Valve-sparing Operations Research Articles

Creation of aortic regurgitation model on isolated porcine heart and aortic valve-sparing root replacement using a new device for aortic valve cusps positioning

Valve-sparing surgery in ascending aortic and root aneurysms combined with aortic regurgitation (AR) is a relevant and actively developing trend. The ways to improve these operations are the development of new devices to simplify and standardize valve-sparing procedures using animal models and testing in experiment. Objective. To review experimental methods of aortic root aneurysm and AR modeling, as well as devices simplifying aortic valve-sparing root replacement, including a new device for positioning of aortic valve (AV) cusps during valve-sparing root replacement with AV reimplantation (David procedure), which we have developed. Materials and methods. The components of the developed device were manufactured by three-dimensional printing with preliminary modeling in the parametric environment of computer-aided design with the open source code FreeCAD 0.20.1. The possibility of David procedure on the isolated swine aortic root in the experiment using the new device was evaluated. Results. During the experiments we performed aortic root replacement with AV reimplantation on the isolated porcine aortic root. We noted that the developed device provides good exposure of the surgical correction zone and reduces the probability of damage to the aortic root structures, especially to the AV cusps, in the process of reimplantation. The device eliminates the necessity to use assistants during the main stage of intervention, which reduces the probability of operator-associated complications. Conclusion. Standardization and simplification of reimplantation of AV cusps into the vascular graft during aortic root replacement with the help of the device developed by us is achieved by performing trial positioning of AV cusps and hydraulic tests at different positions of the cusps, which simplifies the search for the optimal point of coaptation and allows to keep the found best position of the cusps until their anchoring inside the graft. The directions of further research are improvement of the design of the developed device, experimental studies with evaluation of the result of valve-sparing surgery under conditions of pulsating fluid flow, testing of the technology on large laboratory animals.

Predictors of post-pericardiotomy syndrome after native valve-sparing aortic valve surgery

Predictors of post-pericardiotomy syndrome after native valve-sparing aortic valve surgery

Minimally invasive versus conventional methods for aortic root surgery: Choosing the right approach.

Partial upper sternotomy is preferred for isolated aortic valve replacement because of its optimal surgical visibility and favorable cosmetic outcomes; however, it is not commonly used for aortic root surgery, and the conventional median sternotomy is still the preferred method for most surgeons. We aimed to compare the safety and effectiveness of a minimally invasive approach (partial sternotomy [PS]) and conventional approach (median sternotomy [FS]) for aortic root surgery. Patients who underwent aortic root surgery at our hospital from 2016 to 2021 were retrospectively enrolled and divided into two groups. After propensity score matching, the conventional group included 156 patients and the minimally invasive group-57 patients. Bicuspid aortic valves were observed in 63 (40.4%) and 33 (57.9%) patients in the FS and PS groups, respectively. Valve-sparing surgery was performed on 69 (44.2%) and 30 (52.6%) patients in the FS and PS groups, respectively. The minimally invasive approach was beneficial in terms of blood loss during the first 24 h after surgery (p = 0.029) and postoperative blood transfusion (p = 0.023). The survival rates and freedom from reoperation or severe aortic regurgitation after the David procedure were comparable between the standard and minimally invasive groups (p = 0.25; p = 0.66) at mid-term follow-up. A minimally invasive approach for aortic root surgery can be safely performed as the standard approach. Partial upper sternotomy has the advantage of lower blood loss in the early postoperative period and does not negatively affect the results of valve-sparing root replacement.

Predictors of Outcomes and Long-Term Morbidity and Mortality in Aortic Valve Sparing Surgery

Predictors of Outcomes and Long-Term Morbidity and Mortality in Aortic Valve Sparing Surgery

The usefulness of the genetic panel in the classification and refinement of diagnostic accuracy of Mexican patients with Marfan syndrome and other connective tissue disorders.

Marfan syndrome (MFS) is a multisystem genetic disorder with over 3000 mutations described in the fibrillin 1 (FBN1) gene. Like MFS, other connective tissue disorders also require a deeper understanding of the phenotype-genotype relationship due to the complexity of the clinical presentation, where diagnostic criteria often overlap. Our objective was to identify mutations in patients with connective tissue disorders using a genetic multipanel and to analyze the genotype-phenotype associations in a cohort of Mexican patients. We recruited 136 patients with MFS and related syndromes from the National Institute of Cardiology. Mutations were identified using next-generation sequencing (NGS). To examine the correlation between mutation severity and severe cardiovascular conditions, we focused on patients who had undergone Bentall-de Bono surgery or aortic valve repair. The genetic data obtained allowed us to reclassify the initial clinical diagnosis across various types of connective tissue disorders. The transforming growth factor beta receptor 2 (TGFBR2) rs79375991 mutation was found in 10 out of 16 (63%) Loeys-Dietz patients. We observed a high prevalence (65%) of more severe mutations, such as frameshift indels and stop codons, among patients requiring invasive treatments like aortic valve-sparing surgery, Bentall and de Bono procedures, or aortic valve replacement due to severe cardiovascular injury. Although our study did not achieve precise phenotype-genotype correlations, it underscores the importance of a multigenetic panel evaluation. This could pave the way for a more comprehensive diagnostic approach and inform medical and surgical treatment decision-making.

The effectiveness of David procedure for aneurysm of the root and ascending part of the aorta

The aim – comparison of the results of David and Bentall operations in patients with aneurysms of the root and ascending aorta. Materials and methods. The one-centre study included 85 patients who underwent planned and urgent surgical treatment from 2019 to 2022. The patients were divided into two groups depending on the type of surgical intervention: the Bentall procedure was performed in the I group, while the David procedure was performed in the II group. Results. The study did not determine statistically significant differences in such indicators as the duration of artificial blood circulation and the time of aortic clamping. No significant differences were found in the duration of artificial lung ventilation and stay in the intensive care unit. However, the total length of hospital stay in the group of patients with David procedure was statistically lower and was 17.3 (8–35) days, while in the group with Bentall operation it was 23.7 (10–40) days (p = 0.01). The results of our analysis show that the early postoperative clinical results of the David and Bentall procedures are good and there are no significant differences. During David procedure, a statistically significant positive result of surgical treatment was revealed by such an indicator as the degree of insufficiency on the aortic valve (before and after the operation, 2.7 ± 1.3 and 0.8 ± 0.6, respectively, p < 0.05). In addition to the above indicator, significant results were found in the indicators: left ventricular end-diastolic size and left ventricular end-diastolic volume. Conclusions. The good immediate results of Bentall and David operations suggest that surgical repair of ascending and aortic root aneurysms using these operations can be equally safe when performed according to absolute anatomical indications and by an experienced surgical team. If both operations might be used in a particular patient, the valve-sparing operation should be preferred, given the lower risk of postoperative complications associated with the presence of a mechanical or biological prosthesis (such as thromboembolism, bleeding associated with anticoagulants, and structural deterioration of the bioprosthesis).

ASSESSMENT OF PATIENTS' QUALITY OF LIFE AFTER DAVID SURGERY

Modern cardiac surgery increasingly requires rapid physical and mental rehabilitation of the patient. Today, more and more attention is paid to the peculiarities of psycho-emotional indicators in patients who are planned or have undergone surgical interventions. The quality of life of patients after David's operation for aneurysm of the root and ascending aorta remains unexplored. The aim: assessment of the quality of life of patients with aortic aneurysm who underwent David's valve-preserving operation. Materials and methods. From December 2015 to April 2023, 38 patients were operated on using the technique of aortic valve reimplantation with direct Dacron prosthesis "David" and 40 patients with prosthetic aortic valve and ascending aorta "Bentall operation". The mean age of patients was 46.97 ± 12.2 years in group 1 and 52.08 ± 12.08 in group 2, respectively. The share of men is 92.1% in group 1 and 97.5% in group 2. The average observation period is 31.89 ± 22.42 months. Results.Not a single fatal case was recorded within 30 days of the postoperative period. The percentage of survival after the observation period is 97.36% in group 1 and 92.5% in group 2. We analyzed the quality of life of all patients according to eight scales: physical functioning (PH), role functioning (RP), pain intensity (BP), general health (GH), vital activity (VT), social functioning (SF), emotional condition (RE) and mental health (MH). When analyzing patient questionnaires in the scale of physical functioning, we calculated a sufficiently high indicator, which was 94.59 ± 6.71% in group 1 and 79.5% ± 8.46% in group 2. On all other scales, there was also an advantage in the group patients who underwent David's operation. Conclusions. From the obtained results, it can be stated that patients after David's operation in the medium term have excellent physical and mental health indicators and are completely adapted to daily life compared to the results after Bentall's operation. David's valve-sparing operation, especially in isolated, planned situations, ensures normal functioning of the aortic valve with no regurgitation. This operation can be performed with very low rates of complications and postoperative mortality. Thus, in our center, all patients with aortic root aneurysms are potential candidates for valve-sparing operations.

Impact of early diagnosis on surgical outcomes in patients with Loeys-Dietz syndrome.

This study aimed to investigate the influence of early diagnosis (ED) on surgical outcomes in patients definitively diagnosed with Loeys-Dietz syndrome (LDS). A retrospective review was conducted on 38 patients with LDS who underwent aortic surgery at our institution between January 1995 and June 2022. The primary endpoint was freedom from aortic reoperation. Among the patients, the median age at the initial surgery was 33 (range: 39-44) years, and 23 (60.5%) patients were male. Twenty-one (55.3%; aortic dissection or rupture (n = 2) and aneurysm (n = 19)) patients were diagnosed with LDS before the initial surgery (ED group). Meanwhile, the remaining 17 (44.7%; aortic dissection or rupture (n = 13) and aneurysm (n = 4)) patients were after surgery [delayed diagnosis (DD) group]. The ED group had significantly lower rates of emergency surgery and concomitant arch procedure (P < .001, respectively) but a higher rate of valve-sparing root surgery (P = .018) compared to the DD group. No in-hospital mortality was observed in either group. Nevertheless, the ED group had a shorter postoperative hospital stay (median difference: 3 days, P = .032) and a lower rate of aortic reoperation (P = .013). Early detection of LDS may help in preventing acute aortic syndrome, reducing the risk of aortic reoperation, and potentially shortening hospital stay. Careful medical management before surgery could contribute to better clinical outcomes and an improved quality of life for patients with LDS.

Aortic valve reconstruction in nonelderly adults: a systematic review, meta-analysis and microsimulation study

Abstract Background Aortic valve disease (AVD) calls for careful planning of treatment strategies that adheres to a patient-tailored lifetime perspective, especially in younger patients. Aortic valve reconstruction (AVr) provides an attractive option in patients with aortic valve regurgitation (AR). Purpose This study aims to provide a comprehensive overview of published outcome after AVr in nonelderly adults and to use microsimulation to obtain age-specific estimates of outcomes. Methods A systematic review of published literature reporting clinical outcome after AVr in nonelderly adults (mean age ≥18y and ≤55y) published between 1/1/1990 and 17/10/2022 was conducted. Publications reporting outcome after AVr were considered for inclusion, including publications on valve-sparing root surgery. Studies that included patients without AVD as the primary indication for AVr were excluded. Early risks (&amp;lt;30d), late event rates (&amp;gt;30d) and time-to-event data were pooled and entered into a microsimulation model. Subgroup analyses were performed for AVr for isolated AR and AVr for bicuspid aortic valves (BAV). Results Thirty-seven studies, all retrospective cohort studies, were included, yielding a total of 4,573 patients with 16,524 patient-years of follow-up (median follow-up: 4.0y; range 0.6-10.5y). Pooled mean age for all repairs, AVr for AR and AVr for BAV was 48.1±13.8, 48.3±13.8, and 42.4±12.5 years, respectively. Pooled early mortality for all repairs, AVr for AR and AVr for BAV, respectively, was 1.7% (95%CI: 1.2-2.3%), 1.5% (1.0-2.1%), and 1.0% (0.6-1.9%), and late pooled mortality rate was 1.0%/y (0.7-1.5%/y), 1.3%/y (0.8-2.1%/y), and 0.8%/y (0.5-1.4%/y), respectively. Microsimulation-based life-expectancy relative to the general population 20 years postoperatively was 92.6% (95% Credible Interval: 90.1-95.3%) after all repairs, 89.0% (85.0-93.0%) after AVr for isolated AR and 94.9% (92.0-97.4%) after AVr for BAV. Microsimulation-based 20-year risk of aortic valve reintervention for all repairs, isolated AR and BAV, respectively, was 25.0%(23.8-26.2%), 25.1%(23.5-26.9%) and 49.9%(48.2-52.0%). The main cause for reintervention was repaired valve dysfunction for all three groups, followed by endocarditis. Estimates of other late complications are shown in Figure 2. Conclusions Aortic valve reconstruction for aortic valve regurgitation effectively postpones valve replacement in nonelderly with satisfactory long-term outcomes but reintervention risks are still considerable, especially in BAV patients. Reconstructive valve surgery is associated with low risks of bleeding and thrombo-embolic events and should be considered in nonelderly adults with aortic regurgitation and carefully weighed against hazards of primary aortic valve replacement.Pooled Kaplan-Meier curves for mortalityMicrosimulation-based event risks (20y)

Determinants and Clinical Outcomes of Patients With Tetralogy of Fallot Lost to Cardiology Follow-up

BackgroundVarious rates of loss to follow-up (LTFU) have been reported in patients with congenital heart disease, but return to follow-up is rarely considered in those analyses. Outcomes of LTFU patients are difficult to assess because the patients no longer attend cardiac care. We leveraged data from the TRIVIA cohort, which combines more than 30 years of clinical and administrative data, allowing us to study outcomes even after LTFU. MethodsThis population-based cohort included 904 patients with tetralogy of Fallot (TOF) born from 1982 to 2015 in Québec, Canada. Risk factors for LTFU and outcomes were calculated by Cox models and marginal means/rates models. Outcomes of LTFU patients were compared with propensity score–matched non-LTFU patients. ResultsThe cumulative risk of experiencing 1 episode of LTFU was 50.3% at 30 years. However, return to follow-up was frequent and the proportion of patients actively followed was 85.9% at 10 years, 76.4% at 20 years, and 70.6% at 30 years. Factors associated with a reduced risk of LTFU were primary repair with conduit (hazard ratio [HR] 0.29, 95% confidence interval [CI] 0.15-0.58) and transannular patch (HR 0.60, 95% CI 0.46-0.79). LTFU patients had lower rates of cardiac hospitalisations (HR 0.49, 95% CI 0.42-0.56) and cardiac interventions (HR 0.32, 95% CI 0.25-0.42), but similar rates of cardiac mortality (HR 0.95, 95% CI 0.24-3.80). ConclusionsThere was a lower proportion of LTFU patients compared with previous studies. Factors associated with lower rates of LTFU were conduits and non–valve-sparing surgery. LTFU patients had lower rates of cardiac procedures and cardiac hospitalisations.

Functional interaction of aortic valve and ascending aorta in patients after valve-sparing procedures

Pressure recovery (PR) is essential part of the post stenotic fluid mechanics and depends on the ratio of EOA/AA, the effective aortic valve orifice area (EOA) and aortic cross-sectional area (AA). In patients with advanced ascending aortic aneurysm and mildly diseased aortic valves, the effect of AA on pressure recovery and corresponding functional aortic valve opening area (ELCO) was evaluated before and after valve-sparing surgery (Dacron graft implantation). 66 Patients with ascending aortic aneurysm (mean aortic diameter 57 +/− 10 mm) and aortic valve-sparing surgery (32 reimplantation technique (David), 34 remodeling technique (Yacoub)) were routinely investigated by Doppler echocardiography. Dacron graft with a diameter between 26 and 34 mm were implanted. EOA was significantly declined after surgery (3.4 +/− 0.8 vs. 2.6 +/− 0.9cm2; p < 0.001). Insertion of Dacron prosthesis resulted in a significant reduction of AA (26.7 +/− 10.2 vs. 6.8 +/− 1.1cm2; p < 0.001) with increased ratio of EOA/AA (0.14 +/− 0.05 vs. 0.40 +/− 0.1; p < 0.001) and pressure recovery index (PRI; 0.24 +/− 0.08 vs. 0.44 +/− 0.06; p < 0.0001). Despite reduction of EOA, ELCO (= EOA corrected for PR) increased from 4.0 +/− 1.1 to 5.0 +/− 3.1cm2 (p < 0.01) with reduction in transvalvular LV stroke work (1005 +/− 814 to 351 +/− 407 mmHg × ml, p < 0.001) after surgery. These effects were significantly better in patients with Yacoub technique than with the David operation. The hemodynamic findings demonstrate a valve-vessel interaction almost entirely caused by a marked reduction in the ascending AA with significant PR gain. The greater hemodynamic benefit of the Yacoub technique due to higher EOA values compared to the David technique was evident and may be of clinical relevance.

Aortic valve-sparing operations: my perspectives.

The online version contains supplementary material available at 10.1007/s12055-023-01587-4.

Cardiovascular Events After Aortic Root Repair in Patients With Marfan Syndrome

BackgroundThe usefulness of aortic valve sparing operations to treat aortic root aneurysm in patients with Marfan syndrome (MS) remains controversial. ObjectivesThe purpose of this study was to evaluate the occurrence of cardiovascular events in patients with MS who have undergone valve-preserving aortic root replacement. MethodsPatients with MS who had aortic valve sparing operations (reimplantation of the aortic valve or remodeling of the aortic root) from 1988 through 2019 were followed prospectively for a median of 14 years. Pertinent data from clinical, echocardiographic, computed tomography, and magnetic resonance images of the aorta were collected and analyzed. ResultsThere were 189 patients whose mean age was 36 years, and 67% were men. Ten patients presented with acute type A dissection and 29 had mitral regurgitation. There were 52 patients at risk at 20 years. Mortality rate at 20 years was 21.5% (95% CI: 14.7%-30.8%); advancing age and preoperative aortic dissections were associated with increased risk of death by multivariable analysis. At 20 years, the cumulative incidence of moderate or severe aortic insufficiency was 14.5% (95% CI: 9.5%-22.0%), reoperation on the aortic valve was 7.5% (95% CI: 3.9%-14.7%), and new distal aortic dissections was 19.9% (95% CI: 13.9%-28.5%). Remodeling of aortic root was associated with greater risk of developing aortic insufficiency and aortic valve reoperation than reimplantation of the aortic valve. ConclusionsAortic valve sparing operations provide stable aortic valve function and low rates of valve-related complications during the first 2 decades of follow-up but aortic dissections remain problematic in patients with MS.

Aortic Valve Sparing Operations in the Presence of Aortic Cusp Prolapse

Aortic Valve Sparing Operations in the Presence of Aortic Cusp Prolapse

Valve Sparing vs Composite Valve Graft Root Replacement: Propensity Score–Matched Analysis

BackgroundBoth valve-sparing root replacement and composite valve graft (CVG) are acceptable options in aortic root replacement. We compare outcomes of these 2 approaches and durability of the aortic valve. MethodsA consecutive 1635 patients without acute dissection underwent primary aortic root replacement from 1997 to 2022; 473 (29%) underwent valve-sparing root replacement, and 1162 (71%) received CVG. Propensity score matching was used to reduce baseline differences. ResultsThe CVG group was older (59 ± 14 years vs 49 ± 14 years; P < .001) with more comorbidities, such as hypertension (88.4% vs 66.4%; P < .001), diabetes (7% vs 1.7%; P < .001), ischemic heart disease (5.1% vs 1.3%; P = .001), pulmonary disease (6.6% vs 1.3%; P < .001), renal impairment (8.6% vs 1.3%; P < .001), class III-IV heart failure (35% vs 9.2%; P < .001), bicuspid aortic valves (44.8% vs 24.1%; P < .001), and severe aortic insufficiency (50.2% vs 13.2%; P < .001). Operative mortality was 0.4% (0% in valve sparing); incidence of major postoperative complications was 2.9% (3.6% vs 1.1%; P = .009). Ten-year survival was 93.1% (91.2% vs 97.7%; hazard ratio [HR], 1.7; 95% CI, 0.9-3.3; P = .120). Mean follow-up was 65 ± 60 months; aortic valve reoperations were similar (5.8% vs 5.7%; HR, 0.8; 95% CI, 0.4-1.4; P = .401). Recurrent moderate-severe aortic insufficiency was less prevalent in CVG (6.1% vs 11.1%; HR, 0.14; 95% CI, 0.07-0.27; P < .001). Propensity score matching identified 225 pairs. There was no difference in 10-year survival or reoperations. Recurrent moderate-severe aortic insufficiency was higher with valve sparing. ConclusionsBoth valve-sparing operations and CVG provide excellent early and late outcomes out to 10 years. Valve sparing is associated with a higher risk for development of aortic insufficiency but no difference in reoperations.

Multi-modality imaging evaluation and pre-surgical planning for aortic valve-sparing operations in patients with aortic root aneurysm

Multi-modality imaging evaluation and pre-surgical planning for aortic valve-sparing operations in patients with aortic root aneurysm

Aortic valve cusp repair does not affect durability of modified aortic valve reimplantation for tricuspid aortic valves

ObjectiveDuring aortic valve reimplantation, cusp repair may be needed to produce a competent valve. We investigated whether the need for aortic valve cusp repair affects aortic valve reimplantation durability. MethodsPatients with tricuspid aortic valves who underwent aortic valve reimplantation from January 2002 to January 2020 at a single center were retrospectively analyzed. Propensity matching was used to compare outcomes between patients who did and did not require aortic valve cusp repair. ResultsCusp repair was performed in 181 of 756 patients (24%). Patients who required cusp repair were more often male, were older, had more aortic valve regurgitation, and less often had connective tissue disease. Patients who underwent cusp repair had longer aortic clamp time (124 ± 43 minutes vs 107 ± 36 minutes, P = .001). In-hospital outcomes were similar between groups and with no operative deaths. A total of 98.3% of patients with cusp repair and 99.3% of patients without cusp repair had mild or less aortic regurgitation at discharge. The median follow-up was 3.9 and 3.2 years for the cusp repair and no cusp repair groups, respectively. At 10 years, estimated prevalence of moderate or more aortic regurgitation was 12% for patients with cusp repair and 7.0% for patients without cusp repair (P = .30). Mean aortic valve gradients were 6.2 mm Hg and 8.0 mm Hg, respectively (P = .01). Ten-year freedom from reoperation was 99% versus 99% (P = .64) in the matched cohort and 97% versus 97%, respectively (P = .30), in the unmatched cohort. Survival at 10 years was 98% after cusp repair and 93% without cusp repair (P = .05). ConclusionsAortic valve reimplantation for patients with tricuspid aortic valves has excellent long-term results. Need for aortic valve cusp repair does not affect long-term outcomes and should not deter surgeons from performing valve-sparing surgery.

Valve-sparing operations after Ross procedure: a single-center experience.

The Ross procedure has demonstrated excellent long-term results, with restoration of life-expectancy in patients with severe aortic valve dysfunction. However, reintervention after Ross can occur, and herein we describe our center's experience with redo surgery after previous Ross procedures. We searched our prospective database for aortic valve-repair and recruited all adult (≥18 years) patients who have undergone valve-sparing root replacements (VSRRs) and/or aortic valve-repair after Ross procedure between July 2001 and July 2022. Univariable logistic regression analysis was performed to identify variables affecting early mortality. Survival, freedom-from-valve-reintervention and freedom-from-aortic regurgitation (AR) grade ≥3 were analyzed with the Kaplan-Meier method. A total of 63 patients were recruited for this study. Indication for reoperation after Ross was aortic aneurysm without AR in 17 (27%), aortic aneurysm with AR in 27 (43%), and isolated AR in 19 (30%) patients. Median follow-up time was 7.82 years. The majority of patients (76%) had undergone the free root technique during their index Ross operation. Cumulative survival, after redo surgery following Ross, was 98.4% [95% confidence interval (CI): 89.3-99.8%] at 1 year, 96.3% (95% CI: 88.2-98.3%) at 5 years, and 92.4% (95% CI: 87.1-98.0%) at 10 years. Freedom-from-reoperation on the aortic valve at 1 year was 98.4% (95% CI: 97.0-99.8%), at 5 years was 96.7% (95% CI: 87.6-99.0%), and 79.7% (95% CI: 71.1-88.3%) at 10 years. Long-term survival after redo surgery following the Ross operation is excellent. The data support our aggressive valve-sparing approach after Ross.

Multi-modality imaging evaluation and pre-surgical planning for aortic valve-sparing operations in patients with aortic root aneurysm.

Cardiac computed tomography (CT) and magnetic resonance (CMR) supplement echocardiography in the evaluation of those with aortic root and ascending aortic dilation, determining timing for intervention, guiding pre-surgical planning and post-operative surveillance. The dynamic, three-dimensional complexity of the aortic root and how it relates to the base of the left ventricle must be understood in any surgical approach addressing the aneurysmal aortic root. With improved imaging technology and the importance for proper patient counseling, it is no longer acceptable to enter the operating theater without a detailed blue print of what the problem is, and how best to address it. In addition, reliance on surgical expertise alone for intraoperative evaluation and decision making could be suboptimal due to the unloaded condition of the aortic root and the variance of experience of the surgeons to successfully repair the aortic valve. This is exemplified by the selective surgeons and centers who have the ability to tackle these aortic valve and root pathologies, compared to mitral valve repair techniques that have been codified and are generalizable. This review discusses a multimodality imaging approach in the patient with aortic root aneurysm, focusing on the precision added with pre-surgical CT assessment to guide aortic-valve sparing operations. This precision is afforded with a detailed understanding of the anatomy of the aortic root and underlying support, and its accurate evaluation by standard two- and three-dimensional imaging. Furthermore, we describe the evolving ability to predict the location of ventricular components of the atrioventricular conduction axis with further clinical imaging to personalize surgical strategies.

Functional and pathomorphological anatomy of the aortic valve and root for aortic valve sparing surgery in tricuspid and bicuspid aortic valves.

Functional and pathomorphological anatomy of the aortic valve and root for aortic valve sparing surgery in tricuspid and bicuspid aortic valves.