Propofol plus low-dose dexmedetomidine infusion and postoperative delirium in older patients undergoing cardiac surgery.

BACKGROUND: Postoperative delirium (POD) is a frequent complication in older patients. Dexmedetomidine might be effective in decreasing the incidence of POD. We hypothesised that adding low-dose rate dexmedetomidine infusion to a propofol sedation regimen would have fewer side-effects and would counteract the possible delirium producing properties of propofol, resulting in a lower risk of POD than propofol with placebo. METHODS: In this double-blind placebo-controlled trial, patients ≥60 yr old undergoing on-pump cardiac surgery were randomised 1:1 to the following postoperative sedative regimens: a propofol infusion and dexmedetomidine (0.4 µg kg-1 h-1) or a propofol infusion and saline 0.9% (placebo group). The study drug was started at chest closure and continued for 10 h. The primary endpoint was in-hospital POD, assessed using the Confusion Assessment Method and chart review method. RESULTS: POD over the course of hospital stay occurred in 31/177 (18%) and 33/172 (19%) patients in the dexmedetomidine and placebo arm, respectively (P=0.687; odds ratio=0.89; 95% confidence interval, 0.52-1.54). The incidence of POD in the intensive care alone, or on the ward alone, was also not significantly different between the groups. Subjects in the dexmedetomidine group spent less median time in a delirious state (P=0.026). Median administered postoperative norepinephrine was significantly higher in the dexmedetomidine group (P<0.001). One patient in the dexmedetomidine group and 10 patients in the placebo group died in the hospital. CONCLUSIONS: Adding low-dose rate dexmedetomidine to a sedative regimen based on propofol did not result in a different risk of in-hospital delirium in older patients undergoing cardiac surgery. With a suggestion of both harm and benefit in secondary outcomes, supplementing postoperative propofol with dexmedetomidine cannot be recommended based on this study. CLINICAL TRIAL REGISTRATION: NCT03388541.

Influence of Sternotomy on Delta Pulse Pressure and Delta Down During Open Chest Cardiac Surgery: A Preliminary Study.

OBJECTIVE: Delta pulse pressure and delta down are used as dynamic preload indicators of fluid responsiveness during closed chest surgery. There are few data regarding their accuracy in open chest surgery. The present study aimed to evaluate the influence of sternotomy on the accuracy of both delta pulse pressure and delta down. DESIGN: Prospective study. SETTING: Single institution, nonacademic hospital. PARTICIPANTS: The study comprised 127 adult patients scheduled for elective open chest cardiac surgery. INTERVENTIONS: Delta pulse pressure and delta down were calculated for all patients before and 10 minutes after sternotomy. MEASUREMENTS AND MAIN RESULTS: Statistical analyses were performed to assess the influence of sternotomy on the accuracy of delta down and delta pulse pressure. Mann-Whitney and Bland-Altman analyses demonstrated a significant influence of sternotomy on delta pulse pressure values but not on delta down values. Among patients who had a positive delta down and/or delta pulse pressure before sternotomy, sternotomy significantly modified the delta pulse pressure value (p = 0.02), but not the delta down value (p = 0.22). The kappa coefficient indicated a very good agreement between delta down before and after sternotomy (0.83) and a fair agreement between delta pulse pressure before and after sternotomy (0.4). The difference between kappa coefficients was highly significant (p < 0.001). CONCLUSIONS: Within the study population, sternotomy significantly influenced delta pulse pressure but not delta down. In this preliminary study, delta down appeared to be more accurate to evaluate fluid responsiveness during open chest surgery than did delta pulse pressure. Before promoting delta down in current practice, confirmation is needed on a larger scale.

Predicting postoperative delirium and postoperative cognitive decline with combined intraoperative electroencephalogram monitoring and cerebral near-infrared spectroscopy in patients undergoing cardiac interventions.

Studies have associated electroencephalogram (EEG) suppression with postoperative delirium (POD) and postoperative cognitive decline (POCD). Otherwise, improving cerebral tissue oxygen saturation (rScO2) seems beneficial. No study has evaluated the impact of EEG suppression and decreased rScO2 on the incidence of POD and POCD when the intraoperative management of patients is performed with a depth-of-anesthesia (DOA) monitor and a cerebral oximetry. In this prospective study patients undergoing cardiac interventions were monitored with the NeuroSENSE® DOA monitor and bilateral cerebral oximetry. An algorithm was used to optimize cerebral oxygenation. EEG suppression was presented as total area under the curve (AUC) of suppression ratio (SR) > 0 s (AUCEEGSR>0s). Cerebral desaturation was defined as AUC of 25% drop of oximetry values as compared to baseline. POD was evaluated by the chart review method. POCD was defined as a Z-score ≤ 2 based on Mini Mental State Examination at baseline and day 5 or if the patient reported any cognitive decline at 3 and at 6 months postoperatively. Among the 1616 patients, 1513 underwent normothermic surgery and were further analyzed. POD and POCD were respectively evaluated in 1504 and 1350 patients of whom 303 (20%) and 270 (20%) were respectively diagnosed positive. Having experienced high magnitudes of EEG suppression (fourth quartile of AUCEEGSR>0s) was significantly associated with POD (OR = 2.247; 95% CI = 1.414-3.571; P = 0.001). Low rScO2 at the end of surgery was statistically associated with POCD (OR = 0.981; 95% CI = 0.965-0.997; P = 0.018). The results of our study show that the degree of intraoperative EEG suppression on one hand, and low rScO2 at the end of procedure on the other hand, are associated with respectively POD and POCD in patients undergoing cardiac interventions.

Fibrinogen concentration significantly decreases after on-pump versus off-pump coronary artery bypass surgery: a systematic point-of-care ROTEM analysis.

OBJECTIVES: Studies have emphasized the importance of normal fibrinogen concentrations in surgical patients. The primary hypothesis of this study was that fibrinogen levels significantly decrease in on-pump coronary artery bypass graft (CABG) surgery versus off-pump coronary artery bypass graft (OPCAB) surgery. The second objective was to show that ROTEM (TEM International, GmbH, Munich, Germany) rapidly detects these abnormalities compared with standard tests. DESIGN: A prospective, nonrandomized study. SETTING: A university hospital. PARTICIPANTS: Forty-two and 62 patients in the CABG and OPCAB groups, respectively, undergoing first-time bypass surgery were included. INTERVENTIONS: CABG versus OPCAB surgery. MEASUREMENTS AND MAIN RESULTS: Routine coagulation tests and ROTEM values were measured before anesthesia (T0), after the first dose of heparin (T1), after protamine (T2), upon intensive care unit arrival (T3), and 4 hours postoperatively (T4). The outcome measures were followed until 4 hours postoperatively. Fibrinogen concentrations were significantly lower in the CABG versus the OPCAB group at T2 (170 ± 44 v 243 ± 73 mg/dL, p < 0.001) and T3 (179 ± 42 v 232 ± 68 mg/dL, p < 0.001). This was confirmed by significantly lower FIBTEM maximal clot firmness values at T2 (9 ± 4 v 14 ± 5 mm, p < 0.001) and T3 (9 ± 4 v 13 ± 6 mm, p < 0.001). In the CABG group, patients received significantly more transfusions of all blood products except fresh frozen plasma. CONCLUSIONS: Fibrinogen concentration significantly decreases after cardiopulmonary bypass. ROTEM helps in its fast detection.

Tricuspid annular dynamics, not diameter, predicts tricuspid regurgitation after mitral valve surgery: Results from a prospective randomized trial.

Objective: Current guidelines advise using prophylactic tricuspid valve annuloplasty during mitral valve surgery, especially in the presence of annular diameter enlargement. However, several retrospective studies and a prospective randomized study from our department could not confirm that diameter enlargement is predictive of late regurgitation. We examined whether 2- and 3-dimensional echocardiographic and clinical characteristics could identify patients who will develop moderate or severe recurrent tricuspid regurgitation. Methods: Patients with less than severe functional tricuspid regurgitation (FTR) were randomized not to receive tricuspid annuloplasty, and 11 of 53 of them were excluded from the study because 3-dimensional echocardiographic analysis was not possible. Cox regression was used to estimate the model-based probability of moderate or severe FTR (vena contracta ≥3 mm) or progression of TR and FTR regression using valve dimensions (annulus area, diameter perimeter, nonplanar angle, and sphericity index), dynamics (annulus contraction, annulus displacement, and displacement velocity), and clinical parameters as possible predictors. Results: At a median follow-up of 3.8 years (range, 3-5.6 years), 17 patients had moderate or severe FTR or progression, and 13 had FTR regression. Our models identified annular displacement velocity as a significant predictor for FTR recurrence and nonplanar angle as a significant predictor for FTR regression. Conclusions: Annular dynamics, not the dimension, predict recurrence and regression of FTR. Annular contraction should be systematically investigated as a possible surrogate of right ventricle function to prophylactically treat the tricuspid valve.

An increase in endogenous erythropoietin concentrations has no cardioprotective effects in patients undergoing coronary artery bypass graft surgery.

OBJECTIVE: Preliminary data showed an increase in endogenous erythropoietin (EPO) concentrations after acute normovolemic hemodilution (ANH) in patients undergoing coronary artery bypass graft (CABG) surgery. Numerous studies have shown the organ protective properties of EPO. The aim of this study was to investigate the cardioprotective effects of these increased EPO concentrations that resulted from ANH during cardiac surgery. DESIGN: A prospective, randomized, blind study. SETTING: A university hospital. PARTICIPANTS: A total of 93 patients undergoing isolated CABG surgery with or without cardiopulmonary bypass (CPB). INTERVENTIONS: Subjects with CPB were randomized into the control (C) or ANH group. Those in the off-pump coronary artery bypass group underwent no treatment. In the ANH group, a precalculated amount of blood was withdrawn and replaced by colloids after the induction of anesthesia. MEASUREMENTS AND MAIN RESULTS: Hemodynamic parameters were recorded intra- and postoperatively. Troponin concentrations were measured as a routine parameter postoperatively. Upon intensive care unit arrival, the EPO levels were higher in the ANH group than in the C group. There was no significant difference between the troponin values of the C and the ANH groups at 4 hours postoperatively. CONCLUSIONS: In patients undergoing CABG surgery on CPB, an increase in endogenous EPO concentrations in the physiologic range has no cardioprotective effects.

Long-term durability of bicuspid aortic valve repair: a comparison of 2 annuloplasty techniques.

OBJECTIVES: To compare long-term outcomes after bicuspid aortic valve (BAV) repair utilizing the Cabrol annuloplasty versus valve sparing Reimplantation technique. METHODS: From 1996 to 2018, 340 consecutive patients underwent BAV repair. Eighty underwent Cabrol annuloplasty and 189 underwent Reimplantation. Exclusion criteria were re-repairs (n = 6), active endocarditis (n = 4), no annuloplasty (n = 41) and ring or suture annuloplasty (n = 20). We compared both groups for survival, reoperations, valve related events and recurrent severe aortic regurgitation (AR > 2+). Inverse probability weighting (IPW) was used to balance the 2 groups. Cox regression analysis was used to identify outcome predictors. RESULTS: After weighting, pre- and intraoperative characteristics were similar between groups, except for aorta replacement techniques and operative time, which was longer in the Reimplantation group (P < 0.001). At 12 years, overall survival was similar between groups (IPW: Cabrol 97 ± 2% vs Reimplantation 94 ± 3%, P = 0.52). Freedom from reoperation and freedom from AR > 2+ were significantly lower in the Cabrol group (reoperation IPW: 69 ± 9% vs 91 ± 4%, P = 0.004 and AR > 2+ IPW: 71 ± 8% vs 97 ± 2%, P < 0.001). The Reimplantation technique was the only independent predictor of reoperation (hazard ratio 0.31; confidence interval 0.19-0.7; P = 0.005). CONCLUSIONS: In this study, comparing 2 annuloplasty strategies for BAV repair, we found statistically significant differences in long-term durability favouring the Reimplantation technique, and no differences in overall survival. The results support our current strategy of Reimplantation technique and repair of AR in patients with BAV. Cabrol annuloplasty is obsolete and should be generally abandoned in patients undergoing BAV repair for AR.

Transesophageal echocardiographic evaluation during aortic valve repair surgery.

For patients with aortic valve (AV) disease, the classic treatment has been AV replacement and this remains true for aortic stenosis. In contrast, repair of isolated aortic insufficiency (AI), with or without aortic root pathology, is emerging as a feasible and attractive option to replacement. The AV is one of the elements of the aortic root. As such, AI can develop if one or more elements of the aortic root are diseased. Intraoperative transesophageal echocardiographic evaluation permits analysis of the mechanisms of aortic regurgitation as well as differentiation between repairable and unrepairable AV pathology. Immediate postrepair transesophageal echocardiography provides important information about the quality and durability of repair and identifies variables associated with recurrent AI.

Free margin length and geometric height in aortic root dilatation and leaflet prolapse: implications for aortic valve repair surgery.

OBJECTIVES: Our goal was to assess the aortic leaflet free margin length (FML) and geometric height (gH) in a normal aortic valve (AV), aorta dilatation and aortic leaflet prolapse. METHODS: We measured the FML and gH intraoperatively in 132 patients operated on for aortic insufficiency, aortic dilatation, endocarditis or fibroelastoma. Patients were divided into 3 groups: normal tricuspid AV (group 1, n = 12), aortic dilatation (group 2, tricuspid = 43, bicuspid = 18) and leaflet prolapse (group 3, tricuspid = 32, bicuspid = 27). The FML and gH were compared between the groups and between the leaflets within each group. RESULTS: In a normal tricuspid AV, the mean FML and gH were 34.7 ± 3.1 mm and 18.8 ± 1.7 mm, respectively. In group 2 tricuspid, the FML and gH were greater than those in group 1 (FML 43.7 ± 4.4, P < 0.001; gH 21.2 ± 1.8, P = 0.003). In group 3, tricuspid, the FML of the prolapsing leaflet was greater than the FML of the non-prolapsing leaflet (48.3 ± 5.4 vs 42.2 ± 3.6; P < 0.001). In group 2, bicuspid, FML of both leaflets were similar in group 2, but augmented on the fused leaflet compared to the non-fused leaflet in group 3 (fused 55.4 ± 6.3; non-fused 46.2 ± 6.2; P < 0.001). In groups 2 and 3 bicuspid, the gH of the non-fused leaflet was systematically greater than the fused leaflet (group 2 non-fused 24.6 ± 2.5 vs fused 20.4 ± 2.1; P < 0.001). CONCLUSIONS: In aortic dilatation and leaflet prolapse, FML and, to a lesser extent, gH increased significantly compared to those of normal AV function. FML and gH dimensions also depended on the valve configuration (tricuspid/bicuspid). These data provide new insight into the pathomorphology of AV disease and will serve to further develop new methods of AV repair based on intraoperative measurements of the FML.

Variability of repairable bicuspid aortic valve phenotypes: towards an anatomical and repair-oriented classification.

OBJECTIVES:: The bicuspid aortic valve (BAV) exists in a wide variety of valve phenotypes. The aim of this study was to assess the anatomical characteristics of the different phenotypes and develop a classification system to aid surgical repair. METHODS:: In 178 consecutive patients operated on for aortic insufficiency or aortic dilatation in 2 centres, 11 anatomical parameters of BAV were measured by echocardiography and intraoperatively. All BAV judged potentially repairable were included in the study. RESULTS:: Commissural orientation correlated positively with fusion length (R2 = 0.6, P < 0.001) and negatively with non-functional commissure height (R2 = 0.45, P < 0.001). The cohort was divided into 3 groups according to their commissural orientation (type A: symmetrical, 160-180°, n = 73; type B: asymmetrical, 140-159°, n = 74; and type C: very asymmetrical, 120-139°, n = 31). The patterns of cusp fusion, annulus and aortic size were similar among the groups. Fusion length and the geometric height of the cusps decreased from type A to C; non-functional commissure height increased from type A to C (P < 0.05). Patient age increased from type A to type C. Isolated aortic dilatation was more frequent in type A, and severe aortic insufficiency was more frequent in types B and C (P < 0.05). Valve repair techniques and management of commissural orientation varied among the 3 groups (P < 0.05). Aortic valve replacement and residual aortic insufficiency after repair were more frequent in type C (P < 0.05). CONCLUSIONS:: The BAV phenotypes follow a continuous spectrum that extends from symmetrical to very asymmetrical BAV. We describe the main anatomical parameters (including commissure orientation, length of fusion and non-functional commissure height) and their variation across this spectrum. We propose a new repair-oriented classification system based on those parameters that can be used to predict valve repair techniques. This classification needs further validation with regards to surgical techniques and long-term outcomes.

Functional anatomy of aortic regurgitation: accuracy, prediction of surgical repairability, and outcome implications of transesophageal echocardiography.

BACKGROUND: For patients with aortic regurgitation (AR), aortic valve sparing or repair surgery is an attractive alternative to valve replacement. In this setting, accurate preoperative delineation of aortic valve pathology and potential repairability is of paramount importance. The aim of the present study was to assess the diagnostic value of preoperative transesophageal echocardiography (TEE) in defining the mechanisms of AR, as identified by surgical inspection, and in predicting repairability, by using the final surgical approach as reference. METHODS AND RESULTS: One hundred and sixty-three consecutive patients (117 males, mean age: 58+/-14 years) undergoing AR surgery were included. Mechanisms of AR were categorized by TEE and surgical inspection as follows: type 1, aortic dilatation; type 2, cusp prolapse; and type 3, restrictive cusp motion or endocarditis. At surgery, mechanisms of AR were type 1 in 41 patients, type 2 in 62, and type 3 in 60. Agreement between TEE and surgical inspection was 93% (kappa=0.90). Valve sparing or repair was performed in 125 patients and valve replacement in 38 patients. TEE correctly predicted the final surgical approach in 108/125 (86%) patients undergoing repair and in 35/38 (93%) patients undergoing replacement. The gross anatomic classification of AR lesions by TEE was determinant of valve repairability and postoperative outcome (4-year freedom from > grade 2 AR, reoperation, or death, P=0.04). CONCLUSIONS: TEE provides a highly accurate anatomic assessment of all types of AR lesions. In addition, the functional anatomy of AR defined by TEE is strongly and independently predictive of valve repairability and postoperative outcome.

Smart Bag vs. Standard bag in the temporary substitution of the mechanical ventilation.

OBJECTIVE: To compare in intubated patients manually ventilated in order to mirror the ventilator, the respiratory and hemodynamic effects induced by a bag device equipped with an inspiratory gas flow-limiting valve (Smart Bag, 0-Two Medical Technologies Inc., Mississauga, ON, Canada) and a Standard bag. DESIGN: Non-randomized crossover study comparing 13 respiratory and eight hemodynamically paired parameters. Eight intubated patients were manually ventilated, each by three different intensive care workers yielding 24 sets of data for comparison. Data were collected during two sessions of manual ventilation, first with the Standard bag and then with the Smart Bag. Between each session, the patient was reconnected to the ventilator until return to the baseline. Patients, included after coronary surgery, were sedated and paralyzed. SETTING: Intensive Care Unit, university hospital. RESULTS: Compared with Standard bag, the Smart Bag provided a decrease of inspiratory flow (23 +/- 4.7 vs. 47.3 +/- 16.5 l/min) with a decrease of peak pressure (13.3 +/- 2.9 vs. 21.9 +/- 7.3 cmH2O) and tidal volume (9.4 +/- 2.8 vs. 12.4 +/- 2.7 ml/kg). While the expiratory time was similar, the inspiratory time increased (1.83 +/- 0.58 vs. 1.28 +/- 0.46 s) with the Smart Bag, limiting the respiratory rate (14 +/- 5 vs. 17 +/- 6 cycles/min) and the minute volume (8.8 +/- 2.9 vs. 14.4 +/- 4.9 l/min). Finally, it limited the fall of the ETCO2 (27.9 +/- 5.1 vs. 24.3 +/- 5.7 mmHg) and probably the risks of severe respiratory alkalosis. The bags similarly affected hemodynamic states. CONCLUSION: In intubated patients manually ventilated, the Smart Bag limits the risks of excessive airway pressure and the fall of the ETCO2, with hemodynamic effects similar to those of the Standard bag.

A Low-dose human fibrinogen is not effective in decreasing postoperative bleeding and transfusion requirements during cardiac surgery in case of concomitant clinical bleeding and low FIBTEM values: A retrospective matched study.

BACKGROUND: Studies evaluating the hemostatic effects of fibrinogen administration in cardiac surgery are not conclusive. AIMS: We investigated whether the use of a low-dose human fibrinogen in case of clinical bleeding after protamine administration and concomitant low FIBTEM values is effective in reducing postoperative bleeding. Secondary end-point was to investigate the consumption of allogeneic blood products. SETTING AND DESIGN: This was a retrospective matched study conducted at university hospital. MATERIALS AND METHODS: Among 2257 patients undergoing surgery with cardiopulmonary (CPB) bypass, 73 patients received a median dose of 1 g human fibrinogen (ROTEM-Fibri group). This group was matched with 73 patients who had not received human fibrinogen (control group) among 390 patients having undergone surgery at the moment FIBTEM analysis was unavailable. STATISTICAL ANALYSIS: Matching was performed for the type and the presence of redo surgery. McNemar and Wilcoxon paired tests were used to respectively compare the categorical and quantitative variables. RESULTS: The CPB bypass time was significantly higher in the ROTEM-Fibri group (P = 0.006). This group showed significantly higher bleeding in the first 12 and 24 h postoperatively (P < 0.001) and required significantly more transfusion of blood products (P < 0.001) and surgical revision (P = 0.007) when compared with the control group. There was no significant difference in the number of thromboembolic complications. CONCLUSIONS: These results show that the administration of 1 g of fibrinogen based on low-FIBTEM values and clinical bleeding after protamine administration does not stop bleeding and the need for transfusion of allogeneic blood products.

The dose of hydroxyethyl starch 6% 130/0.4 for fluid therapy and the incidence of acute kidney injury after cardiac surgery: A retrospective matched study.

The safety of hydroxyethyl starches (HES) is still under debate. No studies have compared different dosing regimens of HES in cardiac surgery. We analyzed whether the incidence of Acute Kidney Injury (AKI) differed taking into account a weight-adjusted cumulative dose of HES 6% 130/0.4 for perioperative fluid therapy. This retrospective cohort study included all adult patients undergoing elective or emergency cardiac surgery with or without cardiopulmonary bypass. Exclusion criteria were patients on renal replacement therapy (RRT), cardiac trauma surgery, heart transplantation, patients with ventricular assist devices, subjects who required a surgical revision for bleeding and those whose medical records were incomplete. Primary endpoint was AKI following the creatinine based RIFLE classification. Secondary endpoints were 30-day mortality and RRT. Patients were divided into 2 groups whether they had received a cumulative HES dose of < 30 mL/kg (Low HES) or ≥ 30 mL/kg (High HES) during the intra- and postoperative period. A total of 1501 patients were analyzed with 983 patients in the Low HES and 518 subjects in the High HES group. 185 (18.8%) patients in the Low HES and 119 (23.0%) patients in the High HES group developed AKI (P = 0.06). In multivariable regression analysis the dose of HES administered per weight was not associated with AKI. After case-control matching 217 patients were analyzed in each group. AKI occurred in 39 (18.0%) patients in the Low HES and 50 (23.0%) patients in the High HES group (P = 0.19). In conditional regression analysis performed on the matched groups a lower weight-adjusted dose of HES was significantly associated with a reduced incidence of AKI [(Odds Ratio (95% CI) = 0.825 (0.727-0.936); P = 0.003]. In the absence of any safety study the cumulative dose of modern HES in cardiac surgery should be kept less than 30 mL/kg.

Robotic mitral valve repair: a European single-centre experience.

OBJECTIVES: We report the outcomes of robotic valve repair for degenerative mitral regurgitation (MR) in our Institution. METHODS: Between February 2012 and July 2016, 134 patients underwent robotic mitral valve (MV) repair with the da Vinci Si system. All the operations were performed through a mini-thoracotomy in the fourth right intercostal space, cardiopulmonary bypass and mild hypothermia. The clinical and echocardiographic follow-up was 100% complete. RESULTS: There was no hospital death. The mean cross-clamp and cardiopulmonary bypass time were 112±23 and 159±33 min, respectively. Pre-discharge echocardiograms showed none-to-mild residual MR in all patients. Median follow-up was 24.1 months. We observed 1 early and 4 late reoperations on the MV for an overall freedom from reoperation of 98.2% and 94.1% at 12 and 36 months, respectively. Furthermore, echocardiographic follow-up revealed freedom from recurrence of MR greater than Grade 1+ of 92.5% and 80.7% at 12 and 36 months, respectively. Nevertheless freedom from recurrence of MR greater than Grade 2+ was 97.2% at 12 and 36 months. CONCLUSIONS: Robotic MV repair is a feasible and safe option for the treatment of degenerative MR in selected patients with excellent perioperative outcomes. Early and midterm results are remarkable and are associated with low risk of late recurrence of MR and reoperation. Long-term follow-up is needed to confirm the durability of valve repair.

Effect of annulus dimension and annuloplasty on bicuspid aortic valve repair.

OBJECTIVES: We have recently shown that valve sparing reimplantation (VSR) improves the durability of bicuspid aortic valve repair in comparison with subcommissural annuloplasty. The aim of this study was to assess the degree of annular reduction provided by these techniques and to correlate these findings with repair durability. METHODS: From 1995 to 2010, 161 patients underwent bicuspid valve repair. We included only patients with subcommissural annuloplasty or reimplantation having intraoperative pre- and post-repair transoesophageal echocardiography images. Pre- and post-repair ventriculo-aortic junction (VAJ) diameters were measured on long axis views. Inclusion criteria were met by 53 patients with subcommissual annuloplasty and 65 with reimplantation. Median follow-up was 53 months in the subcommissual annuloplasty group and 42 months in the reimplantation group. Follow-up completeness was 100% in subcommissural annuloplasty and 94% in reimplantation. RESULTS: There was no operative or late mortality. Mean preoperative VAJ was similar in both groups (reimplantation: 28 ± 3 mm vs subcommissural annuloplasty: 28 ± 3, P = 0.16). Preoperative VAJ was larger in patients <40 years and with aortic regurgitation (AR) ≥ 3+ (P < 0.01). Mean postoperative VAJ was smaller in reimplantation compared with subcommissural annuloplasty (21 ± 2 mm vs 24 ± 3 mm, P < 0.01). In univariate analyses, subcommissural annuloplasty, preoperative VAJ ≥ 30 mm, postoperative VAJ ≥ 25 mm and cusp repair with patch were predictive of recurrent AR > 1+. In the subcommissural annuloplasty group, VAJ≥ 30 mm preoperatively and ≥ 25 mm postoperatively were associated with decreased 6 years freedom from recurrent AR>1+ (<30 mm: 74% vs ≥ 30 mm: 39%, P = 0.01; <25 mm: 80% vs ≥ 25 mm 31%, P = 0.02) In the reimplantation group, VAJ dimension had no effect on recurrent AR >1+ (P = 0.93). CONCLUSIONS: In bicuspid aortic valve repair, the circumferential annuloplasty of VSR offers greater reduction of VAJ compared with the non-circumferential annuloplasty provided by the subcommissural annuloplasty. The degree and extent of VAJ reduction in reimplantation seem to be factors among others that positively influence repair durability particularly in patients with a large VAJ (≥ 30 mm).

Aortic valve repair with ascending aortic aneurysms: associated lesions and adjunctive techniques.

OBJECTIVE: Patients with supracoronary ascending aortic aneurysms can have aortic insufficiency (AI) due to dilatation of the sinotubular junction and/or associated cusp pathology. The incidence and types of cusp lesions as well as the effect of AI severity and cusp repair techniques on outcome in this patient population is not well defined. METHODS: Since 1996, 55 patients (mean age: 65 ± 13 years, 17 bicuspid valves) presented with supracoronary ascending aortic aneurysms and AI that was mild/moderate in 27 (49%) and severe in 28 (51%). Associated pathology included cusp prolapse in 18 (33%), cusp restriction in nine (16%) and both in three (5%). All patients underwent aortic replacement and remodeling of the sinotubular junction. Adjunctive techniques included subcommissural annuloplasty in 38(69%) and cusp repair in 28 (51%). RESULTS: AI severity was not significantly associated with the presence of cusp pathology (p=0.35). Cusp disease was present in 100% of bicuspid aortic valves compared with only 34% of trileaflet valves (p<0.001). There was no hospital mortality and overall survival was 94 ± 4% and 75 ± 10%, respectively, at 5 and 7 years. Freedom from re-operation was 100% at 7 years and freedom from recurrent AI (>2+) was 87 ± 7% at 5 years. Neither the presence of preoperative severe AI, nor the need for cusp repair was predictive of late outcome. CONCLUSIONS: Cusp pathology is frequently encountered in patients with ascending aortic dilatation and AI. Severe AI is not a contraindication to valve-preserving surgery, but careful identification and repair of cusp pathology, in addition to sinotubular junction reduction, is critical for durable, long-term outcome.