Selection of prosthetic aortic valve and root replacement in patients younger than age 30 years.

OBJECTIVE: Long-term outcomes of prosthetic aortic valve/root replacement in patients aged 30 years or younger are not well understood. We report our single institutional experience in this young cohort. METHODS: From 1998 to 2016, 99 patients (age range, 16-30 years) underwent aortic valve replacement (n = 57), aortic valve replacement and supracoronary ascending aorta replacement (n = 6), or aortic root replacement (n = 36). A prospectively maintained aortic valve database was retrospectively reviewed to complete longitudinal functional and clinical data. Total follow-up was 493 patient years. RESULTS: Surgical indications included primary stenosis/insufficiency (52% [n = 51]), Marfan syndrome (10% [n = 10]), and endocarditis (33.3% [n = 33]). Fifty-eight patients (59%) underwent mechanical valve replacement, with 41 patients (41%) receiving a biologic/bioprosthetic valve. Twenty-five patients underwent aortic valve reoperation after index procedure with following indications: prosthesis-patient mismatch 1.0% (n = 1), prosthetic valve degeneration/dysfunction 10% (n = 10), connective tissue 2% (n = 2), and endocarditis 12% (n = 12). Mortality (30-day/in-hospital) and stroke rate were 3.0% (n = 3) and 1% (n = 1), respectively. One-, 5-, and 10-year actuarial freedom from aortic valve reoperation by valve type was 89.1%, 84.6%, and 69.4% for the Mechanical Valve group and 89.6%, 70.9%, and 57.6% for the Biologic/Bioprosthetic Valve group, respectively (log rank P = .279). Replacement valve size ≤21 mm was a significant risk factor for reoperation, and was associated with progression of mean aortic valve transvalvular gradients over follow-up. Valve type had no effect. CONCLUSIONS: The choice of mechanical versus biologic/bioprosthetic valve does not affect freedom from reoperation or survival rates in this young cohort during mid- to long-term follow-up. Smaller aortic valve replacement size (≤21 mm) is a significant risk factor for reoperation and progression of mean aortic valve gradients.

Predictors of Recurrent Aortic Insufficiency in Type I Bicuspid Aortic Valve Repair.

BACKGROUND: Annular stabilization techniques in bicuspid aortic valve (BAV) repair include valve-sparing root reimplantation (VSRR), external subannular aortic ring (ESAR), and subcommissural annuloplasty (SCA). Unlike VSRR that offers neoroot creation, ESAR and SCA offer annular reduction only. We compared long-term functional outcomes to understand BAV repair durability. METHODS: From 2004 to 2017, 137 patients underwent Sievers type I BAV repair (VSRR, n = 54; ESAR, n = 22; SCA, n = 51). Prospectively maintained BAV repair database was queried for clinical and functional outcomes. Data were analyzed by logistic regression, threshold regression, multistate survival, and transition models for BAV repair durability. RESULTS: VSRR patients had larger preoperative sinus dimensions (p < 0.001), but mean preoperative annulus size was similar for VSRR, ESAR, and SCA (29.3 ± 3.7 mm, 29.8 ± 3.8 mm, and 29.7 ± 3.8mm, respectively; p = 0.807). Degree of annular reduction (p = 0.280) was comparable between the groups. Intraoperative postrepair freedom from aortic insufficiency (AI) 1+ or greater was 100% across the entire cohort. By logistic regression, important predictors of recurrent AI (1+ and ≥2+) were preoperative annulus of 30 mm or more for SCA. Threshold regression confirmed annulus of 30 mm or more as risk factor for recurrent AI of 1+ or greater for SCA. Risk to relapse from no AI to AI 1+ was equal between the groups; however, once AI 1+ was reached, there was a 2.5-fold increased risk for patients with annulus of 30 mm or more who underwent SCA to progress to recurrent AI of 2+ or greater. CONCLUSIONS: VSRR is associated with improved longitudinal BAV durability compared with SCA. Preoperative annulus diameter of 30 mm or more is associated with increased recurrent AI, especially for SCA patients. For annular indications, ESAR might offer comparable functional outcomes with VSRR; however, further follow-up is critical.

Fate of remnant sinuses of Valsalva in patients with bicuspid and trileaflet valves undergoing aortic valve, ascending aorta, and aortic arch replacement.

OBJECTIVE: In patients presenting with aortic valvulopathy with concomitant ascending aortic aneurysm, surgical management of the sinus of Valsalva segment remains undefined, especially for moderately dilated aortic roots. In patients with this pathology undergoing aortic valve replacement with supracoronary ascending aorta replacement, we assessed the fate of the remnant preserved sinus of Valsalva segment stratified by aortic valve morphology and pathology. METHODS: From 2002 to 2015, 428 patients underwent elective aortic valve replacement with supracoronary ascending aorta replacement. Patients were stratified on the basis of valvular morphology (bicuspid aortic valve [n = 254] and tricuspid aortic valve [n = 174]), valvular pathology (bicuspid aortic valve with aortic stenosis [n = 178], bicuspid aortic valve with aortic insufficiency [n = 76], tricuspid aortic valve with aortic stenosis [n = 61], tricuspid aortic valve with aortic insufficiency [n = 113]), and preoperative sinus of Valsalva dimensions (<40, 40-45, >45 mm). RESULTS: Kaplan-Meier analysis revealed no significant difference in freedom from reoperation in tricuspid aortic valve versus bicuspid aortic valve (P = .576). Multivariable Cox regression model performed with sinus of Valsalva dimensions at baseline and follow-up as time-varying covariates did not adversely affect survival. A repeated-measure, mixed-effects model constructed to assess longitudinal sinus of Valsalva trends revealed that the retained sinus of Valsalva dimensions remain stable over long-term follow-up (discharge to ≥10 years), irrespective of valvular morphology/pathology (bicuspid aortic valve with aortic insufficiency, tricuspid aortic valve with aortic insufficiency, tricuspid aortic valve with aortic stenosis) and preoperative sinus of Valsalva groups (<40, 40-45, >45 mm). CONCLUSIONS: In patients with nonaneurysmal sinuses of Valsalva undergoing aortic valve replacement with supracoronary ascending aorta replacement, the sinus segment can be preserved irrespective of the type of valvular pathology (aortic stenosis vs aortic insufficiency) or valvular morphology (bicuspid aortic valve vs tricuspid aortic valve). Aortic valve replacement with supracoronary ascending aorta replacement may have a stabilizing effect on the sinus segment over long-term follow-up in patients with tricuspid aortic valves or bicuspid aortic valves.

Have hybrid procedures replaced open aortic arch reconstruction in high-risk patients? A comparative study of elective open arch debranching with endovascular stent graft placement and conventional elective open total and distal aortic arch reconstruction.

OBJECTIVE: Open total arch procedures have been associated with significant morbidity and mortality in patients with multiple comorbidities. Aortic arch debranching with endovascular graft placement, the hybrid arch procedure, has emerged as a surgical option in this patient population. This study evaluates the outcomes of a contemporary comparative series from one institution of open total arch and hybrid arch procedures for extensive aortic arch pathology. METHODS: From July 2000 to March 2009, 1196 open arch procedures were performed, including 45 elective and 7 emergency open total arch procedures. From 2005 to 2009, 64 hybrid arch procedures were performed: 37 emergency type A dissections and 27 elective open arch debranchings. Hemiarch procedures were excluded. RESULTS: The hybrid arch cohort was significantly older (P = .008) and had greater predominance of atherosclerotic pathophysiology (P < .001). The incidence of permanent cerebral neurologic deficit was similar at 4% (1/27) for the hybrid arch cohort and 9% (4/45) for the open aortic arch cohort. In-hospital mortality was similar at 11% (3/27) for the hybrid arch cohort and 16% (7/45) for the open aortic arch cohort. However, in the open arch group, there was a significant difference in mortality between patients aged less than 75 years at 9% (3/34) and patients aged more than 75 years at 36% (4/11) (P = .05). CONCLUSIONS: Hybrid arch procedures provide a safe alternative to open repair. This study suggests the hybrid arch approach has a lower mortality for high-risk patients aged more than 75 years. This extends the indication for the hybrid arch approach in patients with complex aortic arch pathology previously considered prohibitively high risk for conventional open total arch repair.

Retrograde and antegrade cerebral perfusion: results in short elective arch reconstructive times.

BACKGROUND: Debate remains regarding optimal cerebral circulatory management during relatively noncomplex, short arch reconstructive times. Both retrograde cerebral perfusion with deep hypothermic circulatory arrest (RCP/DHCA) and antegrade cerebral perfusion with moderate hypothermic circulatory arrest (ACP/MHCA) have emerged as established techniques. The aim of the study was to evaluate perioperative outcomes between antegrade and retrograde cerebral perfusion techniques for elective arch reconstruction times less than 45 minutes. METHODS: Between 1997 and September 2008, 776 cases from two institutions were reviewed to compare RCP/DHCA and ACP/MHCA perfusion techniques. At the University of Pennsylvania, 682 were treated utilizing RCP/DHCA cerebral protection. At the University of Bologna, 94 were treated with ACP/MHCA and bilateral cerebral perfusion. RESULTS: Mean cerebral ischemic time and visceral ischemic time differed between RCP/DHCA and ACP/MHCA (p < 0.001). Multivariate analysis showed age more than 65 years, atherosclerotic aneurysm, and cross-clamp time as predictors of the composite endpoint of mortality, neurologic event, and acute myocardial infarction. There was no significant difference in permanent neurologic deficit, temporary neurologic dysfunction, or renal failure, between RCP/DHCA and ACP/MHCA. Mortality was comparable across both techniques. CONCLUSIONS: Both RCP/DHCA and ACP/MHCA have emerged as effective techniques for selected aortic arch operations with low morbidity and mortality. Univariate analysis revealed no statistically significant differences in primary or secondary outcomes between techniques for aortic reconstruction times less than 45 minutes. Data from this study demonstrate that selective use of either RCP/DHCA or ACP/MHCA provides excellent cerebral and visceral outcomes for elective open aortic surgery with short arch reconstructive times.