Long-term outcomes after aortic root repair using selective sinus replacement.

OBJECTIVES: The study aim was to evaluate long-term results after anatomic restoration of the aortic root. METHODS: During an 18-year period, a total of 669 patients underwent valve-sparing root repair (aneurysm 554, dissection 115) using selective sinus replacement. None/trivial, mild, moderate, and severe (grades 3+ and 4+) insufficiency were present in 57, 146, 204, and 262 patients, respectively. RESULTS: The anatomic repair was adjusted to the existing aortic annulus diameter, which was 27.0 ± 3.0 mm on average. Replacement of 1, 2, or 3 sinuses of Valsalva was performed in 209, 234, and 226 patients, respectively. Altogether, 454 additional procedures on the cusps were performed, mostly as cusp patch plasty with pericardium (210). Thirty-day mortality was 0.6%. The mean follow-up duration was 7.1 ± 4.1 years (range, 0.01-19.1 years). The estimated freedom from relevant aortic insufficiency grade 3+ or greater (15 events) was 98% ± 1%, 97% ± 1%, and 94% ± 3% at 5, 10, and 15 years, respectively. On echocardiogram, no patient revealed a considerable change of the form or size of the repaired root, which was confirmed radiologically in 160 patients who received computed tomography angiography for any reason. Multivariate logistic regression analysis identified cusp prolapse/pseudo-prolapse as the only independent risk factor for the development of recurrent insufficiency grade 2+ or greater (41 occurrences), with a hazard ratio of 3.258 (95% confidence interval, 1.658-6.403; P = .001). An association between aortic annulus size and functional results could not be demonstrated. CONCLUSIONS: Patient-tailored root repair using isolated sinus replacement offers excellent functional long-term results regardless of underlying root pathology or annulus size. Aortic cusp pathology was decisive for long-term valve function.

Long-term outcomes after valve-sparing anatomical aortic root reconstruction in acute dissection involving the root.

OBJECTIVES: To evaluate long-term results after valve-sparing surgery of acutely dissected aortic root in which a restoration of root anatomy adjusted to the existing aortic annulus diameter, rather than any kind of downsizing, was performed. METHODS: Among 286 consecutive patients operated on because of type A aortic dissection during the last 17 years were 100 patients (35.0%), mean age 63 ± 13 years (range, 29-88 years), in whom an anatomical restoration of the involved root was performed. Twenty-eight patients presented with severe (3+ or 4+), 37 with mild to moderate (2+), and 24 with mild (1+) insufficiency. In 5 patients, the valve was bicuspid. In all patients, a curative root repair with replacement of all dissected aortic wall was performed, containing a selective replacement of pathologic/dissected aortic sinuses, which were 1, 2, or all 3 sinuses in 62, 32, and 6 patients, respectively. Concomitant cusp repair was necessary in 18 patients. RESULTS: Thirty-day mortality was 1.0%. Survival was estimated starting with surgery and was 89.4 ± 3.4% (95% confidence interval, 80.5-94.4) and 68.8 ± 6.4% (95% confidence interval, 54.4-79.5) at 5 and 12 years, respectively. No patient required reoperation on the aortic root and/or valve during the follow-up period of 70 ± 50 (range, 3-202) months. A freedom from any aortic valve/root reintervention and/or relevant (>2+) aortic insufficiency at 12 years was 100%. CONCLUSIONS: Selective replacement of pathologic sinuses offers an anatomophysiological albeit curative restoration of acutely dissected aortic root resulting in excellent and durable outcomes in selected patients with acute aortic dissection.