Twenty-year experience of aortic valve reimplantation using the Valsalva graft.

OBJECTIVES: Over the past 20 years, valve-sparing aortic root replacement has aroused increasing interest because of a progressive attitude towards the preservation of natural tissue. Aortic reimplantation is the most used technique to spare the valve, allowing simultaneously aortic root replacement and aortic annular stabilization. The reimplantation into a graft with sinuses guarantees an optimal anatomic and functional reconstruction with established good results at 15 years. The aim of this study is to report the world longest follow-up (up to 20 years) of aortic valve reimplantation using the Valsalva graft. METHODS: From February 2000 to December 2021, 265 consecutive patients with aortic root aneurysm received aortic valve reimplantation using the Valsalva graft. From 2018, leaflet plication with the routine use of calliper was performed. For each patient, we performed both intraoperative and post-procedural transoesophageal echocardiography. All patients were followed with clinical assessment and echocardiography. The mean duration of follow-up was 85 ± 63 months. RESULTS: The study cohort had a median age of 55 ± 18 and 87.2% were male. The aortic root aneurysm was associated to bicuspid aortic valve in 18.9% of patients and to Marfan syndrome in 10.6% of cases. 55.9% had an aortic regurgitation ≥ 2+. Overall survival at 15 was 87.6 ± 3.4. Freedom from cardiac death was stable at 99.6 ± 0.4 at 5, 10 and 15 years. Freedom from recurrent AR ≥3+ and freedom from reoperation remained stable at 10 and 15 years at 92.2 ± 2.1 and 95.9 ± 1.6, respectively. There was a minimal incidence of infective endocarditis (0.8%), thromboembolism (2.2%) and haemorrhage (2.0%). Six out of 7 patients requiring reoperation had surgery in the first period of our experience (last in 2004). Early suboptimal results had a negative effect on residual aortic regurgitation. Moreover, we hypothesized that the routine use of calliper may have contributed to a further improvement of the outcome, even if these data need to be confirmed by a longer follow-up. CONCLUSIONS: The first long-term follow-up after aortic valve reimplantation using the Valsalva graft demonstrated excellent results. These long-term results gradually improved with learning curve, remaining stable during the second decade of observation. The systematic use of calliper may have contributed to a further improvement of the outcome.

Aortic root anatomy after aortic valve reimplantation.

OBJECTIVE: During the last decade, special concerns have been raised about the anatomic relationships among the sinotubular junction, ventricular-aortic junction, and virtual basal ring to improve the results of root reconstruction. The aim of this study is to evaluate the in vivo anatomy of the aortic root after reimplantation with the Valsalva graft and the anatomic relationship between its components. METHODS: We analyzed 10 consecutive patients with tricuspid aortic valves who underwent reimplantation with the Valsalva graft between September and December 2019. Surgical clips were applied as markers at the level of proximal annular knots and at the distal reimplanted commissures on the neo-sinotubular junction. Electrocardiogram-gated computed tomography scan of the aortic root was performed. Coordinates of the markers were exported on a 3-dimensional modeling software, and the distances between the virtual basal ring and the Dacron graft basal landmarks were measured. RESULTS: The mean heights of Dacron graft basal landmarks from virtual basal ring were right-left commissure 7.1 ± 5.1 mm; right sinus 4.7 ± 4.1 mm; right-noncoronary commissure 2.8 ± 2.2 mm; noncoronary sinus 1.4 ± 1.6 mm; left-noncoronary commissure 2.2 ± 2.3 mm; and left sinus 2.0 ± 0.9 mm. The mean planar distances of basal Dacron graft landmarks from virtual basal ring (thickness) were right-left commissure 5.3 ± 3.1 mm; right sinus 2.8 ± 1.4 mm; right-noncoronary commissure 2.2 ± 1.5 mm; noncoronary sinus 1.5 ± 1.5 mm; left-noncoronary commissure 1.3 ± 1.0 mm; and left sinus 3.4 ± 2.5 mm. CONCLUSIONS: After reimplantation, despite a complete dissection of the root, slight asymmetry of graft proximal seating exists. The inner annuloplasty is on the virtual basal ring, and the proximal edge of the Dacron graft is on the ventricular-aortic junction at a slightly different thickness and height along the annular circumference. At the level of the right sinus and left/right commissure, the Dacron graft is higher than the virtual basal ring and the relative wall thickness is increased. The annular stabilization is unaffected.

Mitral repair of myxomatous valves with simple annuloplasty: a follow-up up to 12 years.

OBJECTIVES: Diffuse myxomatous mitral valve degeneration (DMD) represents a challenge in the reparative mitral valve surgery. A subgroup of patients with symmetrical DMD can be effectively treated with a simple band-annuloplasty with good early and mid-term results. Here, we evaluate the long-term outcomes in terms of freedom from reoperation, recurrence of moderate or severe mitral regurgitation (MR) and overall survival. METHODS: Between April 2006 and December 2020, patients with DMD causing severe MR and the echocardiographic features of symmetrical bileaflet prolapse, central regurgitant jet(s), annular dilation and no chordal ruptures were treated using a simple annuloplasty with a semi-rigid band. These patients were prospectively collected and retrospectively analysed. RESULTS: Seventy-five patients were enrolled. The mean clinical follow-up time was 104 [standard deviation (SD): 43] months, and echocardiographic follow-up time was 95 (SD: 43) months. The mean age was 54 (SD: 15) years, and 56% were females. Long-term overall survival was 98.2% [standard error (SE): 1.8], 93.7% (SE: 4.7) and 93.7% (SE: 4.7) at 4, 8 and 12 years, respectively. The freedom from reoperation was 100% at 4 and 8 years and 94.1% (SE: 5.7) at 12 years. The freedom from recurrent moderate or severe MR was 98.3% (SE: 1.7), 98.3% (SE: 1.7) and 92.8% (SE: 5.5) at 4, 8 and 12 years, respectively. CONCLUSIONS: Mitral repair with the simple band-annuloplasty for the treatment of MR due to symmetrical DMD seems to be stable and effective in the long term.

Excision of large right atrial myxoma through a right mini thoracotomy.

Cardiac myxoma is the most common primary benign cardiac tumor in adults and right atrial myxoma is a rare observation. We report a case of a 56-year-old woman who presented with dyspnea and diagnosed with a right atrial myxoma. Urgent operation through a right mini thoracotomy was done and myxoma was completely excised. Traditionally, median sternotomy with cardiopulmonary bypass is used for excision of cardiac myxoma. Excision through a mini thoracotomy for patients with right atrial myxoma appear to be safe, feasible and efficacious.

Biological Valves Impervious to Calcification: Is this Holy Grail a Cup Ready to Drink?

An indefinitely lasting bioprosthesis that does not require anticoagulation treatment is the holy grail of substitutive heart surgery. However, this goal is not yet in sight with the present state of technology. Over the past few years, tremendous advances have been achieved regarding tissue anticalcification processes, hemodynamic performance and future-proofing by ensuring compatibility with transcatheter valve-in-valve procedures. The Inspiris Resilia valve (Edwards Lifesciences, Irvine, CA) was designed to incorporate all of these enhancements. It is now leaving the experimental phase and is being tested in the real world. We present here a comprehensive review of the evolution of biological prostheses, details of new anticalcification technologies, and early results of published studies as well as the experience at the European Hospital (Rome, Italy), the site of the first European implant and a leading center in various protocols. In our two years of experience with the Inspiris Resilia, there have been no cases of structural valve deterioration, endocarditis, detachment or periprocedural complication, and gradients seem to be superior to those with the previous generation of Edwards valves. While longer-term experience is clearly needed, the results thus far are encouraging.

The black root: Aortic valve sparing in alkaptonuria.

We report an unusual case of black discoloration of an aortic root aneurysm and aortic valve cusps due to homogentisic acid deposition in a patient suffering from alkaptonuria. The patient underwent a valve-sparing aortic root replacement after careful and objective evaluation of the valve cusps. Despite alkaptonuria is classically associated with aortic valve stenosis and replacement, in the present case, the affected valve cusps were suitable for repair. To our knowledge, this is the first reported case of aortic valve-sparing procedure performed in a patient with alkaptonuria.

Root Reimplantation and Aortic Annuloplasty With External Ring in Bicuspid Aortic Valve: An Anatomical Comparison.

Aortic annuloplasty has demonstrated to be a protective factor in valve-sparing root replacement and aortic valve repair. Both reimplantation for aortic root aneurysms and external ring annuloplasty for isolated aortic regurgitation have demonstrated good long-term results. The aim of this anatomical study is to compare aortic reimplantation with Valsalva graft with aortic external ring annuloplasty in bicuspid aortic valves, analyzing their morphological features with CT scan. We selected 56 patients with bicuspid aortic valve who underwent reimplantation procedure with Valsalva graft or external ring annuloplasty; after propensity-matching, 2 homogeneous groups of 10 patients each were obtained. Through multiplanar ECG-gated CT-Scan reconstructions, pre- and postoperative, aortic annular, and valve geometrical characteristics were compared (diameters, perimeter, area and ellipticity index for the annulus; effective height, coaptation length and commissural height for the valve). Aortic root volume was also analyzed. Postoperative comparison of the two groups showed similar geometric features of the aortic annulus in terms of major and minor diameters, perimeter, area and ellipticity index. Analysis of valve's parameters showed similar results in terms of effective height and coaptation length (respectively 10.9 ± 2.1 mm and 7.5 ± 1.9 mm in External Ring group and 10.1 ± 2.0 mm and 7.6 ± 1.6 mm in the Reimplantation group). Both techniques achieve an efficient annuloplasty with similar anatomical results on bicuspid the aortic valves. The stability of these results needs to be confirmed by long-term clinical and echocardiographic follow-up.

Optimized Use of the "Skirt" of the Valsalva Graft for the Completion Bentall Procedure.

This report discusses the case of a patient with an aortic root aneurysm who had previously undergone aortic valve replacement with a large mechanical prosthesis that proved to be normally functioning at the time of reoperation. This report describes a technique of replacing the aortic root while retaining the existing aortic valve, similar to the completion Bentall procedure, using a 32-mm Valsalva graft by suturing the skirted portion of the graft to the sewing ring of the mechanical valve. The ability of the skirt to increase its diameter is the key to this approach.

The Skirt and Collar of The Valsalva Graft: One Dress Fits All.

In the original pre-formed Valsalva graft, the skirt is the defining feature. It is a self-expanding portion, obtained by 90° rotation of the Dacron fabric corrugation with respect to the rest of the graft. Due to this manufacturing feature, the skirt length is equal to the graft diameter and, once pressurized, it expands by 25-30% (up to 10 mm) from the nominal size. Proximal to this bulged portion, a small collar completes the prosthesis. By virtue of this anatomical design, the Valsalva graft is recommended for most aortic root surgeries including valve-sparing and Bentall procedures. The skirt, by recreating the pseudo-sinuses, represents the key feature of the graft when used for aortic valve-sparing procedures (remodeling and reimplantation). However, in the Bentall procedure, the graft collar is an important feature because it is useful to attach the Valsalva graft to the valve prosthesis sewing ring when making a valved conduit. Moreover, once the graft is pressurized, the whole volume of the skirt better accommodates the struts and the leaflets of biological and mechanical prostheses. Furthermore, the expanded skirt reduces the distance and the tension on the coronary button anastomosis, increasing safety and possibly reducing complication rates. This review demonstrates the versatility of the Valsalva graft in various scenarios of aortic root surgery, with special emphasis on different uses of the skirt and the collar.

External Stents for Vein Grafts in Coronary Artery Bypass Grafting: Targeting Intimal Hyperplasia.

INTRODUCTION: Progressive saphenous vein graft (SVG) failure remains a key limitation to the long-term success of coronary artery bypass grafting (CABG). SVG disease after the first year is dominated by intimal hyperplasia, which predisposes the SVG to thrombosis and accelerated atherosclerosis. The objective of this study was to review and summarize the latest experimental and clinical data on the use of mechanical external stents for vein grafts. METHODS: In January 2020, the PubMed database was searched using the terms "external stent", "CABG", "saphenous vein graft" and "intimal hyperplasia". The results were reviewed and only randomized experimental and clinical studies that analyzed the effect of external stenting on venous intimal hyperplasia were included in the analysis, together with studies that investigated the clinical benefit of external stenting. RESULTS: Eight experimental and four clinical trials met the search criteria. Controlled trials in different large animal models concluded that external stenting significantly reduced intimal hyperplasia 3-6 months post implantation, and reduced both thrombosis rates and the development of lumen irregularities. Data from randomized controlled trials with a follow-up period of 1-4.5 years supported the pre-clinical findings and demonstrated that external stents significantly reduced vein graft disease. CONCLUSION: Strong evidence indicates that supporting the vein with external stents is safe and leads to clear advantages at both the anatomical and cellular levels. With the further accumulation of consistent positive results, external stenting of SVG may become the standard of care in future CABG.

A direct correlation between commissural orientation and annular shape in bicuspid aortic valves: a new anatomical and computed tomography classification.

OBJECTIVES: The shape of the aortic annulus is still under debate. Recent findings suggest a possible gradual spectrum of circularity from tricuspid aortic valves (TAVs), to type 1 bicuspid aortic valves (BAVs) to type 0 BAVs. BAVs have been recently classified in a symmetrical (type A), asymmetrical (type B) or very asymmetrical (type C) phenotype according to the commissural orientation (CO) (160°-180°, 140°-159° and 120°-139°, respectively). The aim of this study is to verify in BAVs the correlation between the aortic annular shape and the CO of valve cusps and to suggest a new anatomical and geometric classification of BAVs based on CO and annular shape. METHODS: We retrospectively selected 191 consecutive patients who underwent both electrocardiography-gated computed tomography scan of the aortic root and transthoracic echocardiography between January 2016 and June 2019. The population was divided into 2 groups: 54 BAVs and 137 TAVs. We analysed the subgroup of BAV patients and divided them into group A, group B and group C depending on the CO. The shape of the aortic annulus was considered 'circular' or 'elliptic' according to the ellipticity index (EI).We studied the possible correlation between CO and annular shape in BAVs. We also analysed the subgroup of TAV patients studying their annular shape and EI. RESULTS: After univariate linear regression, BAV patients showed a significant correlation between the CO and the EI (R = -0, 445, R2 = 0, 198, P = 0.001). As the CO decreases, the EI increases and approaches an elliptical shape. After grouping BAVs according to the CO, a mean EI of 1.10 ± 0.07 was found in group A, 1.13 ± 0.08 in group B, 1.18 ± 0.07 in group C, P = 0.0097 indicating a gradual spectrum of ellipticity with the decrease of CO. TAVs subgroup showed a mean EI of 1.27 ± 0.09, suggesting that the more the CO is reduced in BAVs, the more the annulus probably tends towards the very elliptical shape of TAVs. CONCLUSIONS: This study shows a linear correlation between CO and annular shape in BAVs. In particular, the aortic annulus follows a continuous spectrum of ellipticity depending on the CO. These findings lay the groundwork for a new anatomical classification of BAVs based on CO and annular shape.

Fate of a coronary artery intramural haematoma complicating aortic root surgery: a case report.

BACKGROUND: Coronary intramural haematoma (CIH) is an uncommon but potentially life-threatening complication during aortic root surgery (such as Bentall procedure). Depending on its extension it can lead to cardiogenic shock. Documented reports of this complication are lacking in literature. CASE SUMMARY: In the report we present a case of CIH and its management and we show a stepwise imaging of the healing process that gives an insight of the fate of CIHs. DISCUSSION: This case raises awareness of CIH as differential diagnosis for myocardial ischaemia during aortic root surgery. It underlines the effectiveness of immediate surgical revascularization, highlights the potential temporary role of coronary artery bypass graft that can stabilize the acute coronary syndrome and may give time to the CIH to reabsorb and native coronary circulation to re-establish.

Latest Advances in Annuloplasty Protheses for Valvular Reconstructive Surgery.

This is the third and final part of our update on the latest advances in cardiac valvular replacement. Part 1 was dedicated to cardiac valvular replacement, and Part 2 focused on transcatheter cardiac valvular treatment. This part concerns annuloplasty prostheses for valvular reconstructive surgery. The number of patients undergoing surgical heart valve repair has been increasing, particularly in high-volume centers. Annuloplasty is now considered the gold standard in mitral valve regurgitation repair secondary to degenerative, ischemic and idiopathic dilated cardiomyopathy disease. The techniques of mitral valve reconstruction have been well established, but controversies remain regarding the type of annuloplasty ring to be used. The available annuloplasty rings include rigid, flexible, complete, partial, and semi-rigid/flexible. The choice of annuloplasty ring has been the focus of extensive investigation and debate, but to date it still largely remains a matter of "surgeon's preference" rather than an evidence-based selection. Functional tricuspid regurgitation was traditionally treated by the classic De Vega annuloplasty, but has since evolved after the development of prosthetic tricuspid annuloplasty. Head-to-head comparisons have demonstrated superior long-term outcomes with device-based annuloplasty compared to suture-based surgery, but the type of ring to be used (flexible versus rigid) has recently been questioned, without reaching definitive conclusions. In contrast to mitral and tricuspid valve repair, aortic repair is more difficult with respect to specific valve features. Annuloplasty is considered to play a key role in controlling aortic regurgitation and preventing recurrence after valve repair. Various modifications of annuloplasty have been advocated (internal/external, with/without ring (suture), rigid/flexible ring). but none of them has become a de facto standard. This paper describes the various rings that are available to help orient surgeons and to serve as a reference for students.

Surgical anatomy of the aortic valve and root-implications for valve repair.

The aortic root is an important anatomical structure positioned at the center of the heart, making it critical to the functioning of the major cardiac chambers. Deep knowledge of the anatomical "surroundings" of the aortic root is crucial for surgeon attempting to spare or repair a leaking aortic valve. In fact, root dissection is a necessary step to "skeletonize" the aortic valve, allowing the surgeon to work on the critical components of its structure, namely the aorto-ventricular junction, the virtual basal ring (VBR) and the sino-tubular junction (STJ). These three components, along with the insertion of the leaflet to the aortic wall, form the skeleton of the aortic valve that is essential in guaranteeing valve competence. A good anatomical proportion between the various component of the skeleton of the aortic valve need to be verified, or re-established in order to set the basis for an optimal aortic valve repair. Once the skeleton of the heart has been correctly addressed, the condition of the valve leaflets need to be considered. Excess of leaflet tissue is treated by leaflet plication or resection and lack of leaflet tissue is addressed by tissue extension with autologous or heterologous materials. In the present manuscript, we highlight the principal structure of the aortic root and describe in detail each anatomical component. This basic anatomical knowledge is also important for a through understanding of the normal function of the valve and root structure during the cardiac cycle. The close boundaries existing between the left ventricular cavity and the aorta are important in explaining the sophisticated function of opening and closing of the aortic valve. Similarly, the role played by the sinuses of Valsalva in regulating the blood flow exiting the ventricle underline the concept that "form follows function" and emphasizes the importance of a good anatomical reconstruction for an optimal and long-lasting valve function.

Morphological modification of the aortic annulus in tricuspid and bicuspid valves after aortic valve reimplantation: an electrocardiography-gated computed tomography study†.

OBJECTIVES: Aortic valve-sparing operations have been shown to produce fewer valve-related complications than valve replacement. The aortic root is a morphological and functional unit in which the annulus plays an important role on dynamism, shape and geometry of the valve with different results in bicuspid aortic valves (BAVs) or tricuspid aortic valves (TAVs). The aim is to evaluate the differences in the size and shape of the aortic annulus between native BAVs and TAVs using ECG-gated computed tomography (CT) after a reimplantation procedure. METHODS: We selected 35 patients scheduled for aortic valve reimplantation who underwent good-quality preoperative and postoperative ECG-gated contrast-enhanced CT scan of the aortic root. Twenty-three patients had TAV, 8 patients type 1 BAV and 4 patients type 0 BAV. Major diameter and minor diameter, perimeter (P) and area (A) were measured. The shape of the aortic annulus was considered 'circular' or 'elliptic' according to the Ellipticity Index. We also selected a subgroup of 18 patients (9 TAVs and 9 BAVs) to evaluate annular shape and size variations through the cardiac cycle and to study the expansibility both in the preoperative and in the postoperative phases. RESULTS: Preoperative CT scans showed an elliptic shape of TAVs (Ellipticity Index 1.3 ± 0.1), a circular shape of type 0 BAVs (1.1 ± 0.1) and an intermediate behaviour of type 1 BAVs, suggesting a possible gradual spectrum of circularity from TAVs to type 1 BAVs to type 0 BAVs. Postoperative CT scans did not show any significant difference in annular shape among the 3 groups, which demonstated a similar roundness, obviating the preoperative differences. Analysing the expansibility of the aortic annulus during the cardiac cycle, we observed that it was completely absent in the preoperative phase in BAVs, while in the postoperative phase, both TAVs and BAVs showed a small but similar expansibility after the annular reduction. CONCLUSIONS: There is a possible gradual spectrum in terms of shape, from native TAVs, to type 1 BAVS to type 0 BAVs. These differences are eliminated in the postoperative phase, suggesting an active role of the annuloplasty on the geometry of the aortic annulus. The preoperative analysis showed a complete inelasticity of BAVs, which was partly restored in the postoperative phase.

Biological solutions to aortic root replacement: valve-sparing versus bioprosthetic conduit.

Composite valve graft implantation described by Bentall and De Bono is a well-documented technique of aortic root replacement used for a large spectrum of pathologic conditions involving the aortic valve and the ascending aorta. While mechanical valves were initially used, biological prostheses were later introduced in order to avoid long-term anticoagulation and its related complications. The increasing age of patients who undergo aortic root surgery, and data supporting the use of a biological aortic valve in the younger population, have significantly increased the need for a composite biological valved conduit. However, parallel to the increased use of biological valve in the context of a Bentall operation, aortic valve-sparing (AVS) operation have also been performed in a growing number of patients. Sarsam and David described the remodeling and the reimplantation procedures more than 25 years ago with the aim of sparing otherwise normal aortic valves in the presence of a root aneurysm. Important achievements in this discipline have occurred over the past decade including development and refinement of valve preserving aortic root replacement techniques, development of a classification system for aortic insufficiency, surgical approaches to cusp disease with different cusp anatomy. Both procedures can now provide excellent root reconstruction and adequate clinical results in terms of late valve durability. The AVS technique offers several advantages over the Bentall procedure, such as no need for oral anticoagulation and lifestyle adjustments. AVS operations have become established alternatives to Bentall procedures for patients with aortic root pathology. However, data comparing the safety and durability of these approaches are lacking.

Biological solutions to aortic root replacement: valve-sparing versus bioprosthetic conduit‡.

OBJECTIVES: Valve-sparing operations and root replacement with a biologic composite conduit are viable options in aortic root aneurysm. This study was conceived to compare the early and mid-term results of these 2 procedures. METHODS: From September 2002 to November 2015, 749 consecutive patients underwent either a valve-sparing operation or a root replacement with a biologic composite conduit at 2 institutions. Propensity score matching was used to compare similar cohorts of patients in the overall population and in the ≤ 55 and ≥ 65-year age groups. RESULTS: Overall operative mortality was 0.4%, mean age 57.4 ± 14.3 years, 84.6% were male. Individuals in the biologic composite conduit group were older and had worse preoperative risk profiles [chronic pulmonary disease (5.5% vs 0.9%; P = 0.001), diabetes (6.4% vs 1.5%; P = 0.001) and NYHA > 2 (25.2% vs 5.2%; P < 0.001)]. Mean follow-up was 27.5 ± 28.4 months. In the unmatched population, there was no difference in in-hospital deaths (0 in the valve-sparing versus 3 in the biologic composite conduit group; P = 0.12). These findings were confirmed in the propensity-matched populations. During follow-up, more patients in the biologic composite conduit group underwent reoperation on the aortic valve (2.6% vs 1.5%; P = 0.026) resulting in a freedom from reoperation of 97.4% vs 98.5%, respectively. Separate analysis for patients stratified by age revealed no difference in outcomes. CONCLUSIONS: In case of aortic root aneurysm, both valve-sparing operations and root replacement with a biologic composite conduit provide excellent outcomes. However, at mid-term follow-up the use of biologic composite conduit is associated with a higher risk of reoperation.