echocardiographic follow-up of reoperation-free survivors showed that 3 patients (all group A, 1.3%) had aortic regurgitation of more than grade II. Root diameter, valve pressure gradient, and valve orifice area were comparable. No gross thromboembolic or bleeding events occurred. Aortic valve-sparing operations can provide acceptable long-term results in both techniques. Particular care to the annulus in the remodeling technique and different prosthesis designs in the reimplantation technique may overcome the intrinsic problems of each procedure.

Panel Discussion: Session I—Ascending Aorta

Panel Discussion: Session I—Ascending Aorta

Aortic Valve Repair: The Functional Approach to Leaflet Prolapse and Valve-Sparing Surgery

Combined aortic valve repair and aortic valve-sparing surgery requires an approach determined by the leaflets and aortic root anatomy. Among patients referred for aortic root aneurysm, 114 patients underwent an aortic valve-sparing procedure in which a reimplantation or remodelling technique was used. The Gelweave Valsalva prosthesis (Sulzer Vascutek, Renfrewshire, UK) was used in 45 patients. Better molding of the prosthesis on the aortic annulus was achieved by a low proximal dissection and incisions on the prosthesis to respect the anatomy of the aortoventricular junction. The reimplantation technique was used in 58%, and 62% of all patients underwent an associated leaflet procedure. The operative mortality rate was 1%, with a 2% immediate reoperation rate. During the mean follow-up 50 +/- 35 months, 3 patients (2.6%) needed reoperation for recurrent aortic regurgitation (n = 2) or aortic stenosis (n = 1). At the end of follow-up, aortic regurgitation grade exceeding 2 had occurred in 2.6% of patients (n = 3), and 98.2% were in New York Heart Association functional class 1 or 2. Neither the early nor mid-term results showed any differences among the different surgical techniques used (reimplantation, remodeling, Valsalva prosthesis, additional leaflet repair). A complete approach to the different components of the aortic root allows good clinical results at mid-term.

Valve-Sparing Aortic Root Replacement: Current State of the Art and Where Are We Headed?

Since Sir Magdi Yacoub pioneered aortic root “remodeling” in 1979 [1, 2] and Tirone David [3] followed in 1988 with the “reimplantation” method to preserve the patient’s native aortic valve when replacing an aortic root aneurysm with a graft, both procedures have been demonstrated to be applicable to many patients with aortic root pathology and aortic regurgitation (AR), including those with the Marfan syndrome (MFS) [4]. The hope has been that cumulative valve-related morbidity and mortality would be lower after a valve-sparing operation compared with after composite valve grafting utilizing a mechanical prosthesis and indefinite warfarin anticoagulation, which represents the surgical “gold standard.” While preserving the native aortic valve liberates the patient from the need for life-long anticoagulation, the unanswered question has been valve durability after a Yacoub or David procedure.

Aortic valve-sparing operation according to DAVID using a prosthesis to remodel the aortic sinuses-a video presentation

Objective: Valve sparing operations in patients with aortic root aneurysm appear to be the treatment of choice as the hemodynamic result is excellent and no anticoagulation is necessary. However, sewing the aortic valve ring to the end of the prosthesis the valve ring's scalloped profile is forced into one level, this may lead to cusp degeneration in the longterm run.

Long-term results of aortic valve-sparing operations for aortic root aneurysm

Long-term results of aortic valve-sparing operations for aortic root aneurysm

Quantitative approach to aortic valve-sparing surgery

Our goal was to understand why it is difficult to achieve reliable valve competence after aortic valve-sparing surgery, and to propose quantitative data aimed at improving the outcome of the procedure. Valve-sparing procedures were performed in patients with dilated aortic roots and aortic regurgitation, and reproduced in physical models to explore what should be the restored dimensions of the aortic root and leaflets for valve sparing to be successful. In parallel, a three-dimensional geometric model of the aortic valve was tested to evaluate its capability to predict the annulus diameter, sinotubular junction diameter, valve height, and leaflet free-edge length and height in competent spared valves. Valve sparing resulted in more or less severe residual regurgitation in all the patients considered. Successful valve-sparing was achieved in vitro by making further changes to the annulus diameter, the leaflet free-edge length and/or graft size. The changes needed were effectively predicted by the geometric model. Tabulated valve dimensions allowing restoration of competence were generated for convenient use by surgeons. A quantitative approach to aortic valve sparing is proposed, putting emphasis on the functional characteristics of the restored valve geometry.

Valve-sparing operation in a young woman with Marfan syndrome: A word of caution

2006;132:683-684 J Thorac Cardiovasc Surg Guillaume Jondeau and Iradj Gandjbakhch Olivier Chavanon, Akhtar Rama, Pascal Leprince, Nicolas Bonnet, Alain Pavie, caution Valve-sparing operation in a young woman with Marfan syndrome: A word of http://jtcs.ctsnetjournals.org/cgi/content/full/132/3/683 located on the World Wide Web at: The online version of this article, along with updated information and services, is

A new approach to the assessment of aortic cusp geometry

perfusion, thus resulting in clinically unspecific symptoms of dyspnea, cough, or impaired right ventricular function mimicking pulmonary thromboembolism in the majority of cases. The radiologic diagnosis can still be difficult despite the technologic advances in imaging techniques. Preoperative biopsy is the only way to establish a proper diagnosis, and it is essential to accurately plan the surgical approach. The only treatment of choice is radical surgical resection. Depending on tumor localization and distal extension, surgical treatment includes PA resection, a polytetrafluoroethylene (Gore-Tex) homograft, or even xenograft reconstruction and pneumonectomy. The use of cardiopulmonary bypass may be essential in patients in whom the tumor originates from the PA trunk or the pulmonary valve. As a palliative treatment, endovascular stent grafting may be an alternative therapeutic option in inoperable cases. Furthermore, neoadjuvant or adjuvant chemotherapy has been mentioned in the literature with doubtful results. Prolonged tumor-free survival is rare. A 10-month survival is reported in the literature for different sarcomas of PA, whereas in our series survival was 7 and 2.5 years, respectively. Conclusion Early diagnosis along with aggressive and extensive surgical treatment in patients with PA leiomyosarcoma without any extrathoracic metastases may provide an opportunity for prolonged survival in addition to palliation.

Rekonstruktive Aortenklappenchirurgie: Ross-, David- und Yacoub-Verfahren

The aortic valve consists of three cusps attached to the wall of the aortic root. During the cardiac cycle, the aortic root undergoes complex movements that precede and aid opening and closing of the aortic valve. The aortic valve cusps themselves form thin-walled pocket-like structures, made from specialized tissue with fibrous, elastic, nervous, and muscular properties. The complex interactions of this tissue with the aortic root and within the cardiac cycle are only incompletely understood yet. In summary, the aortic valve is a complex structure which shows a perfect function in systole and diastole and under a wide range of hemodynamic conditions. No valve prosthesis (so far) can keep up with the function of the native aortic valve. Therefore, surgical techniques have been invented that aim at sparing the aortic valve or replacing it with very similar autologous tissue. Besides the resulting (near) normal valve function, one appealing advantage of these techniques is that oral anticoagulation can be abandoned completely. If the valve cusps themselves are normal, but the aortic root is aneurysmatic or dissected (with or without resulting secondary aortic insufficiency), the aortic valve can be spared by resecting the aortic root tissue and replacing it by a vascular graft. The aortic valve can then be implanted into the vascular graft in a way described by David, or can be remodeled into it (Yacoub technique) - in this case, the graft first needs to be incised at its base so that the three commissures of the valve can be sewn into the three incisions. This way pseudosinuses within the vascular graft are created. The sinuses within the aortic root are considered important for aortic valve function and coronary perfusion. On the other hand, incisions at the base of the vascular graft harbor the potential for redilatation of the aortic root because of a missing circular fixation. Such a fixation is achieved by the David technique. Therefore, there is a great debate in the surgical community which valve-sparing technique is the best and numerous modifications of the original techniques exist. A clear clinical advantage of one technique over the other could not be demonstrated so far, but many authorities advise that the David technique is to be used preferentially in patients with Marfan's syndrome (or other connective tissue disorders) and those with a very wide basal aortic root. If the aortic valve cusps themselves are diseased and cannot be reconstructed, the autologous pulmonary valve is the most physiological substitute. Replacing the aortic valve with the autologous pulmonary valve is named Ross procedure. The defect in the right ventricular outflow tract that is created while harvesting the autograft must be reconstructed during the same procedure; usually, a pulmonary valve allograft is used for this purpose. With all reconstructive surgical techniques and with all autologous replacements there is a risk of reoperation, mainly (besides technical issues) because it is feared that leaving autologous tissue in place leads to recurrence of the original illness. The published results, however, with aortic valve-sparing surgery and with the Ross procedure show that the risk of reoperation appears to be very acceptable. This statement is especially true for the Ross procedure for which more and longer experience exists worldwide. Echocardiographic studies show that the aortic valve function after valve-sparing techniques and - especially - after the Ross procedure is indeed excellent. Therefore, patients with aortic root pathologies or aortic valve diseases should be informed about valve-sparing aortic root reconstructive techniques or the Ross procedure. The choice of technique should be made in close contact between patient, cardiologist, and cardiac surgeon. However, the described techniques require extensive experience within the surgical team.

Long-term results of aortic valve-sparing operations for aortic root aneurysm

To examine the results of aortic valve sparing for aortic root aneurysm. Two hundred twenty consecutive patients who had aortic valve sparing for aortic root aneurysm were prospectively studied with annual clinical assessments and echocardiography. Their mean age was 46 +/- 15 years, 40% had Marfan syndrome, 17% had aortic dissection, and 7% had bicuspid aortic valve. Reimplantation of the aortic valve was performed in 167 patients and remodeling of the aortic root in 53. Aortic cusp repair was performed in 80 patients, and reinforcement of the free margin of one of the cusps with a fine polytetrafluoroethylene (Gore-Tex) suture in 48. The mean follow-up was 5.2 +/- 3.7 years and it was complete. There were 3 operative and 13 late deaths. Patients' survival at 10 years was 88% +/- 3%. Age older than 65 years, advanced functional class, and ejection fraction less than 40% were independent predictors of death. Moderate aortic insufficiency developed in 7 patients and severe insufficiency in 6. Freedom from moderate or severe aortic insufficiency at 10 years was 85% +/- 5% for all patients, but it was 94% +/- 4% after reimplantation and 75% +/- 10% after remodeling (P = .04). Five patients required aortic valve replacement; the freedom from valve replacement at 10 years was 95% +/- 3%. One case of endocarditis developed 11 years postoperatively. At the latest follow-up, 88% of the patients were in functional class I, and 10% were in class II. Aortic valve-sparing operation is associated with low rates of valve-related complications. The probability of late aortic insufficiency was lower after the reimplantation procedure than after remodeling in our experience.

Can we consider thymectomy before pregnancy in female patients with myasthenia gravis?

I read with interest a recent article by Thubrikar et al.[1] where they suggest that in dilated aortic roots theanatomically normal leaflets, however, were not geome-trically normal. Thus they conclude that during valve-sparing surgery, it may be necessary in some cases tocorrect not only the dilatation of the aortic root but alsothe leaflet free-edge length in order to achieve a competentvalve.We studied the nervous fibers distributions with glycosa-minolglycans’ (GAG’s) leaflet distribution in 15 aortic valveleafletsinaorticrootdilatedandjudgedanatomicallynormaland 15 leaflets in normal aortic valve (homograft). We founda significant decrease in the fibers innervation — acetylcho-linesterase positive fibers — and also in GAG’s total quantityand distribution [2,3].The simple, anatomical, analysis of aortic leaflet beforethe surgery cannot be sufficient. As a matter of fact, thisquestion is particularly relevant in case of plastic of aorticvalve leaflets or valve-sparing procedures.

Aortic Valve-Sparing Operations: Early and Midterm Results

Aortic valve-sparing operations have provided very good clinical outcomes. However, there is still a debate about valve durability because of the absence of the Valsalva sinuses, and various techniques have been proposed to reproduce the native anatomy of the aortic root. We reviewed our total experience with aortic valve-sparing operations to determine early and midterm outcomes. Between July 2001 and August 2004, 85 patients underwent valve-sparing operations. There were 67 (78.8%) male and 18 (21.2%) female patients with a mean age of 58.8 +/- 14.6 years. Sixty-five patients with an aortic root aneurysm underwent the David I reimplantation technique, and a Gel-weave Valsalva graft was used in 57 patients. Twenty patients with an ascending aortic aneurysm underwent replacement of the ascending aorta with sinotubular junction reduction. There were 3 in-hospital deaths (3.5%) and 2 late deaths. Two of 4 patients with acute aortic dissection died. The 3-year survival for patients with an aortic root aneurysm was 95.4% +/- 2.6%, and for patients with an ascending aortic aneurysm it was 89.2% +/- 7.3 (P = .464). Seven patients developed 3 to 4+ aortic insufficiency, and 5 of them required aortic valve replacement. The 3-year freedom rate from grade 3 to 4 aortic insufficiency was 88.9% +/- 5.2% for patients with an aortic root aneurysm and 88.2% +/- 7.8% for those with an ascending aortic aneurysm. At 3 years, the freedom rates from late aortic valve replacement were 92.2% +/- 4.9% in the aortic root aneurysm group and 88.2% +/- 7.8% in the ascending aortic aneurysm group. Aortic valve-sparing operations showed excellent results in patients electively operated on for aortic root ectasia, and the results in acute aortic dissection were very disappointing. The Gelweave Valsalva prosthesis demonstrated ease of implantability and good reproduction of the pseuodosinuses. Long-term follow-up is necessary to determine if this graft will enhance the function and increase the durability of the aortic valve.

Aortic valve sparing operation: Hemodynamic performance during moderate exercise

Aims: Aortic valve replacement according to Yacoub and David implies the benefit of preserving the patient's natural aortic valve leaflets. Exercise and post exercise hemodynamic data are not well studied.

Valve sparing aortic root repair with patch technique

Objectives: Aortic root repair with patch technique has been established at our clinic as the technique of choice for valve-sparing surgery of aortic root diseases combined with aortic regurgitation. The aim of the study was to evaluate the intermediate clinical and echocardiographic results.

Valsalva prosthesis in aortic valve-sparing operations

Aortic valve-sparing operations have provided very good clinical outcomes. However, the absence of the sinuses of Valsalva might limit valve durability. The Gelweave Valsalva prosthesis, which presents pre-fashioned neo-sinuses, has been designed in order to avoid early leaflets deterioration. We report our results in 63 patients who underwent valve-sparing operations (reimplantation technique) using the Gelweave Valsalva graft. The main indication was ascending aorta aneurysm or annuloaortic ectasia, with or without aortic insufficiency. The operation was performed also in cases of Marfan syndrome, Bicuspid Aortic Valve (BAV), and acute Type A dissection. In-hospital mortality was of 4.7%, and two thirds were acute Type A dissection patients (P=0.01). There were no late deaths. Three years freedom from grade 3-4 AI and freedom from late aortic valve replacement were 91.7+/-4.3% and 93.8+/-5.1%, respectively. Aortic valve-sparing operations show good results in patients electively operated for aortic root ectasia. Aortic cusps repair may lead to late failure. Even if the Gelweave Valsalva prosthesis is easy to implant and it also reproduces pseudosinuses, a long-term follow up is necessary to determine if this graft may reduce leaflets deterioration.

Aortic valve-sparing operation and a total arch replacement by an elephant trunk method for Marfan’s syndrome with aortic regurgitation and a DeBakey type IIIb dissection

A 35 year-old male with Marfan's syndrome was referred with a fortuitous echographic finding of an abdominal aorta flap. Transthoracic echocardiography showed moderate aortic regurgitation and an aneurysm in the sinus of Valsalva. Computed tomography demonstrated an aneurysm in the sinus of Valsalva 60 mm in size and a DeBakey type IIIb dissection extending from the left subclavian artery to the right common iliac artery. An aortic valve-sparing operation (reimplantation), total aortic arch replacement and the elephant trunk method were used in this patient. An aortic valve-sparing operation is preferable because the patient is young, and has no need for anticoagulant therapy after surgery. The extent of the aortic reconstruction, including the intact aortic arch, was appropriate to prohibit future dilatation of the aortic arch and retrograde dissection from a DeBakey type IIIb dissection.