Valve-preserving aortic replacement: does the additional repair of leaflet prolapse adversely affect the results?

OBJECTIVE: Valve-preserving aortic replacement has evolved into an accepted therapeutic option for aortic ectasia with morphologically intact leaflets. Some patients, however, exhibit additional leaflet prolapse. We compared the results of established valve-preserving techniques with those of the combination of valve-preserving aortic surgery and additional repair of leaflet prolapse. METHODS: Between October 1995 and March 2000, 99 patients underwent valve-preserving root replacement by means of root remodeling or valve reimplantation for acute dissection (n = 25), chronic dissection (n = 4), or aneurysm (n = 70). In group A (63 patients) either root remodeling (n = 49) or valve reimplantation (n = 14) was performed with a standard technique. In group B (36 patients) valvepreserving aortic replacement (remodeling, n = 31; reimplantation, n = 5) was combined with repair of leaflet prolapse in the presence of bicuspid (n = 24) or tricuspid (n = 12) valve anatomy. Additional replacement of the aortic arch was required more frequently in group A (group A, n = 43; group B, n = 14; P =.006); otherwise, the groups were comparable. RESULTS: Cardiopulmonary bypass (group A, 133 +/- 31 minutes; group B, 117 +/- 30 minutes; P =.006) and myocardial ischemia times (group A, 96 +/- 25 minutes; group B, 88 +/- 20 minutes; P =.05) were significantly longer in group A. Mortality was not significantly different between groups (group A, 4.8%; group B, 0%). One patient in each group underwent secondary valve replacement, and all other patients had stable valve function. Freedom from aortic regurgitation of grade 2 or greater after 48 months was 93.0% in both groups. CONCLUSION: Repair of leaflet prolapse in conjunction with valve-preserving root replacement leads to midterm results that are equal to those of valve-preserving root replacement for morphologically intact leaflets.

Valve-preserving operation in acute aortic dissection type A.

BACKGROUND: The standard treatment in patients with acute aortic dissection type A (AADA) and aortic regurgitation is either supracommissural aortic or composite replacement of ascending aorta and valve. Valve-preserving surgical procedures provide a promising alternative. We retrospectively analyzed midterm results after these different approaches. METHODS: From October 1995 to December 1999, 52 patients (35 men, 17 women) underwent repair of AADA. Patient ages ranged from 30 to 83 years. Composite replacement was chosen for degenerated aortic valves or prior valve replacement (group A; n = 8). With normal root diameter, supracommissural replacement of the ascending aorta was performed (group B; n = 22). For preexisting root dilatation the aortic root was either remodeled (root diameter 30 to 50 mm, group C; n = 17) or the valve reimplanted within a vascular graft (root diameter more than 50 mm, group D; n = 5). RESULTS: All patients underwent either proximal (n = 46) or total (n = 6) arch replacement under circulatory arrest. Eight patients (15.4%) died (group A: n = 3; group B: n = 3; group C: n = 2). Freedom from aortic regurgitation of grade 2 or more at 2 years was 100% in groups A and D, 90.9% in group C, and 75% following supracommissural replacement. At 2 years freedom from proximal reoperation was 100% in groups A, C, and D and 84.5% in group B. CONCLUSIONS: In AADA valve-preserving root replacement leads to improved stability of aortic valve function without an increased operative risk. Midterm results are promising and may show further superiority over supracommissural aortic replacement in the future.

Remodeling of the aortic root and reconstruction of the bicuspid aortic valve.

BACKGROUND: Currently, isolated reconstruction of a regurgitant bicuspid aortic valve can be performed with adequate early results. Dilatation of the proximal aorta is known to be associated with this valve anomaly and may be partially responsible for the development of primary regurgitation or secondary failure of valve repair. We have used repair of the bicuspid valve with remodeling of the aortic root as an alternative to insertion of a composite graft. METHODS: Between October 1995 and May 1999, 16 patients (12 men, 4 women, aged 35 to 73 years) were seen with a regurgitant bicuspid aortic valve and dilatation of the proximal aorta of more than 50 mm. All patients underwent repair of the valve using either coapting sutures alone (n = 12) or in combination with triangular resection of a median raphe (n = 4). Using a Dacron graft, the aortic root was remodeled and the ascending aorta (n = 16) and proximal arch (n = 4) replaced. RESULTS: No patient died. The postoperative degree of aortic regurgitation was less than grade II in all patients. Valve function has remained stable in all patients between 2 and 43 months postoperatively. CONCLUSIONS: Reconstruction of the regurgitant bicuspid valve in the presence of proximal aortic dilatation is feasible with good results by combining the root remodeling technique with valve repair.

[Quality in aortic valve replacement--how good have hybrid valves have to be?]. / Qualität der chirurgischen Behandlung von Aortenklappenvitien. Welche Verbesserungen sind von Hybridklappen zu erwarten?

The current enthusiasm with the development of catheter-based aortic valve replacement suggests a critical appraisal of the quality of conventional techniques. Currently surgical treatment of diseased aortic valves includes different methods that can be employed with a low risk. Risk prediction is difficult, the Euroscore largely overestimates mortality. By comparison, there is no evidence that the risk of implantation is reduced by catheter-based implantation. Specific complications (stroke, AV-block, perivalvular leak) are more frequent compared to conventional replacement. Despite the current enthusiasm over the feasibility of catheter-based implantation of hybrid aortic valves they should still be used cautiously.

Valve repair in aortic regurgitation without root dilatation--aortic valve repair.

BACKGROUND: Aortic valve repair was established in the context of aortic root remodeling. Variable results have been reported for isolated valve repair. We analyzed our experience with isolated valve repair and compared the results with those of aortic root remodeling. METHODS: Between October 1995 and August 2003, isolated repair of the aortic valve was performed in 83 patients (REP), remodeling of the aortic valve in 175 patients (REMO). The demographics of the two groups were comparable (REP: mean age 54.4 +/- 20.7 yrs, male-female ratio 2.1 : 1; REMO: mean age 60.8 +/- 13.6 yrs, male-female ratio 2.4 : 1; p = ns). In both groups the number of bicuspid valves was comparable (REP: 41 %, REMO: 32 %; p = ns). All patients were followed by echocardiography for a cumulative follow-up of 8204 patient months (mean 32 +/- 23 months). RESULTS: Overall in-hospital mortality was 2.4 % in REP and 4.6 % in REMO ( p = 0.62). Systolic gradients were comparable in both groups (REP: 5.8 +/- 2.2, REMO: 6.5 +/- 3.1 mm Hg, p = 0.09). The mean degree of aortic regurgitation 12 months postoperatively was 0.8 +/- 0.7 after REP and 0.7 +/- 0.7 after REMO ( p = 0.29). Freedom from significant regurgitation (> or = II degrees ) after 5 years was 86 % in REP and 89 % in REMO ( p = 0.17). Freedom from re-operation after 5 years was 94.4 % in REP and 98.2 % in REMO ( p = 0.33). CONCLUSIONS: Aortic regurgitation without concomitant root dilatation can be treated effectively by aortic valve repair. The functional results are equivalent to those obtained with valve-preserving root replacement. Aortic valve repair appears to be an alternative to valve replacement in aortic regurgitation.

[Progression of an intramural hematoma to dissection]. / Progression eines intramuralen Hämatoms zur Dissektion.

Intramural hematoma is a spontaneous, localized bleeding in the wall of the thoracic aorta without evidence of intimal tear. Clinically, intramural hematoma manifests itself as an acute thoracical pain in patients with hypertension and therefore shows parallels with the classical aortic dissection. In the literature there is controversial discussion whether intramural hematoma can be regarded as its own aortic pathology or a precursor in the development of classical aortic dissection. We present the case of a 66 year old male who showed an intramural hematoma of the descending aorta which rapidly progressed to classical dissection within 3 months. This finding was secondarily accompanied by a dilatation of the descending aorta which leads to operative treatment with replacement of the proximal aorta descendens. This case supports the hypothesis that intramural hematoma is a potential early manifestation of aortic dissection and at the same time stresses the necessity for frequent follow-up investigations and, if necessary, early operative therapy.

Mid-term results of aortic valve preservation: remodelling vs. reimplantation.

OBJECTIVE: Valve-preserving root replacement has become an accepted alternative to composite replacement both in dissection and in aneurysmal disease. We retrospectively analysed 5-year results comparing root remodelling and reimplantation procedures. METHODS: From October 1995 to January 2001, 119 patients underwent either root remodelling (group A; n = 98; age: 61 +/- 14 years) or valve reimplantation within a vascular graft (group B; n = 21; age: 47 +/- 17 years). In group A, 26 patients were operated for aortic dissection type A and 72 for aortic valve regurgitation and aneurysmal disease. In group B, 8 patients were operated for aortic dissection type A, 13 for aortic valve regurgitation and aneurysm. Concomitant arch surgery was performed in 65 patients (group A: 57; group B: 8). RESULTS: Time on cardiopulmonary bypass was 121 +/- 30 min in group A, 143 +/- 24 min in group B, and aortic cross-clamp time was 87 +/- 19 min in group A and 113 +/- 24 min in group B. Average duration was therefore longer in group B (p = n.s.) Hospital mortality was 3.1 % in group A and 0 % in group B. Following elective procedures, hospital mortality was 1.1 % in group A. Freedom from aortic regurgitation over grade 2 at 4 years was 86 % in group A and 94.7 % in group B. At 4 years, freedom from proximal reoperation was 97.8 % in group A and 100 % in group B. There was no deterioration of valve function or need for reoperation observed after 1 year in either group. CONCLUSION: Five-year results are comparable and encouraging for remodelling and reimplantation procedures. If the initial valve function and geometry is adequate, the chance of secondary failure beyond the first year is minimal.

[Reconstruction of the bicuspid aortic valve]. / Rekonstruktion der bikuspiden Aortenklappe.

Reconstruction of a regurgitant bicuspid aortic valve is a new alternative to aortic valve replacement. With concomitant aortic root dilatation adequate reconstruction is feasible by valve-sparing aortic replacement. Between 10/95 and 02/00, 30 patients underwent reconstruction of a regurgitant bicuspid aortic valve. Additional aortic replacement was performed in 23 cases. Valve reconstruction was performed by plication of the prolapsing leaflet. No patient died peri- or postoperatively. Freedom from aortic valve regurgitation > or = II as well as freedom from reoperation were 100% after 48 months. Reconstruction of a regurgitant bicuspid aortic valve is feasible with encouraging mid-term results. With concomitant dilatation of the ascending aorta, a combination of aortic replacement and valve reconstruction can achieve stable results even in bicuspid valve anatomy.