Novel technique of valve-sparing aortic root replacement in two children younger than 3 years of age

A novel technique of valve-sparing aortic root replacement was applied to 2 children younger than 3 years of age with Marfan syndrome and large aortic root aneurysms. Using elements of both the remodeling and reimplantation techniques, circumferential rings from a 20-mm to 22-mm polyester graft provide stabilization at the subannular and sinotubular levels, and bovine pericardial patches create pseudosinuses. Follow-up at 2 years in 1 patient and 7 months in a second patient revealed satisfactory valve function with stable aortic root size.     

A simple modification of 'David-V' aortic root reimplantation.

Valve-sparing aortic root reimplantation with creation of Dacron graft pseudosinuses is a popular and promising surgical choice for annuloaortic ectasia or ascending aortic aneurysm. We have developed a simple modification of the David-V technique, which facilitates free adjustment of the size of the new aortic annulus and the pseudosinus of each patient, as well as the creation of pseudosinuses of excellent shape, with only one Dacron graft.     

One-year appraisal of a new aortic root conduit with sinuses of Valsalva.

OBJECTIVES: We evaluate the clinical results 1 year after an anatomic reconstruction of the aortic root in which we used a specifically designed aortic root prosthesis that incorporates the sinuses of Valsalva. MATERIAL AND METHODS: The new aortic Dacron prosthesis has a proximal portion in the Dacron conduit that expands on implantation, creating pseudosinuses. During a 12-month period, 28 patients (mean age 59 +/- 14 years) underwent a Bentall operation (12 cases), a remodeling procedure (7 cases), and a reimplantation procedure (9 cases) with the use of a new aortic root conduit. All patients had aortic root aneurysm with an anatomically normal (for the valve-sparing procedure) or diseased aortic valve (for the Bentall operation). Five patients had aortic dissection and 5 had Marfan disease. The mean follow-up was 6 +/- 3 months. All patients underwent postoperative transesophageal and transthoracic echocardiographic studies. RESULTS: All patients survived and were in good clinical condition at the latest follow-up. Postoperative echocardiography showed a marked reduction in ventricular volumes in all patient groups (P <.0005). In the Bentall group the new prosthesis appeared to reduce the tension on the coronary ostial sutures. In patients undergoing both types of valve-sparing procedures a similar normal anatomy of the aortic root was reconstructed. In the reimplantation group the anulus was smaller than in the remodeling group (P =.01). Patients undergoing the reimplantation procedure had less bleeding and a lower incidence of residual valve insufficiency. CONCLUSIONS: The new aortic root prosthesis allowed the reconstruction of the aortic root anatomy in all types of surgical techniques with low postoperative morbidity.     

Time-resolved three-dimensional magnetic resonance velocity mapping of aortic flow in healthy volunteers and patients after valve-sparing aortic root replacement

OBJECTIVE: To provide more complete characterization of ascending aortic blood flow, including vortex formation behind the valve cusps, in healthy subjects and patients after valve-sparing aortic root replacement (David reimplantation). METHODS: Time-resolved 3-dimensional magnetic resonance imaging velocity mapping was performed to analyze pulsatile blood flow by using encoded 3-directional vector fields in the thoracic aortas of 10 volunteers and 12 patients after David reimplantation using a cylindrical tube graft (T. David I) and two versions of neosinus recreation (T. David-V and T. David-V-S mod ). Aortic flow was evaluated by using 3-dimensional time-resolved particle traces and velocity vector fields reformatted onto 2-dimensional planes. Semiquantitative data were derived by using a blinded grading system (0-3: 0, none; 1, minimal; 2, medium; 3, prominent) to analyze the systolic vortex formation behind the cusps, as well as retrograde and helical flow in the ascending aorta. RESULTS: Systolic vortices were seen in both coronary sinuses of all volunteers (greater in the left sinus [2.5 +/- 0.5] than the right [1.8 +/- 0.8]) but in only 4 of 10 noncoronary sinuses (0.7 +/- 0.9). Comparable coronary vortices were detected in all operated patients. Vorticity was minimal in the noncoronary cusp in T. David-I repairs (0.7 +/- 0.7) but was prominent in T. David-V noncoronary graft pseudosinuses (1.5 +/- 0.6; P = .035). Retrograde flow (P = .001) and helicity (P = .028) were found in all patients but were not distinguishable from normal values in the T. David-V-S mod patients. CONCLUSIONS: Coronary cusp vorticity was preserved after David reimplantation, regardless of neosinus creation. Increased retrograde flow and helicity were more prominent in T. David-V patients. These novel magnetic resonance imaging methods can assess the clinical implications of altered aortic flow dynamics in patients undergoing various types of valve-sparing aortic root replacement.     

Valsalva prosthesis in aortic valve-sparing operations

Aortic valve-sparing operations have provided very good clinical outcomes. However, the absence of the sinuses of Valsalva might limit valve durability. The Gelweave Valsalva prosthesis, which presents pre-fashioned neo-sinuses, has been designed in order to avoid early leaflets deterioration. We report our results in 63 patients who underwent valve-sparing operations (reimplantation technique) using the Gelweave Valsalva graft. The main indication was ascending aorta aneurysm or annuloaortic ectasia, with or without aortic insufficiency. The operation was performed also in cases of Marfan syndrome, Bicuspid Aortic Valve (BAV), and acute Type A dissection. In-hospital mortality was of 4.7%, and two thirds were acute Type A dissection patients (P=0.01). There were no late deaths. Three years freedom from grade 3-4 AI and freedom from late aortic valve replacement were 91.7+/-4.3% and 93.8+/-5.1%, respectively. Aortic valve-sparing operations show good results in patients electively operated for aortic root ectasia. Aortic cusps repair may lead to late failure. Even if the Gelweave Valsalva prosthesis is easy to implant and it also reproduces pseudosinuses, a long-term follow up is necessary to determine if this graft may reduce leaflets deterioration.     

UT modification of the "David-V" procedure

Valve-sparing aortic root reimplantation with creation of pseudosinuses, so-called "David-V" procedure,is a promising surgical choice to treat annuloaortic ectasia (AAE). We have developed a simple modification of this procedure, which facilitates exposure and also enables good adjustment of the native aortic root anatomy and the graft. In this article we describe our original technique and its mid-term results.     

Results of surgery for aortic root aneurysm in patients with Marfan syndrome

OBJECTIVES: This study was undertaken to examine the long-term results of surgery for aortic root aneurysm in patients with Marfan syndrome. METHODS: Forty-four patients underwent aortic root replacement and 61 underwent aortic valve-sparing operations for aortic root aneurysm. Patients who underwent aortic root replacement had more severe symptoms, worse left ventricular function, more severe aortic insufficiency, and larger aortic root aneurysms than did patients who had aortic valve-sparing operations. Two types of valve-sparing operations were performed: reimplantation of the aortic valve in 39 patients and remodeling of the aortic root in 22 patients. Echocardiography was performed annually during follow-up. The mean follow-ups were 75 +/- 54 months for the aortic root replacement group and 49 +/- 38 months for the aortic valve-sparing group. RESULTS: There were 1 early death and 7 late deaths; 6 deaths were in the aortic root replacement group and 2 were in the aortic valve-sparing group. Survivals at 10 years were 87% in the aortic root replacement group and 96% in the aortic valve-sparing group (P =.3). Freedoms from reoperation at 10 years were 75% in the root replacement group and 100% in the valve-sparing group (P =.1). Freedoms from valve-related mortality and morbidity were 65% after root replacement and 100% after valve-sparing operation (P =.02). Freedom from aortic insufficiency greater than 2+ after aortic valve-sparing operations was 75% at 10 years and was similar for both types of valve-sparing operations; however, the diameters of the aortic annulus and neoaortic sinuses increased only after the remodeling procedure. CONCLUSIONS: This study suggests that aortic valve-sparing operations provide similar survival but lower rates of valve-related complications than aortic root replacement for patients with Marfan syndrome. Reimplantation of the aortic valve may be more appropriate than remodeling of the aortic root to prevent dilation of the aortic annulus, and for this reason we now use only this technique to treat patients with Marfan syndrome.     

New vascular graft for simplification of the aortic valve reimplantation technique

Achievement of optimal valve geometry in valve-sparing aortic root repairs is a prerequisite for favorable valve function and, therefore, the simplification of these procedures is of utmost importance. The aim of the study was to determine the feasibility of the new vascular graft for aortic valve reimplantation technique and evaluate the early and intermediate functional results. Five patients with different aortic root and valve pathologies (1 acute aortic dissection, 4 chronic aneurysms, and 1 bicuspid valve) of whom two patients suffered from severe (4+) aortic regurgitation, underwent valve-sparing aortic root repair using the reimplantation technique with the new graft. Three patients required, in addition to the aortic root repair, other procedures on the valve cusps. In all patients, optimal root restoration with no or slight valve insufficiency could be achieved, and these results remained unchanged over the follow-up time of up to two years. The new aortic root graft simplifies aortic root repair using the valve reimplantation technique, and despite its straight form, allows easy restoration of the aortic root, which fits perfectly with patients' anatomy.     

A new simple and objective method for graft sizing in valve-sparing root replacement using the reimplantation technique

The methods of graft sizing in valve-sparing surgery are criticized for their complexity and subjectivity in application. We propose a simple method for graft sizing in valve-sparing root replacement using the reimplantation technique. Practically, the height of the commissure between the noncoronary cusp and the left coronary cusp give the size of the graft. This new method of graft sizing was successfully applied in the last 27 consecutive patients with good immediate results. Graft sizing with this objective and reproducible simple method results in restoration of normal aortic valve geometry and function.     

Aortic repair in Marfan's syndrome: prevention of mechanical leaflets damage

Aortic incompetence in Marfan's syndrome results from distortion or dilatation of the sinuses of Valsalva, annuloaortic ectasia or a combination of these problems. Valve leaflets in these patients are macroscopically normal in spite of aortic insufficiency. Replacement of the ascending aorta, root and aortic valve with a composite graft was, for a long time, the treatment of choice for Marfan patients. Valve-preserving procedures (remodeling or reimplantation) provide the advantages of avoiding the shortcomings of standard surgical techniques, and maintaining the functional integrity of the left ventricular (LV) outflow tract, aortic root and ascending aorta. We developed a modified valve-sparing reimplantation technique for avoiding leaflet damage. This was achieved by leaving a 'cushion' of aortic wall (8--10 mm) that, sewn on the Dacron graft, works as a 'damper' and prevents leaflets injury during the systolic opening of the valve. For final judgment of this operative method long-term results are necessary.     

Valve-sparing aortic root replacement (remodeling/reimplantation) in acute type A dissection

BACKGROUND: High reoperation rates after supracommissural tube graft replacement for acute type A dissection due to sinus of Valsalva dilation have been reported. Valve-sparing operations focusing on the replacement of the sinus of Valsalva are an appealing alternative. The applicability of these techniques in acute type A dissection remains debatable and results are limited. METHODS: From 1992 to 1998, 20 patients with acute type A dissection received a valve-sparing aortic root replacement. Two different types of aortic valve-sparing operations were performed: the remodeling technique in 11 patients and the reimplantation technique in 9 patients. Patients were followed for 26 +/- 18 months. Echocardiographic studies were performed every 6 months. RESULTS: There were 2 early postoperative deaths and no late death, no reoperation, and no thromboembolic events. The latest echocardiographic studies of the 18 survivors showed a competent valve in 12 and a trivial aortic valve insufficiency in 6 patients. The mean aortic valve pressure gradient was 4.3 +/- 1.3 mm Hg. CONCLUSIONS: These midterm results support the surgical strategy of valve-sparing aortic root replacement in patients with acute type A dissection.     

Reimplantation Valve‐Sparing Aortic Root Replacement for Aortic Root Aneurysm in the Elderly: Are We Pushing the Limits?

Abstract   Objectives: Reimplantation valve-sparing aortic root replacement has been increasingly performed with improving perioperative and midterm results. However, extending the age criterion in patient selection remains a debate. This study reviews the results of reimplantation valve-sparing aortic replacement in patients greater than 60 years of age. Methods: During a 51-month period, 63 patients with aortic root aneurysms underwent reimplantation valve-sparing aortic root replacement. The Gelweave Valsalva™ prosthesis (TERUMO CardioVascular Systems Corp., Ann Arbor, MI, USA) was used in all but one case. The patients were predominantly male, and the mean age was 67 years (range, 61–83 years). Four patients had congenital bicuspid aortic valves, and cusp repair was required in one patient. The mean follow-up was 25 months (range, 1–51 months). Results: There were one hospital and two late deaths. Overall survival at 51 months was 84 ± 9.9%. During follow-up, one patient developed severe aortic incompetence (AI) requiring an aortic valve replacement (AVR). Freedom from reoperation at 51 months was 92.8 ± 6.8%. Moderate AI was present at latest echocardiogram in one patient. Freedom from moderate or severe AI at 51 months was 90 ± 9.4%. There was no episode of endocarditis on follow-up. Univariate analysis demonstrated that no preoperative or intraoperative factor was a predictor for late reimplantation failure. Conclusions: Reimplantation valve-sparing aortic root replacement in patients greater than 60 years old can be performed with satisfactory perioperative and midterm results. Long-term results are needed to define the durability of this technique and its role in this subset of patients. (J Card Surg 2010;25:56-61)     

Aortic valve-sparing operations in patients with aneurysms of the aortic root or ascending aorta

BACKGROUND: Aortic valve-sparing operations are an alternative to aortic root replacement in patients with aortic root aneurysms, or aortic valve replacement and supracoronary replacement of the ascending aorta in patients with ascending aorta aneurysms and dilated sinotubular junctions with consequent aortic insufficiency. METHODS: From 1988 to 2001, 230 patients underwent aortic valve-sparing operations for aortic root aneurysms (151 patients) or ascending aortic aneurysms with aortic insufficiency (79 patients). Two types of aortic valve-sparing operations were performed in patients with aortic root aneurysms: reimplantation of the aortic valve and remodeling of the aortic root. Mean follow-up was 3.8 +/- 2.8 years. RESULTS: Patients with aortic root aneurysms were younger, had less severe aortic insufficiency, less extensive vascular disease, and better left ventricular function than patients with ascending aorta aneurysms. The 8-year survival was 83% +/- 5% for the first group and 36% +/- 14% for the second. The freedom from aortic valve reoperation at 8 years was 99% +/- 1% for the first group and 97% +/- 2% for the second. In patients who had aortic root aneurysms, 3 developed severe aortic insufficiency (AI), and 15 developed moderate AI, for an 8-year freedom from significant AI of 67% +/- 7%. But freedom from AI was 90% +/- 3% after the technique of reimplantation, and 55% +/- 6% after the technique of remodeling (p = 0.02). In patients with ascending aortic aneurysms, the freedom from AI greater than 2+ at 8 years was 67% +/- 11%. CONCLUSIONS: The long-term results of aortic valve sparing for aortic root aneurysms are excellent, and reimplantation of the aortic valve may provide a more stable repair of the aortic valve than remodeling of the aortic root.     

Valve-sparing root replacement after the Ross procedure

ObjectivesThe Ross procedure is a preferred treatment for infants and children with aortic valve disease. Progressive neoaortic root dilation and neoaortic insufficiency can occur after the Ross procedure, and because of the young age of these patients, valve-sparing aortic root replacement procedures have advantages compared with the Bentall procedure. The aim of this study is to describe our experience with different techniques of aortic valve-sparing root replacement in this unique cohort of patients.MethodsPatients undergoing valve-sparing aortic root replacement with a history of the Ross procedure between January 2001 and March 2021 were identified. A retrospective chart review was performed, and clinical characteristics of these patients were analyzed. The results of different types of valve-sparing aortic root replacement were also compared.ResultsForty-two patients who had previously undergone a Ross procedure in childhood presented for reintervention for neoaortic root or valve pathology. Seventeen of these patients were considered for valve-sparing aortic root replacement but underwent bioprosthetic or mechanical valve replacement, and 25 patients underwent successful valve-sparing aortic root replacement. Patients who underwent valve-sparing aortic root replacement received a traditional aortic root remodeling procedure with or without suture annuloplasty (Yacoub technique, group 1, n = 7), an aortic root reimplantation procedure (David technique, group 2, n = 11), or a modified root remodeling procedure that also used a geometric annuloplasty ring (group 3, n = 7). Patient demographics and comorbidities were similar between groups. Mean follow-up for these 3 cohorts was 14 years, 4 years, and 1 year, respectively. Overall survival was good, with 1 early death due to hemorrhage in group 2 and 1 death due to malignancy in group 1. Eight patients (7 in group 1; 1 in group 2) required subsequent aortic valve replacements due to neoaortic insufficiency, whereas none in group 3 have required any reintervention. Overall, patients requiring valve replacement after valve-sparing aortic root replacement had lower grades of preoperative neoaortic insufficiency and higher grades of postoperative neoaortic insufficiency. Greater than mild postoperative neoaortic insufficiency was associated with the need for subsequent neoaortic valve replacement.ConclusionsValve-sparing aortic root replacement is safe in patients with a prior Ross procedure. Reimplantation offers superior durability compared with the traditional remodeling procedure. Greater than mild neoaortic insufficiency on postoperative echocardiogram should prompt additional attempts at valve repair. A modified remodeling procedure with geometric ring annuloplasty that is personalized to the patient's individual anatomy is safe with good short-term results, but longer follow-up is needed.     

Valve-sparing aortic root replacement

The aortic root has a unique 3-dimensional configuration and the distinctive function of supporting the aortic valve and blood vessels. The sinuses of Valsalva are crucial to create appropriate eddy currents that are important in initiating and coordinating aortic valve closure and promoting coronary artery blood flow. Most aneurysms in the aortic root are associated with degenerative changes in the elastic media rather than atherosclerosis. Valve-sparing root repair has become widely accepted, although the Bentall procedure remains the gold standard. Because reimplantation using the Valsalva graft allows root geometry to be retained and theoretically and practically prevents recurrent aortic valve regurgitation, it is considered the most reliable and preferred technique among various valve-sparing aortic root repair procedures.     

Aortic root surgery in Marfan syndrome: Comparison of aortic valve-sparing reimplantation versus composite grafting

OBJECTIVE: The objective of this study was to compare the results of aortic valve-sparing reimplantation and aortic root replacement with mechanical valve conduits in patients with Marfan syndrome undergoing operation for aortic root aneurysms.Patients and methods Between March 1979 and April 2002, 119 patients with clinical evidence of Marfan syndrome underwent composite graft replacement with mechanical valve conduits (n = 74) or aortic valve-sparing reimplantation according to David (n = 45). The underlying causes were aortic dissection type A (43 patients) and aneurysms (76 patients). RESULTS: Patients undergoing aortic valve reimplantation were younger compared with patients undergoing composite grafting (28 vs 35 years, P =.002) and had longer intraoperative aortic crossclamp times (125 vs 78 minutes, P <.0001) and extracorporeal circulation times (162 vs 124 minutes, P <.0001). Early postoperative mortality was 6.8% (n = 5) in patients undergoing composite grafting and 0% in patients undergoing aortic valve reimplantation (P =.15). Mean follow-up was 30 months for patients undergoing aortic valve reimplantation and 114 months for patients undergoing composite grafting. Freedom from reoperation and death after 5 years postoperatively was 92% and 89% in patients undergoing composite grafting and 84% and 96% in patients undergoing aortic valve reimplantation (P =.31; P =.54), respectively. Thromboembolic complications or late postoperative bleeding occurred in 17 patients undergoing composite grafting, and an early postoperative event occurred in 1 patient undergoing aortic valve reimplantation. CONCLUSIONS: The results of aortic valve reimplantation and composite grafting of the aortic valve and ascending aorta with mechanical valve conduits are similar with regard to early and mid-term postoperative mortality and to the incidence of late reoperations in patients with Marfan syndrome. The low risk of thromboembolic or bleeding complications favors aortic valve reimplantation in these patients.     

Valve-sparing aortic root replacement and aortic valve repair for a 2-year-old girl with Loeys–Dietz syndrome

We report the case of a 2-year-old girl with Loeys–Dietz syndrome complicated by aortic root dilatation and aortic regurgitation. We performed valve-sparing aortic root replacement with reimplantation technique and aortic valve repair using central plication and free-margin reinforcement simultaneously. The postoperative course was uneventful and the latest echocardiography, 5 years after procedure, revealed trivial aortic insufficiency.     

Successful valve-sparing in aortic root reconstruction under endoscopic guidance.

OBJECTIVE: Aortic insufficiency (AI) associated with ascending aneurysm can be corrected by valve-sparing aortic root reconstruction ('David' reimplantation, 'Yacoub' remodeling). Intraoperative endoscopic evaluation in the aortic root may help to clarify the procedure and to access competence of the preserved valve. METHODS: Following cross-clamping of the ascending aorta, an endoscopy was inserted into the proximal aortic root. Perfusion of crystalloid cardioplegia enabled the visualization of the pressure-loaded valve in the closed position. Conventional macroscopic evaluation would have overlooked valve prolapse because of a release from perfusion pressure. Valve coaptation was imaged directly before and after the valve-sparing procedure. A total of 17 patients underwent aortic root reconstruction under endoscopic guidance. Indications of the valve-sparing were determined with endoscopic findings. The degree of AI before and after the surgery was evaluated by aortography and scored (0, none; 1 trivial; 2, mild; 3, moderate; 4, severe). RESULTS: Remodeling was employed to eight patients and reimplantation to four. The other five patients were replaced with prosthetic valved-conduit. There was no early and late mortality. Before and after the valve-sparing surgery, grades of AI were significantly reduced. Three patients who underwent reimplantation procedure required late valve replacement for late progression of AI, however, none of the patients with remodeling required reoperation. CONCLUSION: Introduction of an endoscopy successfully reduced postoperative AI and clarified indications and limitations of valve-sparing aortic root operations.     

Valve sparing aortic root replacement for dilatation of the pulmonary autograft and aortic regurgitation after the Ross procedure

BACKGROUND: Aortic insufficiency secondary to progressive dilatation of the pulmonary autograft is being recognized with increasing frequency after the Ross procedure. We reviewed our experience with valve-sparing aortic root replacement concomitant with aortic annuloplasty to assess the effectiveness of this approach. METHODS: Four patients, aged 8 to 27 years, presented with moderate to severe aortic insufficiency associated with progressive root dilatation from 1 to 8 years after a Ross procedure. All patients had 0 to 1+ aortic insufficiency early after the Ross procedure, with a mean maximal sinus diameter of 37 mm (range 30 to 45 mm). At reoperation the maximum diameter of the root ranged from 45 to 55 mm (mean 50 +/- 4 mm). A valve-sparing aortic root replacement with annular reduction was performed. The annulus was decreased from a mean of 27 mm to 23 mm. For the root replacement, 1 patient underwent a standard root remodeling procedure; in the others, a separate piece of scalloped Dacron (C.R. Bard, Haverhill, PA) graft material was used for each sinus to facilitate optimal exposure. RESULTS: All 4 patients are in New York Heart Association functional class I at a mean follow-up of 6 months. The most recent echocardiography demonstrated 0 to 1+ aortic insufficiency with good left ventricular function. Histology of the excised pulmonary autograft walls demonstrated severe elastin fragmentation. CONCLUSIONS: Aortic root remodeling with annular reduction is an effective treatment for aortic root dilatation and aortic insufficiency after the Ross operation. This procedure allows correction of aortic insufficiency and avoids the need for a prosthetic valve and anticoagulation.     

Midterm results after aortic valve-sparing operation

OBJECTIVES: We have conducted aortic valve-sparing operation for patients having aortic root dilatation and almost normal aortic valve leaflets since August 1998, and here report midterm results. METHODS: Patients with dilated aortic annulus or Marfan's syndrome were treated with reimplantation, and the remaining patients with remodeling. Either 24 or 26 mm graft was selected based on aortic annular diameter and leaflet size. Aortic valve competence was assessed regularly with echocardiography. RESULTS: Five patients (age: 29 +/- 13 yr), including 4 with Marfan's syndrome, had undergone reimplantation, and 3 (age: 46 +/- 18 yr) remodeling by December 2000. Mean follow-up was 18 (range: 10-32) months, and no postoperative death has occurred and no reintervention has been required thus far. All the patients in the remodeling group showed only a small pressure gradient through the aortic valve and decreased left ventricular diameter. Two in the reimplantation group showed a pressure gradient exceeding 20 mmHg. Two Marfan's syndrome patients in the reimplantation group showed slightly increased diastolic left ventricular diameter and 3 slightly increased systolic left ventricular diameter. Although aortic regurgitation had diminished in all patients by discharge, moderate aortic regurgitation recurred in 1 non-Marfan's syndrome patient in the reimplantation group because of degenerated aortic valve. CONCLUSION: Although postoperative aortic valve function was not perfect in all patients undergoing reimplantation, midterm results after aortic valve-sparing operation were generally satisfactory. Proper selection of patients, procedures, and graft size was thought to be important to ensure a favorable surgical outcome.