Aortic valve repair versus mechanical valve replacement for root aneurysm: the CAVIAAR multicentric study.

OBJECTIVES: Despite growing evidence that aortic valve repair improves long-term patient outcomes and quality of life, aortic valves are mostly replaced. We evaluate the effect of aortic valve repair versus replacement in patients with dystrophic aortic root aneurysm up to 4 years. METHODS: The multicentric CAVIAAR (Conservation Aortique Valvulaire dans les Insuffisances Aortiques et les Anévrismes de la Racine aortique) prospective cohort study enrolled 261 patients: 130 underwent standardized aortic valve repair (REPAIR) consisting of remodelling root repair with expansible aortic ring annuloplasty, and 131 received mechanical composite valve and graft replacement (REPLACE). Primary outcome was a composite criterion of mortality, reoperation, thromboembolic or major bleeding events, endocarditis or operating site infections, pacemaker implantation and heart failure, analysed with propensity score-weighted Cox model analysis. Secondary outcomes included major adverse valve-related events and components of primary outcome. RESULTS: The mean age was 56.1 years, and valve was bicuspid in 115 patients (44.7%). Up to 4 years, REPAIR did not significantly differ from REPLACE in terms of primary outcome [Hazard Ratio (HR) 0.66 (0.39; 1.12)] but showed significantly less valve-related deaths (HR 0.09 [0.02; 0.34]) and major bleeding events (HR 0.37 [0.16; 0.85]) without an increased risk of valve-related reoperation (HR 2.10 [0.64; 6.96]). When accounting for the occurrence of multiple events in a single patient, the REPAIR group had half the occurrence of major adverse valve-related events (HR 0.51 [0.31; 0.86]). CONCLUSIONS: Although the primary outcome did not significantly differ between the REPAIR and REPLACE groups, the trend is in favour of REPAIR by a significant reduction of valve-related deaths and major bleeding events. Long-term follow-up beyond 4 years is needed to confirm these findings.

Standardized approach to valve repair using an expansible aortic ring versus mechanical Bentall: early outcomes of the CAVIAAR multicentric prospective cohort study.

OBJECTIVE: The study objective was to compare the 30-day outcomes of a standardized aortic valve repair technique (REPAIR group) associating root remodeling with an expansible aortic ring annuloplasty versus mechanical composite valve and graft (CVG group) replacement in treating aortic root aneurysms. METHODS: A total of 261 consecutive patients with aortic root aneurysm were enrolled in this multicentric prospective cohort (131 in the CVG group, 130 in the REPAIR group) in 20 centers. The main end point is a composite criterion including mortality; reoperation; thromboembolic, hemorrhagic, or infectious events; and heart failure. Secondary end points were major adverse valve-related events. Crude and propensity score adjusted estimates are provided. RESULTS: The mean age was 56.1 years, and the valve was bicuspid in 115 patients (44.7%). The median (interquartile range) preoperative aortic insufficiency grade was 2.0 (1.0-3.0) in the REPAIR group and 3.0 (2.0-3.0) in the CVG group (P = .0002). Thirty-day mortality was 3.8% (n = 5) in both groups (P = 1.00). Despite a learning curve and longer crossclamp times for valve repair (147.7 vs 99.8 minutes, P < .0001), the 2 groups did not differ significantly for the main criterion (odds ratio, 1.31; 95% confidence interval, 0.72-2.40; P = .38) or 30-day mortality (odds ratio, 0.99; 95% confidence interval, 0.28-3053; P = .99), with a trend toward more frequent major adverse valve-related events in the CVG group (odds ratio, 2.52; 95% confidence interval, 0.86-7.40; P = .09). At discharge, 121 patients (96.8%) in the REPAIR group had grade 0 or 1 aortic insufficiency. CONCLUSIONS: A new standardized approach to valve repair, combining an expansible aortic annuloplasty ring with the remodeling technique, presented similar 30-day results to mechanical CVG with a trend toward reducing major adverse valve-related events. Analysis of late outcomes is in process for 3- and 10-year follow-ups.

Remodeling of the aortic root combined to an expansible aortic ring annuloplasty.

Aortic root aneurysms are characterized by dilation of both functional aortic annulus diameters (aortic annular base and sino-tubular junction), preventing coaptation of otherwise pliable valves often associated with cusp prolapse. Multiple techniques of aortic valve sparing procedures try to restore the complex interplay of aortic valve and root function in order to improve durability of the repair. Ideally, procedures should treat dilatation of the aortic annular base, while preserving dynamics of the aortic root with vortices (neosinuses of Valsalva) and root expansibility (interleaflet triangles). We describe a standardized approach, combining the advantages of both the remodeling and reimplantation technique by adding an external subvalvular ring annuloplasty to the physiological remodeling of the aortic root. To address the need for a dedicated aortic annuloplasty device, a new expansible aortic ring was designed in order to achieve a complete and calibrated annuloplasty in diastole, while maintaining systolic expansibility of the aortic root.

An aortic ring to standardise aortic valve repair: preliminary results of a prospective multicentric cohort of 144 patients.

OBJECTIVES: Multiplicity of aortic valve repair or sparing techniques results in a lack of standardisation, limiting widespread adoption of such procedures. To treat dilated diameters at the aortic annular base and sinotubular junction while maintaining root dynamics, we propose a standardised and physiological repair approach to the surgical management of aortic root aneurysms, consisting of root remodelling, cusp re-suspension and subvalvular aortic ring annuloplasty. METHODS: From May 2003 to September 2009, 144 unselected patients with aortic root aneurysms underwent remodelling with external subvalvular ring annuloplasty in 13 centres (21 surgeons). Preoperative aortic insufficiency (AI) > or =grade 2 was present in 63.9% (92), Marfan syndrome in 12.5% (18) and bicuspid valve in 22.9% (33). Cusp repair was performed in 40.3% (58) patients. RESULTS: Valve repair was successful in all but two cases. Repair of cusp prolapse was necessary in 58 patients, significantly more frequent in bicuspid (24/33, 72.7%) than in tricuspid (34/111, 30.6%) valves (p<0.05). Operative mortality was 2.8% (four). Subvalvular ring implantation produced a significant annular base reduction from 27.6+/-2.5 mm to 20.5+/-2.6 mm (p<0.01) without significant mean trans-valvular gradient (7.2+/-1.7 mmHg). During follow-up (median 2.2 years (0.75-4.4, maximum 6.25 years)), five patients died while eight required a re-operation. Six were operated on during our early experience. Strategy for cusp re-suspension evolved over three operative periods, with a significant increase in the rate of cusp repair. From May 2003 to December 2006: eye balling evaluation (15/67 (22.4%)); from January 2007 to August 2008: alignment of cusp free edges (17/38 (44.7%)); and from September 2008 to September 2009: a two-step standardised repair consisting of alignment of cusp free edges and effective height re-suspension (26/39 (66.7%) p<0.05). Freedom from AI> or =grade 2 was 91.3% (115) at the end of follow-up. CONCLUSIONS: Implantation of an external aortic ring provides a reproducible technique for aortic valve repair with satisfactory preliminary results. The ongoing CAVIAAR trial (Conservative Aortic Valve surgery for aortic Insufficiency and Aneurysm of the Aortic Root) will compare this standardised repair technique using an expansible aortic ring to mechanical valve replacement.