Aortic valve/root procedures in patients with an anomalous left circumflex coronary artery and a bicuspid aortic valve: anatomical and technical implications.

An anomalous origin of the left circumflex coronary artery that arises as a side branch of the right coronary artery from the right coronary sinus of Valsalva encircling the aortic annulus is usually an incidental finding. However, in patients undergoing aortic valve procedures, its existence can significantly complicate the surgical treatment. We report our operative strategy in patients with an anomalous left circumflex coronary artery, a bicuspid aortic valve morphology and different aortic valve pathologies.

The David procedure for salvage of a failing autograft after the Ross operation.

BACKGROUND: Dilatation of the pulmonary autograft is a major fear after the Ross procedure. We analyzed the results after reoperation for autograft dysfunction using a valve-sparing reimplantation technique (David procedure). METHODS: From 1995 to 2012, 645 Ross operations were performed, with 630 (98%) of these as freestanding root replacements (mean follow-up, 8.3 ± 4.6 years). Forty-nine autograft reoperations occurred in 46 patients (0.89%/patient-year). Between 2005 and 2013, reoperation using a David procedure was performed in 18 of 35 patients (52%) with autograft dilatation at a mean interval of 11 ± 3.2 years after the Ross operation. RESULTS: The mean age of 18 patients receiving a David procedure as reoperation was 49.8 ± 13.9 years; 83% were male. The 30-day reoperative mortality was zero. The mean vascular graft size used for reimplantation was 29.5 ± 1.7 mm. At a mean follow-up time of 3.2 ± 2.3 years (100% complete), all patients (18 of 18) were alive and in New York Heart Association functional class I. One patient (5%) needed valve replacement for recurrent aortic regurgitation 2.6 years after the David procedure. In the remaining patients (95%), freedom from aortic regurgitation of grade 2 or greater was 100% at 3 years (regurgitation grade <1, 14 of 17; 82%). Aortic valve gradients were clinically insignificant at 5.8 ± 2.1 mm Hg. CONCLUSIONS: Performing a David procedure was successful in the vast majority of patients with dilatation of the pulmonary autograft after a Ross operation and revealed good function of the preserved autograft at midterm follow-up. Reoperations could be performed with low perioperative morbidity and mortality.

Quo vadis pulmonary autograft--the ross procedure in its second decade: a single-center experience in 645 patients.

BACKGROUND: The enthusiasm about the advantages of a viable autologous transplant faded with recent reports of autograft deterioration and associated reoperations after the Ross procedure. This report evaluates predictors for autograft failure and outcomes extending into the second decade after a Ross procedure. METHODS: From 1995 through 2012, 645 consecutive patients (mean age, 42.3 ± 14.2 years; 76% males) underwent a Ross operation using mainly the root replacement technique (98%). They were prospectively followed up with clinical and echocardiographic evaluations. Total follow-up was 5,349 patient-years and was 96% complete. Mean follow-up duration was 8.4 ± 4.6 years (range, 0 to 17.4 years). RESULTS: Early mortality was 0.9% (n = 6). Cumulative survival at 15 years was 92.7% (95% confidence interval, 90.1% to 95.3%) and did not differ from the general German population (p = 0.261). Freedom from reoperation on the autograft or the pulmonary allograft at 12 years was 91.6% (95% confidence interval, 88.5% to 94.9%) and 95.0% (95% confidence interval, 92.8% to 97.2%), respectively. Sixty-five patients (10.1%) required a total of 78 valve-related reoperations after a Ross procedure (1.5%/patient-year) with a reoperative hospital mortality of 3.8% (n = 3). Forty-seven autograft reoperations were observed in 44 patients (0.87%/patient-year); 22 of them (47%) could be performed as a valve-sparing procedure. Preoperative aortic valve regurgitation and an aortic annulus of at least 26 mm were identified as predictors for autograft failure. CONCLUSIONS: In this large series, the Ross procedure resulted in excellent long-term survival rates with a low risk of valve-related morbidity and a considerably low rate of reoperations in young and middle-aged patients and should be considered as an important treatment option in this cohort.

Valve-sparing reimplantation technique for treatment of neoaortic root dilatation late after the arterial switch operation: raising the bar.

Neoaortic root dilatation can develop during long-term follow-up after an arterial switch operation (ASO). Although few patients require surgical reintervention, significant valve regurgitation is still an important cause of late morbidity. We report on a 15-year-old boy with significant dilatation of the neoaortic root that was treated with the valve-sparing reimplantation technique. There is only one reported case of valve-preserving surgery late after the ASO. Valve preservation is believed to be superior to valve replacement in patients with aortic regurgitation due to better hemodynamic performance and avoidance of anticoagulation therapy.

The David procedure in different valve pathologies: a single-center experience in 236 patients.

BACKGROUND: Reports of the long-term outcome after the David procedure in different valve pathologies are limited. We compared our results in patients with tricuspid and bicuspid aortic valves, including those who required additional cusp repair. METHODS: Between 1997 and 2011, 236 patients (76% males; mean age, 56 ± 15; range, 12 to 79 years) underwent valve-sparing aortic root replacement (David procedure) for aortic regurgitation and were prospectively followed up clinically and echocardiographically. RESULTS: The follow-up was 94% complete. Cumulative follow-up time was 896 patient-years (mean follow-up time, 4.5 ± 2.7; range, 0.6 to 13.7 years). The 30-day mortality was 1.7% (4 of 236), and late mortality was 4% (10 of 232), with one cardiac-related death due to aortic valve regurgitation. Overall freedom from valve replacement was 94% and 87% at 5 and 10 years, respectively. In 201 patients with tricuspid aortic valves, freedom from reoperation was 94% and 90% at 5 and 10 years, respectively. This was comparable to the 53 patients with bicuspid aortic valves, with a freedom from reoperation of 97% at 5 years (p = 0.632). Forty-two patients (18%) required additional cusp repair and had a 100% freedom from reoperation at 5 years. Overall, 10 patients (4%) required reoperation, with a mean interval of 11.5 ± 10.7 months. Reasons for reoperation were recurrent aortic valve regurgitation grade II (n = 6), aortic stenosis (n = 2), endocarditis (n = 1), and a ruptured central plication (n = 1). CONCLUSIONS: The David procedure revealed excellent long-term outcomes independently from the valve morphology. Rates of reoperations and valve-related morbidity were acceptably low. Additional cusp repair was no predictor for failure of this procedure.

Strategies for biological heart valve replacement: stentless xenografts fail to evolve into an alternative pulmonary valve substitute in a Ross procedure.

The Ross operation is a complex procedure for aortic valve replacement in which the pulmonary autograft is replaced by a homograft. However, homograft availability is becoming limited. This report evaluates the performance of porcine stentless prostheses as alternative pulmonary substitutes. Echocardiographic results from two patient cohorts were compared at time of discharge and 1 year after a Ross procedure. Thirty-three patients (median age 42 years, range 17-62 years, 76% male) received a stentless prosthesis (median size 25.6 mm, range 25-29 mm) for right ventricular outflow tract reconstruction. Clinical data were not significantly different from 106 patients (median age 47 years, range 2-68 years, 75% male) who received cryopreserved homografts (median size 26 mm, range 20-33 mm). At time of discharge, peak pressure gradients (ΔPmax ) across the stentless valve (median ΔPmax 13 mmHg, range 2-26 mmHg) were higher compared to homografts (median ΔPmax 7 mmHg, range 1-32 mmHg, p<0.001). At 1 year, gradients increased in both groups, but were significantly higher across stentless valves (median ΔPmax 23 mmHg, range 10-81 mmHg vs. median ΔPmax 13 mmHg, range 2-74 mmHg, p<0.001). Eleven patients (33%) in the stentless-valve group were classified "at risk" with a ΔPmax of ≥30 mmHg. Four of them (12%) had to be re-operated. In conclusion, stentless valves showed higher pressure gradients and their performance was inferior to cryopreserved homografts. See accompanying commentary by Ulrich Stock DOI: 10.1002/biot.201200341.

Approaching a paradigm shift: endoscopic ablation of lone atrial fibrillation on the beating heart.

BACKGROUND: Percutaneous catheter ablation has been the preferred treatment strategy for many patients with symptomatic drug-refractory atrial fibrillation (AF). However, incomplete ablation lines and varying success rates remain a problem in certain subgroups. This article evaluates the feasibility and efficacy of endoscopically performed left atrial ablation in patients with lone AF. METHODS: Epicardial bipolar radiofrequency ablation was performed on the beating heart through a bilateral endoscopic approach in 89 consecutive patients with lone AF. This included isolation of the pulmonary veins using a clamp; isolation of the posterior left atrial wall, including a trigonal line to the aortic noncoronary sinus using a linear ablation device; and resection of the left atrial appendage (LAA). Preoperative, perioperative, and postoperative data were collected prospectively and included questionnaires and 24-hour Holter monitoring at 6 and 12 months and annually thereafter. RESULTS: Mean follow-up was 12±6 months (range, 4-28 months). No patients were lost to follow-up. Mean duration of AF was 6.4±5.7 years, with 35% paroxysmal AF and 65% persistent or long-standing persistent AF. Mean operation time was 180±43 minutes. There were no deaths, no conversion to sternotomy, and no early or late stroke. Freedom from AF was 88%, 90%, and 90% at 6, 12, and 24 months, respectively. Freedom from AF without antiarrhythmic drugs was 71%, 82%, and 90% at 6, 12, and 24 months, respectively. CONCLUSIONS: Endoscopic radiofrequency ablation on the beating heart reveals high success rates with low procedure-related morbidity. For improvement of future treatment strategies, a randomized trial is advisable to compare this procedure with catheter ablation in certain patient subgroups.

Replacement of the aortic valve and ascending aorta with an extended root stentless xenograft.

PURPOSE: We present an early series to determine the technical feasibility of simultaneous aortic valve and complete ascending aortic replacement using a longer stentless aortic xenograft, harvested with an extended root. DESCRIPTION: The stentless xenograft valved conduits commercially available are too short for complete ascending aorta replacement, and usually a prosthetic tube graft is required distally. EVALUATION: To avoid this extra prosthetic conduit distally a number of stentless aortic xenografts with extended conduit were obtained from a supplier (Medtronic Inc). They were inserted in 6 elderly patients (67.8 +/- 7.1 years) who all required aortic valve and ascending aorta replacements owing to pathologic dilation. CONCLUSIONS: In all cases an extra prosthetic conduit was avoided, and the length of the available biological conduit comfortably allowed total ascending aortic replacement without tension. The advantages therefore were one less suture line, cost saving regarding the prosthetic conduit, shorter cross-clamping time, and possibly shorter time spent on hemostasis.