[Does aortic cusp repair influence the outcome of valve sparing aortic root replacement?].

BACKGROUND: Outcome of the patients who underwent aortic root replacement with valve sparing procedure concomitant with cusp repair was evaluated. METHODS: Between October 1999 and April 2009, valve sparing aortic root replacement were performed in 62 patients. Isolated valve sparing procedure was performed in 38 patients (control) and concomitant cusp repair was performed in 24 patients (aortic valve plasty: AVP). Cusp prolapse was corrected by plication of Arantius body (n = 13), cusp perforations were closed by pericardial patch (n = 6) or reinforcement of free margin (n = 6). RESULTS: No patient died during the hospital stay and no thromboembolic events occurred in the follow up. Pre-operative grade of aortic insufficiency was 3.0 +/- 0.9 in AVP group vs. 2.5 +/- 1.3 in control (NS). There was no significant difference between both groups regarding age, cardiac function and preoperative aortic root diameter. However, eccentric jet by preoperative transesophageal echocardiography (TEE) was more often in group AVP than in control (p<0.01). Five patients underwent reoperation because of recurrent aortic regurgitation (AR) or hemolysis. Postoperative AR grade were similar in both groups (0.9 +/- 0.5 vs 0.5 +/- 0.6). During follow up, the 5 year freedom from re-operation (aortic valve replacement: AVR) was 85.1+/- 8.2% in AVP and 94.0 +/- 4.1% in control (NS). 5-year-survival was 100% and 95.0 +/- 4.9% (NS), respectively. CONCLUSIONS: Valve sparing aortic root replacement with concomitant cusp repair provided satisfactory midterm result.

Multiple penetrating atherosclerotic ulcers of the aorta: report of a case.

A 69-year-old hypertensive man who had 7 pseudoaneurysms caused by penetrating atherosclerotic ulcers underwent 2-staged endovascular grafting in the thoracic and thoracoabdominal aorta and a conventional graft replacement of the abdominal aorta. He had an uneventful postoperative course; follow-up computed tomography demonstrated that all aneurysmal lesions treated by endovascular grafting completely disappeared. He has been free from any aortic events 20 months after the last surgery.

Clinical outcomes of combined aortic root reimplantation technique and total arch replacement.

OBJECTIVES: The goal of this study was to evaluate early and late outcomes of combined valve-sparing aortic root replacement and total arch replacement (TAR). METHODS: From October 1999 to May 2014, 195 patients underwent valve-sparing operations using the David reimplantation technique. Thirty-one patients underwent combined TAR for aortic regurgitation (AR) with extended aortic aneurysm from the aortic root to the aortic arch. Aetiologies included acute type A aortic dissection in 12 cases, chronic aortic dissection in 8 cases and non-dissecting aneurysm in 11 cases. There were 9 patients with Marfan syndrome. The preoperative severity of AR was mild in 4, moderate in 16 and severe in 11. Even though half of those were emergent operations for acute aortic dissection, preoperative haemodynamic conditions were stable in all patients. RESULTS: No hospital deaths occurred. Postoperative complications included prolonged mechanical ventilation (>48 h) in 1 case and re-exploration for bleeding in 2 cases. Other complications, such as neurological dysfunction or low cardiac output syndrome, were not observed. At hospital discharge, 2 patients had mild AR, 22 had trace AR and 7 had no AR. During follow-up, 2 patients had moderate AR, 7 had mild AR, 18 had trace AR and 3 had no AR. Follow-up was completed in 95.1% of patients, and the mean follow-up period was 60.5 ± 9.1 months. No late death and thromboembolic complication occurred during follow-up. One patient required reoperation for AR. Freedom from reoperation at 5 and 10 years was 100 ± 0 and 83.3 ± 3.5%, respectively. Freedom from moderate or severe AR at 3 and 5 years was 83.3 ± 3.5 and 83.3 ± 3.5%, respectively. CONCLUSIONS: Early outcomes of combined aortic root reimplantation and TAR were satisfactory and provided excellent freedom from thromboembolic complication. The rate of freedom from reoperation during long-term follow-up was acceptable. Further follow-up is required to evaluate this procedure.

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

BACKGROUND: The mid-term results of valve-sparing aortic root reimplantation (VSRR) for various indications were investigated. METHODS: 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). RESULTS: 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). CONCLUSIONS: 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.

Aortic root replacement through right anterolateral thoracotomy.

A 59-year-old woman had undergone total arch replacement, followed by the mediastinal omental flap installation because of postoperative mediastinitis. One year later, she was diagnosed with annuloaortic ectasia with mitral regurgitation and underwent aortic root replacement (modified Bentall procedure) plus mitral valve annuloplasty through the right anterolateral thoracotomy. Her postoperative course was uneventful. The approach could be an alternative for the aortic root replacement in patients with previous median sternal wound complications.