Aortic root anatomy: insights into annular and root enlargement techniques.

The introduction of the Y(ang)-technique for aortic root enlargement has sparked a renewed interest in annular and root enlargement procedures world-wide. In order to execute these procedures proficiently however, it's important to understand the complex three-dimensional structure of the aortic root and left ventricular outflow tract, and also be familiar with the different enlargement techniques. Herein, we are providing a description of the aortic root anatomy and the most commonly utilized root enlargement procedures. This should facilitate clinical decision making and guidance of patients towards the most appropriate procedure, which should not only treat the patients' acute symptoms, but should also set the patient up for potentially needed future procedures and respective life-time management of aortic valve disease.

Continuous or interrupted pledgeted suture technique in stented bioprosthetic aortic valve replacement: a comparison of in-hospital outcomes.

BACKGROUND: There is ambiguity in the literature regarding the continuous suture technique (CST) for aortic valve replacement (AVR). At our center, there has been a gradual shift towards CST over the interrupted pledgeted technique (IPT). This study aims at comparing outcomes for both techniques. METHODS: We performed a retrospective analysis of a single-center study of patients undergoing AVR between January 2011 and July 2020. Patients were divided into two groups: Continuous suture technique and interrupted pledget-reinforced sutures. The pre-operative and In-hospital clinical characteristics and echocardiographic hemodynamics (i.e. transvalvular gradients and paravalvular leakage) were compared between CST and IPT. RESULTS: We compared 791 patients with CST to 568 patients with IPT (median age: 73 and 74 years, respectively, p = 0.02). In CST there were 35% concomitant procedure vs. 31% in IPT (p = 0.16). Early mortality was 3.2% in CST versus 4.8% in IPT (p = 0.15), and a second cross-clamp due to a paravalvular-leak in 0.5% vs. 1.2%, respectively (p = 0.22). The CST was not associated with new-onset conduction-blocks mandating pacemaker implants(OR 1.07, 95% CI 0.54-2.14; P = 0.85). The postoperative gradients on echocardiography were lower in CST compared to IPT, especially in smaller annuli (peak gradients: 15.7mmHg vs. 20.5mmHg, in valve size < 23 mm, p < 0.001). CONCLUSIONS: The continuous suture technique was associated with lower postoperative gradients and shorter cross-clamp time compared to interrupted pledgeted technique. Differences in paravalvular leaks were non-significant, although slightly less in the continuous suture technique. There were no further differences in valve-related complications. Hence, continues suture technique is safe, with better hemodynamics compared to the interrupted pledgeted technique. This may be of clinical importance, especially in smaller size annular size.

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.

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.

Valve-sparing aortic root replacement using the reimplantation (David) technique: a systematic review and meta-analysis on survival and clinical outcome.

Background: Current guidelines recommend valve-sparing aortic root replacement (VSRR) procedures over valve replacement for the treatment of root aneurysm. The reimplantation technique seems to be the most widely used valve-sparing technique, with excellent outcomes in mostly single-center studies. The aim of this systematic review and meta-analysis is to present a comprehensive overview of clinical outcomes after VSRR with the reimplantation technique, and potential differences for bicuspid aortic valve (BAV) phenotype. Methods: We conducted a systematic literature search of papers reporting outcomes after VSRR that were published since 2010. Studies solely reporting on acute aortic syndromes or congenital patients were excluded. Baseline characteristics were summarized using sample size weighting. Late outcomes were pooled using inverse variance weighting. Pooled Kaplan-Meier (KM) curves for time-to-event outcomes were generated. Further, a microsimulation model was developed to estimate life expectancy and risks of valve-related morbidity after surgery. Results: Forty-four studies, with 7,878 patients, matched the inclusion criteria and were included for analysis. Mean age at operation was 50 years and almost 80% of patients were male. Pooled early mortality was 1.6% and the most common perioperative complication was chest re-exploration for bleeding (5.4%). Mean follow-up was 4.8±2.8 years. Linearized occurrence rates for aortic valve (AV) related complications such as endocarditis and stroke were below 0.3% patient-year. Overall survival was 99% and 89% at 1- and 10-year respectively. Freedom from reoperation was 99% and 91% after 1 and 10 years, respectively, with no difference between tricuspid and BAVs. Conclusions: This systematic review and meta-analysis shows excellent short- and long-term results of valve-sparing root replacement with the reimplantation technique in terms of survival, freedom from reoperation, and valve related complications with no difference between tricuspid and BAVs.

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%.

Surgical Management of Aortic Regurgitation in Takayasu's Arteritis: A Systematic Review of Techniques and Outcomes.

IntroductionTakayasu's arteritis (TA) is an inflammatory condition that affects large vessels and frequently involves the aortic valve causing valve regurgitation. Surgical management is recommended for symptomatic severe aortic regurgitation (AR); however, the optimal surgical approach is yet unclear. This study aims to review surgical treatment options for AR in TA and determine which procedure has a lower chance of late postoperative events and/or mortality. MethodsAn electronic database search was performed within PubMed, EMBASE, Web of Science, and SCOPUS to identify articles from 1975 to 2016 focusing on surgical management of the AR in TA. ResultsTwenty seven studies encompassing a total of 194 cases (77% females) were included. Isolated aortic valve replacement (AVR) was performed in 105/194 cases (54%) (Group A), while combined aortic valve and root replacement (CAVRR) was performed in 87/194 (45%) (Group B). Prosthetic valve detachment was reported in 10/105 cases (9.5%) in group A and 1/87 cases (1.2%) in group B (p = 0.02). Dilation of the residual aorta was reported in 10/105 cases (9.5%) in group A and 1/87 cases (1.2%) in group B (p = 0.02). Any late (≥ 30 d) postoperative cardiac event was reported in 26/105 cases (24.8%) in group A, and in 7/87 cases (8.1%) in group B (p = 0.003). ConclusionsAlthough CAVRR is a more complex procedure, it might offer a better outcome in terms of late postoperative cardiac events compared to isolated AVR procedure. Future prospective studies are required to help determine the best surgical approach in such a population.

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.