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.

Selective sinus replacement for aortic root repair in bicuspid aortopathy.

OBJECTIVES: To evaluate the results after selective sinus replacement (SSR) for aortic root remodeling in bicuspid aortopathy. METHODS: Among 662 patients who underwent root repair using SSR between 2005 and 2020, there were 114 with bicuspid aortopathy. SSR was performed either as an isolated procedure (31) or as an adjunct to aortic valve repair (83) and was adjusted to the existing aortic annulus diameter rather than a downsized diameter. In valves with asymmetrical commissural orientation, the repair aimed for the achievement of a 180°-commissural orientation. RESULTS: Abolishment of aortic insufficiency (AI) ≥2+ using root repair alone was only possible in 2 patients with acute-dissection-related AI, yet isolated root repair was also performed in 29 further patients with no/mild AI. All remaining patients with AI ≥2+ presented cusp-related regurgitation and necessitated an additional valve repair. During the mean follow-up of 91 months (range, 13-196), a relevant valve defect (AI ≥3+ in 8, stenosis in 2) occurred in 10 patients (all after combined repair) resulting in an estimated freedom from a relevant aortic valve defect and/or reoperation of 96 ± 2%, 89 ± 4%, and 82 ± 6% at 5, 10, and 12 years, respectively. Echocardiographically, no patient revealed a considerable change of form or size of the repaired root nor was any root reintervention necessary. CONCLUSIONS: Patient-tailored root repair using SSR is a very effective and durable valve-sparing approach for bicuspid aortopathy. Aortic cusp repair is decisive for both abolishment of AI in bicuspid aortopathy and for the functional durability of the repaired aortic valve.

Reconstructive aortic valve surgery in the elderly: Techniques and outcomes.

OBJECTIVES: The aim of the study was to evaluate operative techniques and long-term results after aortic valve or root repair in patients aged 75 years or more. METHODS: Between November 2002 and January 2016, a total of 815 patients underwent aortic valve or root repair. Among them were 100 patients aged 75 years or more (mean, 78 ± 3; range, 75-88 years), including 17 patients operated on an emergency basis because of acute aortic dissection. None/trivial, mild, moderate, and severe insufficiency grades were presented in 9, 23, 27, and 41 patients, respectively. The surgery comprised root repair, cusp repair, and a combination of both in 45, 16, and 39 patients, respectively. RESULTS: Early (30-day) mortality and the rate of permanent neurologic deficit were 2% for each. The follow-up was 99% complete, resulting in 427 patient/years. During the follow-up period (mean duration, 4.3 ± 3.2; range, 0.02-11.1 years), only 1 patient developed a relevant aortic insufficiency and required aortic valve reoperation. There were 24 late deaths, which occurred on average 50.0 ± 40.6 months (range, 2.4-135.0) after surgery at the average patient age of 82 ± 5 years (range, 75-90). Estimated survival at 5 and 8 years was 76.4% ± 5.1% and 71.3% ± 5.9%, respectively, and was similar to those of the sex- and age-matched general population. CONCLUSIONS: Reconstructive aortic valve surgery is a suitable and justifiable surgical option in selected elderly patients undergoing operation by surgeons with considerable experience in this kind of surgery. It offers low cardiac and valve-related mortality and morbidity, leading to life expectancy applicable to the patients' ages.

Patient-tailored aortic root repair in adult marfanoid patients: Surgical considerations and outcomes.

OBJECTIVE: The aim of the study was to evaluate the operative and functional results after individual, patient-tailored aortic root repair in marfanoid patients. METHODS: Among 518 patients who underwent operation between 2002 and January 2016, using patient-tailored aortic root repair with isolated sinus replacement, 42 patients fulfilled the original Ghent criteria. None/trivial, mild, moderate, and severe insufficiency grades were present in 5, 16, 10, and 11 patients, respectively. RESULTS: The repair was adjusted to the existing aortic annulus diameter. Replacement of 1, 2, or 3 sinuses of Valsalva was performed in 1, 14, and 27 patients, respectively. Concomitant cusp repair was performed in 17 patients (40.5%), and 10 patients (23.8%) underwent arch repair (total in 3). All patients survived surgery, and the follow-up (mean, 6.1 ± 3.1; range, 0.8-14.2 years) was 100% complete. No patient had a change in the form or size of the aortic neo-root, especially the size of aortic annulus and sinotubular junction during the follow-up time. No and trivial/mild insufficiency were present in 22 and 18 patients, respectively, and 2 patients with recurrent aortic insufficiency caused by cusp pathology underwent aortic valve replacement 43 and 66 months after the primary surgery, respectively. Thus, the estimated survival free from aortic valve/root reoperation for any reason at 5 and 8 years was 96.8% ± 3.2% and 91.4% ± 6.0%, respectively. CONCLUSIONS: Patient-tailored root repair using isolated sinus replacement is an effective and durable method of valve-sparing repair in select marfanoid patients with a satisfactory quality of aortic cusps, which seems to be decisive for long-term valve function.

Valve-sparing aortic root repair without down-sizing of the annulus.

OBJECTIVES: The study was conducted to evaluate the intermediate results after patient-tailored aortic root repair with replacement of isolated sinuses adjusted to the existing aortic annulus diameter rather than annulus downsizing. METHODS: Between 2000 and 2009, 236 patients with aortic root disease underwent patient-tailored restoration of the aortic root according to its anatomopathologic condition with repair of 1, 2, or all 3 sinuses in 73, 94, and 69 patients, respectively. Concomitant cusp repair was performed in 106 patients. Insufficiency grades of 0/1+, 2+, 3+, and 4+ were presented in 59, 74, 74, and 29 patients, respectively. All data were collected prospectively and intention-to-treat analysis was performed. RESULTS: Valve repair was successful in all but 6 patients. At the most recent clinical and echocardiographic follow-up of the remaining patients, which averaged 43 ± 24 months (range, 0.3-115 months), 216 patients showed no or slight aortic regurgitation (grade 0/1+) and 10 patients showed grade 2+. Another 4 patients had grade 3+ regurgitation and underwent aortic valve replacement. The actuarial freedom from aortic regurgitation grade 3+ or more at 8 years was 95.2%. Multivariate logistic regression analysis identified cusp repair as the independent risk factor for an aortic regurgitation grade of 2+ or more with an odds ratio of 10.9 (95% confidence interval, 2.5-47.7; P = .002). The association between aortic annulus size and functional results after repair could not be demonstrated. CONCLUSIONS: Aortic root repair with replacement of isolated sinuses adjusted to the existing aortic annulus leads to excellent, durable results and can be recommended. Cusp disease is a leading aspect affecting functional results of repair. Therefore, establishment of reproducible cusp repair techniques is of utmost importance for further development of reconstructive aortic valve surgery.

Aortic root reconstruction using new vascular graft.

The aim of this study was to determine the feasibility of the new vascular graft for aortic root reconstruction using two different surgical techniques and to evaluate the intermediate clinical and functional results. Between January 2006 and December 2007, a total of 79 patients with aortic root and valve pathologies (chronic aneurysm 70, acute aortic dissection 9) underwent valve-sparing aortic root repair at our facility. Moderate to severe (3+) or severe (4+) aortic regurgitation was present in 19 (24%) and 7 (9%) patients, respectively. A new vascular aortic root graft was used in all patients. The 30-day mortality was zero. The aortic valve had to be replaced before discharge due to recurrent insufficiency in one patient. In all remaining patients, the postoperative echocardiography at discharge showed no, trivial, or mild insufficiency in 61, 15 and two patients, respectively. During the follow-up time, which was completed for all patients and averaged for repair survivors 15+/-7 (range, 6-29 months), these echocardiographic findings remained unchanged. The new vascular aortic root graft is feasible for aortic root reconstruction using both reimplantation technique and single patch remodeling technique. It provides very good surgical handling and leads to excellent early and intermediate functional results.