Geometrical difference between an ascending aneurysm and a root aneurysm in valve-sparing operations.

OBJECTIVE: The aortic root geometry of the leaflet size and coaptation in an ascending aortic aneurysm, and in a root aneurysm, may predict the early and late outcomes from valve-sparing surgery. METHODS: The aortic root was investigated using intraoperative endoscopy before and after valve-sparing root reconstruction. The definition of 'root aneurysm' was marked sinus dilatation proximal to the sinotubular junction. 'Ascending aneurysm' was defined as dominant dilatation distal from the sinotubular junction. Fifteen cases were examined and classified into two groups; Group A with an ascending aneurysm (four patients), and Group R with a root aneurysm (eleven patients). RESULTS: Cusp prolapse was seen in 10 (90.9%) patients of Group R, and in only one (25%) patient of Group A. The length of the free margin of all cusps in Group R was significantly longer than those in Group A. In Group R, the lengths of the free margin of an individual cusp were significantly different, indicating asymmetric cusps. In Group A, the length of the free margin were similar, indicating symmetric cusps. There was no significant difference in the degree of immediate postoperative aortic insufficiency, between the two groups. At the most recent follow-up, progressive aortic insufficiency was present in two patients of Group R. CONCLUSIONS: A root aneurysm had asymmetric, elongated and prolapsed aortic cusps, while an ascending aneurysm had symmetric cusps without prolapse. The mechanism of aortic insufficiency in a root aneurysm was more complex, suggesting a difficulty in achieving long-term valve competence. Such geometrical difference should be considered in the indication for the surgical technique of valve-sparing operations.     

A case of combined operation of aortic valve slicing and root remodeling for ascending aortic aneurysm with aortic regurgitation]

A 56-year-old female admitted with severe back pain, and her chest computed tomography demonstrated non-dissecting sclerotic aneurysm of the ascending aorta. Aortography and echocardiography showed marked dilatation of the ascending aorta and the Valsalva sinuses resulting in disappearance of the sinotubular junction. Aortic regurgitation of grade three was, also, recognized. A combined operation of aortic valve slicing of the right and the left coronary cusps and aortic root remodeling (Yacoub's method) was successfully performed. A woven Dacron double-veloured graft (Hemashield) of 22 mm in diameter was used for reconstruction of the ascending aorta and its root. Postoperative aortography figured the new sinotubular junction and the new Valsalva-like sinus composed by the graft, and aortic regurgitation was controlled to grade one.     

Results of aortic valve-sparing operations.

OBJECTIVE: To review the late results of valve-sparing operations in patients with aortic root aneurysm and in those with ascending aortic aneurysm and aortic insufficiency. METHODS: From May 1988 to June 2000, 120 patients with aortic root aneurysm and 68 with ascending aortic aneurysm and aortic insufficiency underwent aortic valve-sparing operations. Patients with aortic root aneurysm were younger, were predominantly male, and had less severe aortic insufficiency than patients with ascending aortic aneurysm, who were older and often had aneurysm of the transverse arch. Forty-eight patients with aortic root aneurysm had the Marfan syndrome. The prevalence of aortic dissection was similar in both groups. Reconstruction of the aortic root was performed by reimplanation of the aortic valve in 64 patients and by remodeling of the aortic root in 56. Patients with ascending aortic aneurysm and aortic insufficiency were treated by replacement of the ascending aorta with reduction in the diameter of the sinotubular junction. Approximately two thirds of the latter patients also required replacement of the transverse aortic arch. The mean follow-up was 35 +/- 31 months for patients with aortic root aneurysm and 26 +/- 23 months for those with ascending aortic aneurysm. RESULTS: There were 2 operative and 5 late deaths in patients with aortic root aneurysm and 1 operative and 9 late deaths in patients with ascending aortic aneurysm. The 5-year survival for patients with aortic root aneurysm was 88% +/- 4% and for patients with ascending aortic aneurysm, 68% +/- 12% (P =.01). Severe aortic insufficiency developed in 2 patients, and they required aortic valve reoperation. The 5-year freedom from aortic valve reoperation was 99% +/- 1% for patients with aortic root aneurysm and 97% +/- 4% for those with ascending aortic aneurysm. Seven patients had moderate aortic insufficiency at the latest echocardiographic study. The 5-year freedom from severe or moderate aortic insufficiency was 90% +/- 4% in patients who had aortic root aneurysm and 98% +/- 2% in those who had ascending aortic aneurysm. CONCLUSIONS: Aortic valve-sparing operations have provided excellent clinical outcomes and few valve-related complications. The function of the reconstructed aortic root remains unchanged in most patients during the first 5 years of follow-up.     

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

OBJECTIVE: To evaluate the results of two operations, aortic valve-sparing and aortic root replacement, in patients with aortic root aneurysm and the Marfan syndrome. METHODS: A retrospective review of 78 consecutive patients with aortic root aneurysm and the Marfan syndrome according to the Gent criteria indicated that 42 patients with normal aortic cusps had an aortic valve-sparing operation, and 36 patients had aortic root replacement (mechanical valve in 25 patients and biological valve in 11). The mean age was similar in both groups, but patients who had aortic root replacement had larger aneurysms, higher grade aortic insufficiency, worse left ventricular function and more cardiac co-morbidity than patients who had aortic valve-sparing operations. The mean follow-up was 41+/-35 months for patients who had aortic valve-sparing, and 65+/-50 months for those who had aortic root replacement. RESULTS: Kaplan-Meyer estimates of survival at 5 years was 100% for patients who had aortic valve-sparing, and 88+/-6% for those who had aortic root replacement (P=0.04). Five patients who had aortic root replacement required seven aortic root re-replacements: three for endocarditis and four for valve failure (biological valves). There have been no reoperations in patients who had aortic valve-sparing operations and annual Doppler echocardiography revealed mild or no aortic insufficiency in 39 patients and moderate aortic insufficiency in three. CONCLUSIONS: These data suggest that aortic valve-sparing operations are safe in patients with the Marfan syndrome and may provide better clinical outcomes than aortic root replacement. Since the size of the aneurysm often determines the feasibility of a valve-sparing procedure, we now recommend surgery when the diameter of the aortic root reaches 50 mm in patients with the Marfan syndrome who have echocardiographically normal aortic valve cusps.     

Giant sinus of valsalva aneurysm with severe aortic incompetence treated with a valve-sparing operation

Typically, a sinus of Valsalva aneurysm with severe aortic incompetence is repaired with patch closure and aortic valve replacement. Here, we describe a very rare case of a giant nonruptured right Valsalva aneurysm, combined with severe aortic incompetence, treated with a valve-sparing aortic root replacement. During surgery we noted that the lengths of the free margin of the cusps and annuli were not uniform. As a result, we placed the first layer of sutures for the Valsalva graft in the same ratio as the annuli. It is difficult to preserve the geometry of the aortic annulus and position the commissures in the graft. One surgical tip for valve-sparing aortic root replacement for a sinus of Valsalva aneurysm with severe aortic incompetence is to suture the commissures inside the graft in the same ratio as the length of the cusp free margins.     

Valve-sparing replacement of the ascending aorta and aortic arch in a child with Loeys-Dietz syndrome

We describe a successful surgical treatment in a 2.5-year old boy with Loeys-Dietz syndrome, in whom we performed aortic arch and ascending aorta replacement with a valve-sparing operation (VSO) of the aortic root because of significant aortic insufficiency and dilation of the aortic root. We believe that VSO is ideal for treating young patients with aortic root aneurysm with normal or minimally diseased aortic cusps to avoid the disadvantages of prosthetic valve replacements.     

Aortic root remodeling with the "cuff" technique for stentless valve implantation

Aortic root and sinotubular junction dilatation and aneurysm of ascending aorta are considered relative contra-indications to implantation of a stentless valve prosthesis, because the modified aortic geometry leads to aortic incompetence and early failure of the prosthesis. Aortic root reconstruction can be performed according to various techniques. We present a surgical technique in which a tubular graft, replacing an ascending aortic aneurysm, allows sinotubular remodeling and satisfactory implantation of a stentless prosthesis. The native aorta is inserted into the vascular prosthesis at the level of the sinotubular junction which is wrapped in order to prevent commissure spreading. Sizing of the vascular and valve prosthesis is made according to annular diameter. Since October 1999, 6 patients have been operated using this technique with good results.     

Aortic valve sparing operations: an update

Background. Aortic valve sparing operations in patients with ascending aorta and/or aortic root aneurysms have been performed for a decade in our institution. Initially only patients with normal aortic valve leaflets had these operations, but more recently we utilized them in patients with prolapse of a single leaflet and in those with a bicuspid aortic valve. This article is an update on the clinical results of these operations.

Methods. From May 1988 to December 1997, 126 patients with ascending aorta and/or aortic root aneurysms and aortic insufficiency underwent replacement of the ascending aorta with reconstruction of the aortic root and preservation of the native aortic valve. There were 85 men and 41 women, with a mean age of 54 years (range, 14 to 84). Thirty-two patients had the Marfan syndrome; 17 patients had acute and 10 had chronic type A aortic dissection; 23 had a transverse arch aneurysm; 26 had coronary artery disease, and 8 had mitral regurgitation. The aortic valve sparing operation consisted of simple adjustment of the sinotubular junction in 33 patients, adjustment of the sinotubular junction and replacement of one or more aortic sinuses in 60, and reimplantation of the aortic valve in a tubular Dacron (C.R. Bard, Haverhill, PA) graft in 33. Fifteen patients also had repair of aortic leaflet prolapse. Only 4 patients had a bicuspid aortic valve.

Results. There were 3 operative deaths due to cardiac failure. Patients were followed from 2 to 117 months, with a mean of 31. There were 11 late deaths: 7 cardiovascular and 4 from unrelated causes. The actuarial survival was 72 ± 8% at 7 years. Two patients required aortic valve replacement; the freedom from aortic valve replacement was 97 ± 2% at 7 years. Doppler echocardiography revealed absent, trivial or mild aortic insufficiency in most patients; only 9 patients had moderate aortic insufficiency.

Conclusions. Aortic valve sparing operations are feasible in most patients with ascending aorta and/or aortic root aneurysms who have normal or near normal aortic leaflets. The functional results of the repaired aortic valve are excellent, and the repair appears to be durable.     

Management of ascending aortic aneurysm and valvular incompetence with external remodeling

Aneurysmatic dilatation of the sinotubular junction may result in aortic valvular incompetence even if the leaflets remain structurally intact. Traditionally, such situations are managed by open techniques of both the ascending aorta and the aortic valve. We present a case of aortic regurgitation, due to a 50-mm diameter ascending aortic aneurysm, which was corrected by sinotubular remodeling and wall-reinforcement without the usage of cardio-pulmonary bypass. The authors describe a calculation-based and a transesophageal echo controlled technique of external reconstruction of the aorta and correction of the aortic regurgitation.     

Replacement of ascending aorta with aortic valve reimplantation: midterm results

Objective: Aneurysms of the aortic root lead to aortic valve incompetence due to dilatation of the sinotubular junction and annuloaortic ectasia. Reimplantation of the native, structurally intact aortic valve within a Dacron tube graft corrects annular ectasia as well as dilatation of sinotubular junction and aortic sinuses. Durability of this valve repair with respect to increased mechanical stress on valve cusps is discussed controversially and is yet unknown. Methods: Since 7/93, replacement of the ascending aorta with repair of the aortic valve was performed in 48 patients (34 male, 14 female; 47±20 years) with aortic insufficiency and aneurysm of the aortic root. Fifteen patients (31%) had Marfan's syndrome and five patients (10%) had an aortic dissection type A (two acute, three chronic). In 11 patients (23%), concomitant replacement of the aortic arch was necessary utilizing elephant trunk technique in two patients. Additionally, one patient required mitral valve repair and two other patients coronary artery bypass grafts. Clinical and echocardiographic follow-up was performed in 6–12 month intervals for a cumulative study period of 100 patient years. Results: There were no operative deaths. Two patients (4%) died 5 and 20 months postoperatively. One additional patient experienced a TIA within the first postoperative week. Three patients (6%) with an early postoperative aortic insufficiency (AI)>1 required aortic valve replacement after 9, 11, and 14 months due to progressive AI. In these patients, distortion of the aortic root geometry led to valve incompetence. All other patients have no or mild aortic insufficiency. The repair now remains stable for up to 63 months (mean 25±18 months). Other valve related complications did not occur. Conclusions: Our results demonstrate that this type of aortic valve repair achieves excellent results in selected patients. Perfect coaptation of valve cusps during the repair with no or only trace AI at initial echocardiography seems to be essential for durability.     

A giant unruptured aneurysm of the sinus of Valsalva together with ectasia of the left coronary artery

A sinus of Valsalva aneurysm is defined as a dilatation of the aortic sinuses, between the aortic valve annulus and the sinotubular junction. They are rare and most frequently involve the right coronary sinus. We report a case of an unruptured giant sinus of Valsalva aneurysm in a patient associated with ectasia of the left main stem and left anterior descending coronary artery. The patient was successfully treated with aortic root replacement using a biologic conduit.     

Aortic valve-sparing operations for aortic root aneurysm

The object of this report is to review the clinical outcomes of aortic valve-sparing operations in patients with aortic root aneurysm. From May 1988 to June 2000, 120 patients with aortic root aneurysm with or without aortic insufficiency underwent aortic valve-sparing operations. There were 83 men and 37 women whose mean age was 46 years (range 16 to 72 years). Forty-eight patients had the Marfan syndrome, and 22 had either acute or chronic type A aortic dissections. Reconstruction of the aortic root was performed using the technique of reimplanation of the aortic valve in 64 patients and the remodeling of the aortic root in 56. The mean follow-up was 35 months (range 2 to 145 months), and it was complete. Aortic valve function was assessed by echocardiography. There were 2 operative and 5 late deaths. The 10-year survival for patients with aortic root aneurysm was 88% +/- 4%. Two patients have required aortic root replacement: one on the first postoperative day because of severe aortic insufficiency and one paraplegic patient 12 years after surgery because of infective endocarditis with aortic root abscess. Both patients survived reoperation. The 10-year freedom from aortic root reoperation was 99% +/- 1%. Three patients suffered transient ischemic attacks. The 10-year freedom from thromboembolic events was 89% +/- 5%. Seven patients had moderate aortic insufficiency at the latest echocardiographic study. The 10-year freedom from severe or moderate aortic insufficiency was 83% +/- 8%. Aortic valve-sparing operations have provided excellent clinical outcomes and few valve-related complications. The function of the reconstructed aortic root remains unchanged in most patients during the first decade of follow-up.     

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.     

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 operation for aortic root aneurysm late after Mustard procedure

The aortic valve reimplantation technique leads to excellent clinical outcome in patients with aortic valve incompetence and aneurysms of the ascending aorta. This technique is now applied for aneurysms of ascending aorta, aortic dissection type A, and even dilatation of pulmonary autograft after the Ross operation. We report a case of aortic root dilatation late after a Mustard operation for transposition of the great arteries that was successfully managed by valve-sparing aortic root reimplantation.     

Surgery for aortic root aneurysm in children: a 21-year experience in 50 patients

BACKGROUND: Ascending aortic aneurysms are unusual in children and have received little attention to develop guidelines for management. This study reviewed our experience with 50 children who have undergone aortic root replacement for ascending aortic aneurysm. METHODS: A retrospective clinical review was conducted using hospital charts and office records. Patients or their physicians were contacted for follow-up and recent echocardiograms were obtained and reviewed. RESULTS: There was no operative or hospital mortality. Twenty-six children had aortic root replacement with a composite graft, 10 patients had replacement with a homograft aortic root, and 14 patients had a David II valve-sparing procedure. Factors related to late morbidity and mortality were analyzed. Long-term results were excellent in the 26 children receiving a composite graft. Twenty-three of these children were New York Heart Association class I (19) or II (4) at study closure. There were 3 late deaths (11, 16, and 17 years postoperative). Seven of 10 children receiving a homograft aortic root are long-term survivors and all 14 children having a valve-sparing procedure are alive. Generally, late results with the David II remodeling procedure have been good although 3 patients developed late aortic insufficiency and two required valve replacement. CONCLUSIONS: Aortic root replacement in children with aneurysms has low operative risk and good long-term results. Composite grafts in particular carry a low risk of endocarditis, thromboembolism, and hemorrhagic events. Homografts are suitable for small patients but lack durability. Late results with the David II remodeling valve-sparing procedure in children have been compromised by late root dilatation.     

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.     

Reduction of the sinotubular junction in patients undergoing ascending aortic replacement with coexisting aortic insufficiency

Abstract Background and Aim of the Study: Dilatation of the STJ may cause consequent aortic insufficiency (AI) in patients with normal aortic valve, in patients with ascending aortic aneurysm. In this study, we analyzed the results of ascending aorta replacement with STJ diameter reduction to correct consequent AI in patients with ascending aortic aneurysm. Methods: Forty‐five consecutive patients who had ascending aortic aneurysm underwent replacement of ascending aorta with reduction of the STJ diameter to correct AI. Mean age of the patients was 61.3 ± 5.2. Twenty‐six (57.8%) were female. Six patients had arch aneurysm. Postoperative echocardiographic studies were performed at discharge and annually thereafter. The mean duration of follow‐up was 4.6 ± 2.9 years. Results: Hospital mortality rate was 4.9% (n = 2). Three patients died during follow‐up. Three patients had late recurrence of AI that was caused by aortic root dilatation. One of these patients required aortic valve replacement because of severe aortic insufficiency. The five‐year survival and survival free from aortic insufficiency were 91.4%± 5.0% and 91.2%± 5.1%, respectively. Conclusions: Reduction of the diameter of STJ can be used to treat AI in patients with ascending aortic aneurysm with nearly normal aortic cusps. Midterm results of this procedure are encouraging. (J Card Surg 2011;26:88‐91)     

Valve-sparing root reduction plasty in aortic aneurysm: the "Jena" technique

Reconstruction of the aortic valve and replacement of the ascending aorta instead of use of a composite graft is the preferred method in patients, who demonstrate an ascending aneurysm accompanied by aortic root enlargement and aortic valve insufficiency with morphologically intact cusps. Two techniques inaugurated by David and Yacoub have gained widespread acceptance. However, both approaches are technically demanding. We present a simplified alternative technique for aortic valve reconstruction by means of a reduction plasty of the aortic root without the necessity of transection maneuvers.     

Plication of the sinotubular junction for aneurysm of the ascending aorta associated with aortic regurgitation: a case report

A 63-year-old woman with aneurysm of the ascending aorta associated with AR due to dilatation of the sinotubular junction (STJ) and with poor LV function, who did not have Marfan syndrome, underwent a plication of the STJ and replacement of the ascending aorta. In operation, we simultaneously performed the plication of dilated STJ (60 mm) and the replacement of ascending aorta using a 26 mm Woven Dacron graft. Post-operative angiogram (1 POM) showed no aortic regurgitation and good recovery of the LV function. This procedure is less invasive, and indicated for patients without significant elongation or thickening of the aortic valve, especially when the patients have higher risk.