Aortic Valve Repair with External Annuloplasty in Bicuspid versus Tricuspid Aortic Valve Patients.

Surgical repair for regurgitant bicuspid aortic valve (BAV) is promising but underutilized due to perceived complexities and lack of long-term data. This study evaluated the efficacy of valve-sparing root remodeling (VSRR) or isolated valve repair combined with calibrated external ring annuloplasty in BAV versus tricuspid aortic valve (TAV) patients. All patients operated on for aortic regurgitation and/or aneurysm at our institution between 2014 and 2022 were included and entered into the Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (AVIATOR). Patients with successful repair at index surgery (100% in the BAV group, 93% in the TAV group, p = 0.044) were included in a systemic follow-up with echocardiography at regular intervals. Among 132 patients, 58 were in the BAV (44%) and 74 in the TAV group (56%). There were no inter-group differences in preoperative patient characteristics, except BAV patients being significantly younger (47 ± 18 y vs. 60 ± 14 y, p < 0.001) and having narrower aortic roots at the level of sinuses (41 ± 6 mm vs. 46 ± 13 mm, p < 0.001) and sinotubular junctions (39 ± 10 mm vs. 42 ± 11, p = 0.032). No perioperative deaths were recorded. At four years, there was no significant difference in terms of overall survival (96.3% BAV vs. 97.2% TAV, p = 0.373), freedom from valve reintervention (85.2% BAV vs. 93.4% TAV, p = 0.905), and freedom from severe aortic regurgitation (94.1% BAV vs. 82.9% TAV, p = 0.222). Surgical repair of BAV combined with extra-aortic annuloplasty can be performed with low perioperative morbidity and mortality and excellent mid-term results which are comparable to TAV repair.

Postoperative Inflammation and Fever After Elective Aortic Valve and Aortic Root Replacement: A Retrospective Cohort Study.

Background: Fever after cardiac surgery is common. More knowledge of postoperative fever could lead to better patient selection for diagnostic workup and empirical antibiotic treatment. We aimed to analyze the postoperative course of inflammation and fever after elective aortic valve and aortic root replacement. Methods: In a retrospective single-center cohort study, we included 3 groups of patients after elective cardiac surgery: aortic root with aortic valve replacement (Bentall procedure, from 2014 to 2021), valve-sparing root replacement (VSRR, from 2014 to 2021), and isolated surgical aortic valve replacement (SAVR, from 2018 to 2021). Exclusion criteria were age <18 years, cardiac surgery other than described, use of deep-hypothermic circulatory arrest, reoperations, and preexisting infections. Primary outcome measure was the number of patients per group with postoperative fever (≥38°C). Secondary outcome measures were the percentage of patients per group with infections and outcome. Results: Among 307 patients included (76 Bentall, 40 VSRR, 191 SAVR), 71% had postoperative fever. Fever occurred significantly more often in the Bentall (84%) and VSRR group (83%) compared with patients after SAVR (64%, P = .001). Seventeen patients had fever due to infection versus 202 with diagnoses of postoperative inflammation. In case of infection, fever was significantly higher (38.8°C vs 38.4°C, P = .03), and both the number of days with fever and hospital admission duration were significantly longer. Conclusions: Postoperative fever is more often observed after Bentall procedure and VSRR compared to SAVR. In diagnoses of infection, there is a higher and prolonged fever.

Research Progress in Valve-sparing Aortic Root Replacement / 中山大学学报(医学科学版)

With continuous improvements in surgical techniques， medical engineering and material science， root replacement with composite valve graft （CVG） or Bentall procedure has become the standard procedure for aortic root lesions. As an alternative to the Bentall procedure， valve-sparing aortic root replacement （VSRR） avoids the complications associated with lifelong anticoagulation and mechanical valves； reduces the incidence of thromboembolic and bleeding events； and its favorable haemodynamics and potentially lower risk of endocarditis ensure durable postoperative aortic valve function and a much better quality of patient survival. This article reviews the indications for root replacement with preservation of the aortic valve， the key points of the standardized technique and its long-term results in different patients.

Proximal aortic repair in asymptomatic patients.

Objective: Current guidelines for elective proximal aortic repair are applicable to elective first-time procedures in asymptomatic patients without other primary indications or connective tissue disorders and with specified aortic diameter or growth rate. The objective was to characterize the surgical outcomes in this narrowly defined patient-population. Methods: Guideline-compliant patients were identified from a recent (2014-2019) single unit consecutive surgical cohort (n = 935) by excluding total arch replacements, redos, acute and symptomatic patients, and genetic syndromes. Remaining patients were included regardless of surgical procedure performed. Early (30-day or in-hospital) and 1-year mortality were primary outcome measures. Major complications (stroke, severe renal or respiratory insufficiency, postcardiotomy shock, deep sternal wound infection, permanent pacemaker, and re-exploration) up to 1 year postoperatively were secondary outcome measures. Results: In the resulting study population (n = 262), median age was 63 (interquartile range, 52-71) years, and median surgical risk (European System for Cardiac Operative Risk Evaluation II) was 3.2% (2.0%-4.4%). Early mortality was 2 of 262 (0.76%) without additional deaths up to 1-year postoperatively. The occurrence of major complications was low: stroke, 2 (0.76%); renal insufficiency, 2 (0.76%); respiratory insufficiency, 1 (0.38%); postcardiotomy shock, 1 (0.38%); deep sternal wound infection, 0; permanent pacemaker, 3 (1.1%); and re-exploration, 20 (7.6%), all occurring in the immediate (30-day) postoperative period and without additional events up to 1 year postoperatively. Conclusions: In this recent cohort including the target population referred to by and managed in accordance with current guidelines, mortality and major complications were exceptionally infrequent. Guidelines should adequately weigh risks of conservative management against current surgical outcomes.

Outcomes in techniques of valve sparing aortic root replacement: A systematic review and meta-analysis.

OBJECTIVE: To compare clinical outcomes of reimplantation versus remodeling in patients undergoing valve-sparing aortic root replacement (VSRR) surgery. METHOD: Electronic database search at PubMed, Scopus, Embase, Ovid, and Google scholar was performed from inception to January 2020. Primary outcomes were aortic valve (AV) reintervention and postoperative grade of aortic insufficiency (AI) while secondary outcomes were 30-day mortality, reoperation for bleeding, and operative times. RESULTS: A total of 21 articles met the inclusion criteria. A total of 1283 patients had reimplantation while 1150 had remodeling. No difference in preoperative demographics was noted except reimplantation patients were younger (48 ± 16 vs. 56 ± 15 years; p < .00001). The cardiopulmonary bypass and aortic cross-clamp times were shorter in the remodeling cohort (168 ± 38 vs. 150 ± 37 min; p = .0001 and 133 ± 31 vs. 112 ± 30 min; p = .0002, respectively). No difference in concomitant total arch surgery (14% in reimplantation vs. 15% in remodeling; p = .53). Postoperatively, there were similar stroke rates (3% in both cohorts; p = .54), rates of reoperation for bleeding (9% in reimplantation vs. 12% in remodeling; p = .88), and 30-day mortality (3% in reimplantation vs. 4% in remodeling; p = .96). No difference in early AV reintervention (1% in reimplantation vs. 2% in remodeling; p = .07), and late AV reintervention (4% in reimplantation vs. 7% in remodeling; p = .07). The AI of +2 grade was significantly lower in the reimplantation cohort (5% vs. 8%; p = .01). CONCLUSION: Our study shows comparable clinical outcomes between both techniques. The practice of each technique is largely center and surgeon dependent. Larger sample size cohorts with minimal confounding factors are required to confirm the above findings.

A reimplantation valve-sparing root replacement (T. David-V) and aortic valve repair procedure in a patient with Marfan syndrome.

Valve-sparing aortic root replacement using the reimplantation technique (T. David-V operation) has become the gold standard in patients with annuloaortic ectasia, given that the aortic valve is morphologically intact or repairable. The benefits of preserving the native aortic valve extend beyond avoiding the inconvenience and complications of prolonged exposure to anticoagulants. This video tutorial provides a step-by-step guide to the T. David-V procedure in a male patient with Marfan syndrome, annuloaortic ectasia, and moderate-to-severe aortic regurgitation.

Second Harmonic Light Manipulation with Vertical Split Ring Resonators.

The second harmonic generation (SHG) of vertical and planar split-ring resonators (SRRs) that are broken centro-symmetry configurations at the interface of metal surface and air is investigated. Strong interactions, better electromagnetic field confinements, and less leakage into the substrate for vertical SRRs are found. Experimental results show a 2.6-fold enhancement of SHG nonlinearity, which is in good agreement with simulations and calculations. Demonstrations of 3D metastructures and vertical SRRs with strong SHG nonlinearity majorly result from magnetic dipole and electric quadrupole clearly provides potential applications for photonics and sensing.

Progress in surgical selection of aortic root diseases / 中国胸心血管外科临床杂志

@#Total root replacement (TRR) with a valved conduit has long been the treatment standard for most aortic root diseases. However, with advances in technology and a deeper understanding of aortic root anatomy and hemodynamics, valve-sparing aortic root replacement (VSRR) and personalised external aortic root support (PEARS) have emerged. It is especially important to choose the appropriate procedure for different aortic root diseases. When evaluating these three surgical procedures, it is necessary to focus on the treatment and prevention of the dissection and balance the short-term and long-term risks of the patients. This article outlines aortic-related diseases and the selection of surgery.

4D flow characterization of aortic blood flow after valve sparing root reimplantation procedure.

Valve-sparing aortic root replacement (VSRR) with reimplantation technique is an effective alternative for young patients with dilated roots and preserved cusps, which avoids the risks of lifelong anticoagulation or valve degeneration. New grafts with anatomically-shaped sinuses have been developed in order to preserve aortic root physiology, which could decrease complication rates and improve durability. However, controversy remains regarding the effect of recreation of the sinuses of Valsalva during VSRR on long-term outcomes. The novel 4D flow technique, exploiting its unique ability to combine anatomical evaluation of the root with fluid-dynamic assessment of aortic flow, enables integrated analysis of the close interaction between graft design, valvular morphology and three-dimensional (3D) flow characteristics. Early experimental studies have shown how graft shape affects the aortic root flow pattern, formation of vortexes and helicity of downstream flow; however, the clinical significance of these findings is yet to be clarified. Various and still unexplored knowledge can be obtained from the qualitative and quantitative analysis of these complex datasets, that could shed more light on which is the best among myriad surgical techniques and grafts adopted in VSRR. The extraordinary potential 4D flow imaging opens new boundless horizons in the perspective of an increasingly patient-tailored surgical planning.