Native Aortic Valve Resection Using a Novel Blade-Based Device.

OBJECTIVE: The aim of this study was to validate the use of a new resection device in patient candidates for surgical aortic valve replacement. We evaluated the efficacy of this new circular blade to resect the aortic valve and the efficacy to collect the debris during the resection. METHODS: For this study, a single size instrument was used, with an external diameter of 22 mm, and patients were selected on the basis of the preoperative assessment of the aortic diameters. RESULTS: From October 2018 to June 2019, 10 patient candidates for surgical aortic valve replacement were selected to undergo native aortic valve resection using a new device, before surgical valve implantation. The mean age of the patients was 74 ± 7.6 years, and 8 of 10 were male. The mean aortic annulus diameter, measured before the procedure, was 25.7 ± 1.57 mm. The resection was complete in 9 (90%) patients. In 1 patient, due to an imprecise positioning of the device, the valve resection was partial. None of the patients showed signs or symptoms due to debris embolism. In all patients, the postoperative course was uneventful. CONCLUSIONS: These preliminary results show that resection of the aortic valve using a circular foldable blade is feasible. This prototype, used during conventional surgery even through a small incision, provided an efficient tool to easily resect the valve without debris release.

[Summary: International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes]. / Resumen: Consenso internacional para la nomenclatura y clasificación de la válvula aórtica bicúspide congénita y su aortopatía, con fines clínicos, quirúrgicos, intervencionistas y de investigación.

This consensus of nomenclature and classification for congenital bicuspid aortic valve and its aortopathy is evidence-based and intended for universal use by physicians (both pediatricians and adults), echocardiographers, advanced cardiovascular imaging specialists, interventional cardiologists, cardiovascular surgeons, pathologists, geneticists, and researchers spanning these areas of clinical and basic research. In addition, as long as new key and reference research is available, this international consensus may be subject to change based on evidence-based data1.

Este consenso de nomenclatura y clasificación para la válvula aórtica bicúspide congénita y su aortopatía está basado en la evidencia y destinado a ser utilizado universalmente por médicos (tanto pediatras como de adultos), médicos ecocardiografistas, especialistas en imágenes avanzadas cardiovasculares, cardiólogos intervencionistas, cirujanos cardiovasculares, patólogos, genetistas e investigadores que abarcan estas áreas de investigación clínica y básica. Siempre y cuando se disponga de nueva investigación clave y de referencia, este consenso internacional puede estar sujeto a cambios de acuerdo con datos basados en la evidencia1.

Valve-sparing operations after Ross procedure: a single-center experience.

Background: The Ross procedure has demonstrated excellent long-term results, with restoration of life-expectancy in patients with severe aortic valve dysfunction. However, reintervention after Ross can occur, and herein we describe our center's experience with redo surgery after previous Ross procedures. Methods: We searched our prospective database for aortic valve-repair and recruited all adult (≥18 years) patients who have undergone valve-sparing root replacements (VSRRs) and/or aortic valve-repair after Ross procedure between July 2001 and July 2022. Univariable logistic regression analysis was performed to identify variables affecting early mortality. Survival, freedom-from-valve-reintervention and freedom-from-aortic regurgitation (AR) grade ≥3 were analyzed with the Kaplan-Meier method. Results: A total of 63 patients were recruited for this study. Indication for reoperation after Ross was aortic aneurysm without AR in 17 (27%), aortic aneurysm with AR in 27 (43%), and isolated AR in 19 (30%) patients. Median follow-up time was 7.82 years. The majority of patients (76%) had undergone the free root technique during their index Ross operation. Cumulative survival, after redo surgery following Ross, was 98.4% [95% confidence interval (CI): 89.3-99.8%] at 1 year, 96.3% (95% CI: 88.2-98.3%) at 5 years, and 92.4% (95% CI: 87.1-98.0%) at 10 years. Freedom-from-reoperation on the aortic valve at 1 year was 98.4% (95% CI: 97.0-99.8%), at 5 years was 96.7% (95% CI: 87.6-99.0%), and 79.7% (95% CI: 71.1-88.3%) at 10 years. Conclusions: Long-term survival after redo surgery following the Ross operation is excellent. The data support our aggressive valve-sparing approach after Ross.

Tricuspid annular dynamics, not diameter, predicts tricuspid regurgitation after mitral valve surgery: Results from a prospective randomized trial.

Objective: Current guidelines advise using prophylactic tricuspid valve annuloplasty during mitral valve surgery, especially in the presence of annular diameter enlargement. However, several retrospective studies and a prospective randomized study from our department could not confirm that diameter enlargement is predictive of late regurgitation. We examined whether 2- and 3-dimensional echocardiographic and clinical characteristics could identify patients who will develop moderate or severe recurrent tricuspid regurgitation. Methods: Patients with less than severe functional tricuspid regurgitation (FTR) were randomized not to receive tricuspid annuloplasty, and 11 of 53 of them were excluded from the study because 3-dimensional echocardiographic analysis was not possible. Cox regression was used to estimate the model-based probability of moderate or severe FTR (vena contracta ≥3 mm) or progression of TR and FTR regression using valve dimensions (annulus area, diameter perimeter, nonplanar angle, and sphericity index), dynamics (annulus contraction, annulus displacement, and displacement velocity), and clinical parameters as possible predictors. Results: At a median follow-up of 3.8 years (range, 3-5.6 years), 17 patients had moderate or severe FTR or progression, and 13 had FTR regression. Our models identified annular displacement velocity as a significant predictor for FTR recurrence and nonplanar angle as a significant predictor for FTR regression. Conclusions: Annular dynamics, not the dimension, predict recurrence and regression of FTR. Annular contraction should be systematically investigated as a possible surrogate of right ventricle function to prophylactically treat the tricuspid valve.

Functional and pathomorphological anatomy of the aortic valve and root for aortic valve sparing surgery in tricuspid and bicuspid aortic valves.

The aortic valve (AV) is a three-dimensional structure, with leaflets that are suspended within the functional aortic annulus (FAA). These structures (AV and FAA) are therefore intrinsically connected and disease of just one component can independently lead to AV dysfunction. Hence, AV dysfunction can occur in the setting of entirely normal valve leaflets. However, as these structures are functionally inter-connected, disease of one component can lead to abnormalities of the other over time. Thus, AV dysfunction is often multifactorial. Valve-sparing root procedures require an in-depth understanding of these inter-relationships, and herein we are providing a detailed account of some of the most pertinent anatomical relationships.

Three decades of reimplantation of the aortic valve-the Brussels experience.

Background: Over the last three decades, the importance of native valve preservation has increasingly become evident. Valve-sparing root replacement procedures, such as the reimplantation or remodeling technique, are therefore being progressively used for aortic root replacement and/or aortic valve repair. Herein, we are summarizing our single-center experience with the reimplantation technique. Methods: We queried our prospective database for aortic valve repair and recruited all adult (≥18 years) patients who have undergone valve-sparing root replacement with the reimplantation technique between March 1998 and January 2022. We subcategorized the patients into three distinct groups: root aneurysm without aortic regurgitation (AR) (grade ≤1+), root aneurysm with AR (grade >1+) and isolated chronic AR (root <45 mm). Univariable logistic regression analysis was performed to identify variables of interest, which were further analyzed by multivariable Cox-regression analysis. Survival, freedom from valve reintervention, and freedom from recurrent regurgitation, were analyzed with the Kaplan-Meier method. Results: A total of 652 patients were recruited for this study; 213 patients underwent reimplantation for aortic aneurysm without AR, 289 patients for aortic aneurysm with AR, and 150 patients with isolated AR. Cumulative survival was 95.4% (95% CI: 92.9-97.0%) after 5 years, 84.8% (80.0-88.5%) after 10 years, and 79.5% (73.3-84.5%) after 12 years, which was comparable to the age-matched Belgian population. Older age (HR 1.06, P≤0.001) and male gender (HR 2.1, P=0.02) were associated with late mortality. Freedom from reoperation on the aortic valve at 5 years was 96.2% (95% CI: 93.8-97.7%), and 90.4% (95% CI: 87.4-94.2%) at 12 years. Age (P=0.001) and preoperative left ventricular end-diastolic dimension (LVEDD) (P=0.03) were associated with late reoperation. Conclusions: Our long-term data supports our reimplantation approach as a viable option for aortic root aneurysms and/or aortic regurgitation, with long-term survival that mirrors that of the general population.

A multicentre, propensity score matched analysis comparing a valve-sparing approach to valve replacement in aortic root aneurysm: Insight from the AVIATOR database.

OBJECTIVES: Our goal was to evaluate the outcome of valve-sparing root replacement (VSRR) and to compare the outcomes to those of patients having composite valve-graft conduit aortic root replacement (CVG-ARR) in a cohort of patients with aortic root aneurysm ± valve insufficiency, without valvular stenosis. Although valve-sparing procedures are preferable in young patients, there is a lack of comparative data in comparable patients. METHODS: The VSRR procedures were performed in 2005 patients, and 218 patients underwent a CVG-ARR procedure. Exclusion criteria included aortic dissection, endocarditis and valvular stenosis. Propensity score matching (3:1 ratio) was applied to compare VSRR (reimplantation 33% and remodelling 67%) and CVG-ARR. RESULTS: We matched 218 patients with CVG-ARR to 654 patients with VSRR (median age, 56.0; median follow-up was 4 years in both groups; interquartile range 1-5 years). Early mortality was 1.1% of those who had VSRR versus 2.3% in those who had CVG-ARR. Survival was 95.4% [95% confidence interval (CI) 94-97%] at 5 years in patients who had VSRR versus 85.4% (95% CI 82-92%) in those who had CVG-ARR; P = 0.002. Freedom from reintervention at 5 years was 96.8% (95% CI 95-98%) with VSRR and 95.4% (95% CI 91-99%) with CVG-ARR (P = 0.98). Additionally, there were more thromboembolic, endocarditis and bleeding events in the patients who had CVG-ARR (P = 0.02). CONCLUSIONS: This multicentre study shows excellent results after valve-sparing root replacement in patients with an ascending aortic aneurysm with or without valve insufficiency. Compared to composite valve-graft aortic root replacement, survival is better and valve-related events are fewer. Consequently, valve-sparing procedures should be considered whenever a durable repair is feasible. We advocate a valve-sparing strategy even in more complex cases when performed in experienced centres.

Robotic mitral valve repair-the Bruxelles experience.

Background: Although the use of the surgical robot facilitates less invasive mitral valve surgery, both real and perceived limitations have slowed the application of this technology. Aim of the present investigation was to report the early and long-term results of robotic mitral valve repair in a single institution over a 10-year period. Methods: Between March 2012 and May 2022, a total of 278 consecutive patients underwent robotically assisted mitral valve repair at the Cliniques Universitaires Saint-Luc (Brussels, Belgium). Indications have evolved over time allowing the treatment of complex mitral valve lesions. Clinical and echocardiographic follow-up were 97.8% and 86.1% complete, respectively. Results: Mean age of the study population was 57.8±11.9 years and 221/278 (79.5%) patients were male. Despite being asymptomatic or mildly symptomatic [New York Heart Association (NYHA) class I-II], most of the patients presented with severe mitral regurgitation (MR). Degenerative mitral valve disease was the most common cause of MR. All patients underwent successful mitral valve repair using different techniques, and 25/278 (9.0%) had one or more concomitant procedures associated. The mean cardio-pulmonary bypass and aortic cross clamp times were 153±37 and 106±25 minutes, respectively. There was no operative or in-hospital mortality. Overall survival rate was 97.8%±3.2%, 95.8%±3.2% and 93.7%±3.0% at 3, 7 and 10 years. One early (0.4%) reoperation with re-repair was recorded for ring disruption, while late mitral valve re-repair was necessary in 4/279 (1.4%) patients for recurrent severe MR in three of them and mitral endocarditis in one. The overall freedom from mitral valve reoperation was 98.1%±1.0% at 3, 7 and 10 years. Overall freedom from MR (grade 2+ or more) was 91.7%±3.2%, 77.8%±4.8% and 67.1%±9.2% at 3, 7 and 10 years, respectively. Conclusions: Robotic mitral valve repair is safe and is associated with excellent clinical and echocardiographic results. The use of robotic technologies allows, after an appropriate learning curve, to reproduce all conventional techniques to treat MR, regardless of the complexity of the valve lesion.

Bicuspid aortic valve repair: the 180°-Reimplantation technique.

Bicuspid aortic valves (BAVs) represent a wide spectrum of aortic valve phenotypes. We have therefore previously proposed a new repair-oriented surgical classification for BAVs in order to facilitate our understanding of any given phenotype and to guide surgical repair. BAVs can range from symmetric to very asymmetric, and classification is determined by commissural orientation. This can therefore range from 180° to 120° respectively, and as such has further implications for the presence or absence of a raphe; the height of the non-functional commissure (raphe); the length of the line of cusp fusion; and the architecture of the aortic valve sinuses. Over the last three decades, we have attempted different repair strategies for BAVs, with its respective learning curves and have achieved the best long-term repair results with our signature approach: the 180°-Reimplantation technique (El Khoury technique). Although very asymmetric and tricuspid aortic valve-like phenotypes are sometimes best repaired through tricuspidization, we have found that the majority of BAVs are amenable to our 180°-Reimplantation technique. This technique creates a symmetric valve, through a selective annuloplasty, and stabilization of the entire functional aortic annulus (FAA) with reimplantation of the commissure at 180° at the level of the virtual basal ring (VBR) and sinotubular junction (STJ). Depending on the valve phenotype, additional cusp modifications are often required to address one or two prolapsing cusps and/or a fibrous raphe. With this, we have previously reported a 12-year survival rate of 94%, which is alike the general population, and also an overall freedom from aortic valve reoperation of 91%.

Outcomes of valve-sparing surgery in heritable aortic disorders: results from the AVIATOR registry.

OBJECTIVES: Root reimplantation has been the favoured approach for patients with heritable aortic disorder requiring valve-sparring root replacement. In the past few years, root remodelling with annuloplasty has emerged as an alternative to root reimplantation in the general population. The aim of this study was to examine the late outcomes of patients with heritable aortic disorder undergoing valve-sparring root replacement and compare different techniques. METHODS: Using the AVIATOR registry (Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry), data were collected from 5 North American and European centres. Patients were divided into 4 groups according to the technique of valve-sparing used (root reimplantation, root remodelling with ring annuloplasty, root remodelling with suture annuloplasty and root remodelling alone). The primary endpoints were freedom from aortic regurgitation (AR) ≥2 and freedom from reintervention on the aortic valve. Secondary endpoints were survival and changes in annular dimensions over time. RESULTS: A total of 237 patients were included in the study (reimplantation = 100, remodelling + ring annuloplasty = 76, remodelling + suture annuloplasty = 34, remodelling alone = 27). The majority of patients had Marfan syndrome (83%). Preoperative AR ≥2 was present in 41% of the patients. Operative mortality was 0.4% (n = 1). No differences were found between techniques in terms of postoperative AR ≥2 (P = 0.58), reintervention (P = 0.52) and survival (P = 0.59). Changes in aortic annulus dimension were significantly different at 10 years (P < 0.05), a difference that started to emerge 4 years after surgery. CONCLUSIONS: Overall, valve-sparring root replacement is a safe and durable procedure in patients with heritable aortic disorder. Nevertheless, root remodelling alone is associated with late annular dilatation. The addition of an annuloplasty, however, results in similar freedom from AR, reintervention, survival and changes in annulus size compared to reimplantation.

Predictors of long-term stenosis in bicuspid aortic valve repair.

OBJECTIVES: The use of modern techniques for bicuspid aortic valve repair has been shown to provide safe and durable results against recurrent regurgitation. However, an emerging body of evidence is indicating that aortic stenosis might be an additional late complication of these procedures. To date, the pathogenesis and clinical impact of aortic stenosis after bicuspid aortic valve repair are poorly understood. METHODS: A retrospective analysis of 367 patients with bicuspid aortic valve repair was performed to identify predictors of reoperation for stenosis. Bicuspid aortic valve repair was performed using a combination of procedures on the leaflet, annulus, and aortic root. RESULTS: During a median follow-up of 8 years, reoperation for stenosis was required in 33 patients (9.0%). Freedom from reoperation for stenosis was 100%, 99.6%, 91.7%, and 74.9% at 1, 5, 10, and 15 years, respectively. The following factors were independently associated with reoperation for aortic stenosis: Leaflet or raphe resection with shaving was a protective factor (hazard ratio, 0.34; 95% confidence interval, 0.16-0.71; P = .004), whereas the use of expanded polytetrafluoroethylene for free-edge running suture (hazard ratio, 2.55; 95% confidence interval, 1.16-5.57; P = .019), supracoronary replacement of the ascending aorta in combination with valve repair (hazard ratio, 5.41; 95% confidence interval, 2.11-13.85; P = .001), and the need for a second aortic crossclamp (hazard ratio, 10.95; 95% confidence interval, 2.80-42.80; P = .001) were associated with increased risk of reoperation for aortic stenosis. CONCLUSIONS: While confirming previous findings, our analysis suggests that the inability to restore leaflet mobility and polytetrafluoroethylene for free-edge running suture are risk factors for stenosis. The so-called ascending phenotypes are probably more prone to stenosis. If the first attempt to repair is unsuccessful, the risk of late reoperation for aortic stenosis is high.