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.

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.

The percutaneous coronary angioplasty gets better, but the surgical coronary artery bypass does not stay behind.

Coronary artery bypass grafting remains one of the most frequently performed cardiac operations, with well-established prognostic benefits in patients with multivessel coronary artery disease and left main disease. Despite an increasingly higher patients' risk profile, the results of this procedure have significantly improved over time, with an evident and striking decrease in operative mortality and peri-operative complications. A fair amount of technical and technological refinements has further improved the short- and long-term results of coronary artery bypass surgery. The improvements in the beating heart coronary surgery and aortic 'no-touch' technique, in the appropriate use of conduits (bilateral internal mammary artery, radial artery, and composite conduits configuration), and in the optimization of venous grafts' patency are reviewed.

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.

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.

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 completion Bentall procedure: aortic root and ascending aorta replacement after prior aortic valve replacement]. / "Completion Bentall": sostituzione della radice e dell'aorta ascendente in un paziente già portatore di protesi valvolare aortica.

We describe the case of a patient with an ascending aorta and aortic root aneurysm who underwent aortic valve replacement, 14 years earlier, with a mechanical prosthesis, which was normally functioning at time of reoperation. We describe the "completion Bentall" technique - a modified Bentall technique -, a procedure for prosthesis-sparing aortic root replacement. This technique simplifies the original procedure in reinterventions, reducing complication rates and aortic cross-clamping and cardiopulmonary bypass times, with a good surgical result.

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.

Long-term follow-up of Bentall procedure using the Perimount bioprosthesis and the Valsalva graft.

OBJECTIVES: Bentall procedure is the gold standard for aortic root pathologies when valve repair is not feasible. The development of durable bioprosthetic valves and improved vascular conduits allowed the implementation of bioprosthetic composite grafts; hereby, we performed a retrospective analysis of long-term follow-up of Bentall procedure using the Valsalva graft and the Perimount Magna Ease prosthesis. METHODS: From June 2000 to March 2019, 309 patients received an aortic root and valve replacement with a bioprosthetic composite graft. The mean age was 69 ± 6.9 years, and the majority were men (88%); most of them were affected by aortic stenosis (86%) and the mean aortic root diameter was 48.6 ± 5.5 mm. RESULTS: Freedom from cardiac death was 76.8% [confidence interval (CI) 32.5-94.0] at 16 years. Freedom from thromboembolism, haemorrhage, structural valve deterioration and infective endocarditis was 98.2% (CI 96.0-98.9), 95.2% (CI 87.1-98.2), 87.5% (CI 63.2-97.1) and 79.6% (CI 45.3-95.6) at 16 years, respectively. Freedom from reoperation was 74.7% (CI 41.9-90.6). CONCLUSIONS: These data indicate that, in experienced centres, the Bentall procedure is a safe and effective intervention. This is the first long-term follow-up that analyses the results after implantation of a composite graft made with the Perimount Magna Ease aortic valve and the Valsalva graft.

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.

Valve sparing root replacement: an update.

PURPOSE OF REVIEW: Until the year 2000, the publications concerning aortic valve sparing (AVS) did not exceed 20 articles; in the following years almost 300 publications have appeared. Over 35 years from the introduction of valve sparing techniques and 500 years after the death of Leonardo da Vinci, this review highlights the significant steps in modern imaging techniques and the excellent clinical results in the field of reconstructive aortic root surgery. RECENT FINDINGS: AVS operations underwent significant modifications over the last few years making it reproducible with satisfactory outcomes. The extraordinary potential of imaging opens new boundless horizons in the perspective of an increasingly patient-tailored surgical planning. The basic surgical concepts include the preservation and resuspension of the aortic valve in a near-normal environment (with the creation of functionally suited neo-aortic sinuses) and the re-establishment of a normal relationship of the aortic root components. SUMMARY: Today is possible to perform a reimplantation procedure with the creation of neo-sinuses or a remodeling procedure with the addition of annular support. Both procedures can now guarantee an anatomical root reconstruction and an increased long-term durability. AVS operations have become established alternatives to Bentall procedures for patients with aortic root pathology, especially in young patients.

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.

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.

Perspective: valve sparing root repair: tips and tricks.

The remodeling and the reimplantation procedures were described 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, and development of surgical approaches to cusp disease with varying cusp anatomy. The main advantage of the reimplantation is the resulting annular support, and the disadvantages are the unfavorable hemodynamics and relatively longer procedural time. Conversely, the main advantages of remodeling are the physiological hemodynamics and the shorter procedural time, and the disadvantage is the lack of annular support. With technical advances and modifications, however, the differences between these two procedures have narrowed. Today preference for a reimplantation procedure is based on the perception of a better reproducibility of the surgical procedure, an increased procedural safety due to the characteristic hemostatic feature of this surgical approach, the possibility of achieving favorable hemodynamics, and a much larger amount of data present in the literature on long-term results.

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.

The fate of small-size pericardial heart valve prostheses in an older patient population.

BACKGROUND: Structural valve deterioration (SVD) is the Achilles' heel of bioprostheses. Its correlation with younger age is well known. In recent years we exclusively reserved use of small-size Mitroflow valve prostheses (LivaNova, London, United Kingdom) to an older patient population with small aortic annuli. This study aimed to assess the incidence of SVD and its effect on patient survival and need for reoperation. MATERIALS AND METHODS: Two hundred five patients (aged 75.9 ± 5.3 years; range, 62-92 years) underwent aortic valve replacement with a 19-mm or 21-mm Mitroflow valve prosthesis between 2005 and 2011. The great majority was female (n = 170; 83%). In half of patients it was an isolated procedure. All valve prostheses were implanted in a supra-annular position using pledgeted sutures. A 19-mm valve was implanted in 93 patients (45.3%), whereas in 112 patients (54.6%) a 21-mm valve was used. RESULTS: Twenty-three patients (11.2%) were diagnosed with early SVD by echocardiography. Average time from surgery to diagnosis of SVD was 64.3 ± 26.8 months. Ten patients needed a reoperation for SVD. Average time from surgery to a second operation was 45.7 ± 35.7 months. Overall survival was 64.5% and 42.3% at 5 and 9 years, respectively. Cumulative freedom from SVD at 5 and 9 years was 94.8% ± 1.6% and 77.4% ± 5.4%, respectively. In 4 patients death was linked to the presence of SVD. There were no differences in mortality, reoperation, or SVD between the 2 Mitroflow valve sizes. CONCLUSIONS: Small-size Mitroflow pericardial valve prostheses have shown a worrisome incidence of SVD even in patients aged >70 years. Based on this experience we have discontinued their use.