ABSTRACT
INTRODUCTION: Conventional aortic root and valve-sparing root replacement surgery are two current surgical treatments for aortic dilatation syndromes. This review article aims to review the current literature surrounding these two established techniques. AREAS COVERED: This review article will address the current indications for valve-sparing root replacement surgery, technical considerations in surgical planning and a comparison of clinical outcomes between these two surgical techniques. EXPERT OPINION: Valve-sparing root replacement surgery is a safe and established treatment for aortic syndromes. Valve-sparing surgery procedure avoids the inherent risk of prosthetic valve dysfunction and prosthesis infection by preserving the native aortic valve compared to conventional aortic root surgery. This has been demonstrated in various observational studies and should be considered in clinically and anatomically appropriate patients. Other technical considerations, such as reimplantation versus remodeling technique and aortic cusp repair in select patients, may impact in short-term procedural and long-term clinical success with valve-sparing surgery.
Subject(s)
Aortic Diseases , Aortic Valve Insufficiency , Heart Valve Prosthesis Implantation , Humans , Syndrome , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis Implantation/methods , Aorta, Thoracic/surgery , Dilatation/adverse effects , Aortic Valve/surgery , Aortic Diseases/surgery , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Treatment Outcome , Aortic Valve Insufficiency/surgery , Retrospective StudiesABSTRACT
Összefoglaló. Bevezetés: A Marfan-szindróma autoszomális domináns módon öröklodo, szisztémás kötoszöveti betegség. A hosszú távú túlélés szempontjából fontos a nagyérkatasztrófák megelozése. Szívsebészeti szempontból a legfontosabb elváltozás az aortagyök tágulata. Aortagyök-rekonstrukciós beavatkozásaink Bentall-DeBono-, David I. és módosított Yacoub-mutétek, melyek mind preventív jelleggel, mind dissectio esetén jó eredménnyel végezhetok. Célkituzés: A marfanos betegeknél eltéro technikával végzett aortagyök-rekonstrukciós mutéteink összehasonlítása. Módszer: A Semmelweis Egyetem Városmajori Szív- és Érgyógyászati Klinikáján 1993 és 2020 között Marfan-szindrómásoknál elvégzett Bentall-DeBono-, David I. és módosított Yacoub-féle aortagyök-rekonstrukciókat elemeztük. A mutét szerinti csoportok életkora a beavatkozás idején 29,69 (21,98-41,25) év, 29,15 ± 11,99 év és 35,29 ± 14,14 év volt, a fenti sorrendben. Az adatok forrásául a Magyar Marfan Regiszter és az Aortagyök-rekonstrukciós Regiszter szolgált. Eredmények: Az utánkövetési ido 132 ± 81,04 hónap volt a Bentall-, 76 ± 27,77 hónap a David-, valamint 4,5 (0,75-11,75) hónap a Yacoub-mutét esetén. A David- és a Yacoub-beavatkozások gyakrabban voltak profilaktikusak, mint a Bentall-operációk (p = 0,0153; p = 0,0085). A Bentall-mutéteknél ritkább volt a primer mutét esetleges késobbi elégtelenségébol fakadó reoperáció, mint a David-operációknál (p<0,001). David-beavatkozásnál a Bentall-mutéthez képest hosszabb volt a cardiopulmonaris bypass (p = 0,0013) és az aortalefogás ideje (p = 0,0048), valamint David- és Yacoub-mutét esetén gyakrabban lépett fel korai posztoperatív szövodmény, mint Bentall-operációnál (p = 0,0005; p = 0,0037). A késoi szövodmények és a túlélés tekintetében a csoportok nem különböztek. Következtetés: Marfan-szindrómában a leggyakrabban halált okozó szövodmény az akut aortaruptura, illetve akut aortadissectio. Eredményeink alapján mindhárom profilaktikus aortagyök-rekonstrukciós mutéti típus jól reprodukálható és jó eredménnyel végezheto Marfan-szindrómában. Orv Hetil. 2021; 162(18): 696-704. INTRODUCTION: Marfan syndrome is an autosomal dominant, systemic connective tissue disorder. Preventing vascular complications is essential for long-term survival. Aortic dilation is the main cardiac surgical manifestation. Bentall-DeBono, David I and modified Yacoub aortic root reconstructions treat and prevent aortic dissections with great outcomes. OBJECTIVE: Comparing results of aortic root reconstructions in Marfan syndrome. METHOD: We analysed the data of Bentall-DeBono, David I and modified Yacoub operations performed in Marfan syndrome at the Heart and Vascular Center, Semmelweis University between 1993 and 2020. Ages of surgical groups at the time of operation were 29.69 (21.98-41.25) years, 29.15 ± 11.99 years and 35.29 ± 14.14 years, respectively. Data were obtained from the Hungarian Marfan Register and the Aortic Root Reconstruction Register. RESULTS: Follow-up time was 132 ± 81.04 months for Bentall, 76 ± 27.77 months for David and 4.5 (0.75-11.75) months for Yacoub groups. David and Yacoub operations were prophylactic more frequently than Bentall ones (p = 0.0153; p = 0.0085). Freedom from reoperation after primary surgery insufficiency was more common for Bentall than for David procedure (p<0.001). Compared to Bentall, David surgeries required longer cardiopulmonary bypass (p = 0.0013) and aortic cross clamp time (p = 0.0048), more early postoperative complications occurred after David and Yacoub, than after Bentall operations (p = 0.0005; p = 0.0037). Late complications and survival did not differ among the groups. CONCLUSION: In Marfan syndrome, acute aortic rupture and dissection are the main contributors to mortality. Based on our results, the prophylactic aortic root reconstructions are reproducible and can be performed with great outcomes. Orv Hetil. 2021; 162(18): 696-704.
Subject(s)
Marfan Syndrome , Adult , Humans , Hungary , Postoperative ComplicationsABSTRACT
A neoaortic aneurysm after a Norwood type reconstruction of the aorta can develop due to systemic pressure on the former pulmonary artery wall. A complex valve sparing procedure can preserve native valves and avoid a valve replacement with requirement for anticoagulation. This type of operation was carried out in 3 patients, 2 of them after a Fontan palliation, 1 after a Norwood-Rastelli repair. The reconstruction was done using Dacron prostheses for the replacement of the dilated wall, similar to a Yacoub modification in 2 cases and to a David's modification in 1 patient. The postoperative course was uneventful and postoperative valve function was good in all cases.
Subject(s)
Aortic Valve Insufficiency , Aorta/diagnostic imaging , Aorta/surgery , Aortic Valve/diagnostic imaging , Aortic Valve/surgery , Fontan Procedure , Humans , Pulmonary Artery/diagnostic imaging , Pulmonary Artery/surgery , ReplantationABSTRACT
BACKGROUND: Valve sparing aortic root reconstruction (VSARR) has become an alternative to traditional aortic root replacement with a valved conduit. There have been various modifications but the two broad types are aortic root reimplantation and the aortic root remodelling procedure. We present the early and late outcomes following valve sparing aortic root reconstruction surgery in Australia. METHODS: We reviewed the ANZSCTS database for patients undergoing these procedures. Preoperative, intraoperative and postoperative variables were analysed. Multivariable regression was performed to determine independent predictors of 30-day mortality. We also obtained five- and 10-year survival estimates by cross-linking the ANZSCTS database with the Australian Institute of Health and Welfare's National Death Index. RESULTS: Between January 2001 and January 2012, 169 consecutive patients underwent VSARR procedures. The mean age of the study population was 54.4 years with 31.4% being females. Overall, nine patients (5.9%) died within 30 days post procedure and five patients (3%) had permanent strokes. However, out of 132 elective cases, only five patients died (3.8%). Independent predictors of 30-day mortality were female gender [OR 5.65(1.24-25.80), p=0.025], preoperative atrial arrhythmia [OR 6.07(1.14-32.35), p=0.035] and acute type A aortic dissection [OR 7.71(1.63-36.54), p=0.01]. Long-term survival was estimated as 85.3% and 72.7% at five- and 10-years, respectively. CONCLUSIONS: Along with an acceptable rate of early mortality and stroke, VSARR procedures provide good long-term survival according to the ANZSCTS database. As promising procedure for pathologies that impair the aortic root integrity, they can be adopted more widely, especially in Australian and New Zealand centres with experienced aortic units. Future studies are planned to assess freedom from valve deterioration and repeat surgery.
