Aortic root replacement versus aortic valve replacement: a case-match study

BACKGROUND: There is increasing evidence that patients with aortic valve disease and dilatation of the ascending aorta are at risk for later dissection or rupture of the aortic wall when the dilated ascending aorta is not replaced or reinforced at the time of aortic valve replacement. In order to find out whether the more complex surgical procedure of aortic root replacement carries a higher early or late postoperative risk than isolated aortic valve replacement, we conducted a matched-pair study with patients of both groups. METHODS: Between June 1993 and August 1998, 100 consecutive patients with aortic valve disease and ectasia/aneurysm of the ascending aorta underwent replacement of the aortic valve and the ascending aorta with a CarboSeal composite graft (CarboSeal; Sulzer Carbo-Medics Inc, Austin, TX). Identical bileaflet valve prostheses (CarboMedics; Sulzer CarboMedics Inc, Austin, TX) were implanted during the same time period in 928 patients for aortic valve disease. On the basis of various preoperative clinical variables 100 patients with aortic valve replacement were matched to the 100 patients with replacement of the aortic root. The duration of follow-up for both groups was similar with 37 + 17 months (range, 9 to 70) for the CarboSeal group and 38 + 14 months (range, 13 to 65) for the CarboMedics group. Survival and morbidity were calculated by Kaplan-Meier analysis and risk-adjusted mortality was evaluated by multivariate analysis in a Cox regression model. RESULTS: The early postoperative mortality of 1% in the CarboSeal group and 4% in the CarboMedics group was insignificantly different. Although the overall survival rate at 5 years was lower (60.7% vs 86.3%; p = 0.13) in the CarboSeal group, the freedom from cardiac mortality and valve-related morbidity was similar in the two groups. CONCLUSIONS: Replacement of the ascending aorta and aortic valve can be performed with similar operative risk, valve-related morbidity, and late cardiac mortality as isolated aortic valve replacement.     

Aortic root replacement after operation for the ascending aorta and/or aortic valve

We reviewed ten cases who underwent aortic root replacement after operation for the ascending aorta and/or aortic valve. As initial operation, aortic valve replacement (AVR) was performed in five patients, replacement of the ascending aorta in two, original Bentall operation in two, and entry closure and suspension of the aortic valve in one. At reoperation, three patients were diagnosed as aneurysm of the ascending aorta, two were annulo-aortic ectasia, and one was acute aortic dissection, chronic dissecting aneusym, pseudoaneurysm of the ascending aorta, prosthetic valve endocarditis, and massive aortic regurgitation. Aortic root replacement was performed using mechanical valved composite graft in all cases. One patient who underwent repeat aortic root replacement for prosthetic valve endocarditis was died of septemia and ventricular fibrillation. Five patients had nine complications (two low output syndrome, respiratory failure and cerebral infarction, one gastrointestinal bleeding, septemia and ventricular fibrillation). In conclusion, aortic root replacement after operation for the ascending aorta and/or aortic valve was performed with acceptable morbidity and mortality.     

Aortic valve replacement with a stentless porcine aortic root bioprosthesis

From April, 1999 to November, 1999, 8 patients underwent the aortic valve replacement using Medtronic Freestyle aortic root bioprosthesis. Mean age was 67.8 years old. Aortic valve etiology was as follows, AS: 1 case, AR: 2 cases, ASR: 3 cases, IE: 1 case, mechanical valve malfunction due to subvalvular pannus: 1 case. The implanted valve size was 25: 2 cases, 23: 3 cases, 21: 1 cases, 19: 2 cases. Surgical technique was subcoronary: 7 cases, full-root: 1 case. Post-op 2D-echo revealed tribial aortic valve incompetence in two cases because of size discrepancy between the aortic annulus and the ascending aorta. Pacemaker implantation was needed in 1 case because of the complete A-V block. In comparison with 5 cases of aortic valve replacement with Hancock II performed in same period, there were no significant differences about the implanted valve size and mean systolic pressure gradient, but the effective orifice area in Freestyle cases was significantly larger than Hancock II cases.     

Aortic dissection late after aortic valve replacement

We experienced 3 cases of an aortic dissection occurring late after an aortic valve replacement, and sucessfully treated by an aortic root replacement. An aortic dissection involving the ascending aorta can develop late after an aortic valve replacement, and such an occurrence is associated with a high mortality and morbidity. The development of effective surgical strategies at the initial aortic valve surgery, strict control of blood pressure after aortic valve replacement, serial evaluations of aortic size, and the prophylactic replacement of the ascending aorta for patients with aortic dilatation after aortic valve replacement, all play clinically important roles in preventing an aortic dissection after aortic valve replacement. When an aortic dissection occurs in patients with a previous aortic valve replacement, an aortic root replacement should be performed in order to avoid leaving the fragile diseased aortic wall including the sinus of Valsalva.     

Rapid-deployment aortic valve replacement after aortic root replacement: A safe alternative to redo root replacement

Reoperative aortic root replacement, following prior biologic or mechanical valved conduit aortic root prosthesis, presents a technical challenge. The rapid-deployment aortic valve prosthesis is an approved alternative to traditional bioprosthetic aortic valve replacement. We present three clinical cases in which rapid-deployment aortic valve prostheses were utilized in lieu of reoperative full aortic root replacement. All three patients recovered uneventfully. The rapid-deployment valve insertion in a prior surgical aortic root prosthesis is a safe option to avoid reoperative full aortic root replacement.     

Stentless bioprosthetic aortic valve replacement after a homograft root replacement: Toronto SPV implantation after a homograft root

Stentless bioprosthetic valves for the aortic position offer excellent hemodynamic characteristics, making them an attractive choice ahead of other valve prostheses. We present a unique case in which a patient underwent aortic valve replacement with a stentless porcine valve and mitral valve repair for severe aortic and mitral regurgitation 1 year after a homograft root replacement for acute aortic endocarditis. The rationale for our approach is outlined in the context of current surgical trends.     

Aortic valve operation after percutaneous aortic balloon valvuloplasty

From January 1986 to May 1988, 179 patients underwent percutaneous aortic balloon valvuloplasty at our institution. Forty-five (25%) patients subsequently required operation at this institution or other institutions. The indication for percutaneous aortic balloon valvuloplasty was patient preference in 15 and an estimation of excessive operative mortality in 30. Three patients required emergency operation immediately after valvuloplasty, and the other 42 had an elective operation a mean of 7.8 months afterward. All but 3 of these patients had major progression of symptoms, and all had valvular restenosis. In spite of the high-risk status of these patients, there were only four hospital deaths among the 45 patients. Three additional patients have died a mean of 11.4 months postoperatively. The condition of all survivors remains clinically improved after the valve operations. Percutaneous aortic balloon valvuloplasty must be recognized as a palliative procedure, and should be reserved for patients who are truly not candidates for operation or situations in which a brief period of reduction in gradient might improve a patient's condition before operation.     

Aortic complications after bicuspid aortic valve replacement: long-term results

BACKGROUND: Bicuspid aortic valve (BAV) is a risk factor for aortic dissection and aneurysm. We studied patients with BAV and tricuspid aortic valve (TAV) to evaluate long-term changes in the ascending aorta after aortic valve replacement (AVR). PATIENTS AND METHODS: One hundred consecutive patients were allocated into two groups according to the presence of BAV (group A, 50 patients) or TAV (group B, 50 patients). Mean age was 51 +/- 12 years in group A, and 50 +/- years 12 in group B. No patients had hypertension or Marfan's syndrome. Until July 2001, mean follow-up was 234 +/- 47 months in group A and 241 +/- 43 months in group B. RESULTS: Five patients (10%, CL 5.7 to 13.9) in group A suffered late acute aortic dissection. Acute aortic dissection (5 vs 0, p = 0.0001) and sudden death (7 vs 0, p = 0.0001) occurred more frequently in patients with BAV. All survivors were assessed by echocardiogram. The mean diameter of the ascending aorta was 48.4 mm in group A and 36.8 mm in group B. Three patients in group A were operated on because of ascending aorta aneurysm more than 6 cm in diameter. CONCLUSIONS: As a result of our experience, we recommend a policy of prophylactic replacement of even a seemingly normal and definitely a mildly enlarged ascending aorta in cases of BAV at the moment of AVR, and consideration of a similar approach for any other cardiac surgical procedure in patients with BAV.     

Aortic valve replacement in rheumatoid aortic incompetence.

Rheumatoid aortic valve disease is uncommon. and there are few reports of valve replacement in this condition. Aortic valve replacement and partial pericardiectomy was performed in a patient with acute rheumatoid aortitis and aortic incompetence. Previous reports suggest that any patient with rheumatoid arthritis who develops cardiac symptoms should be carefully assessed for surgically treatable involvement of the pericardium or heart valves.     

Aortic valve replacement in the calcified small aortic root by hemitranslocation of the valve

An alternative technique of aortic valve replacement is described for a small aortic root with a severe large calcific degeneration of the supraaortic area at the noncoronary sinus. This technique is used when Nicks or Manouguian procedures are not applicable.     

Aortic allografts and pulmonary autografts for replacement of the aortic valve and aortic root

Background. Extensive experience has accumulated with the use of aortic and pulmonary autografts for replacement of the aortic valve and the aortic root. Three general techniques for insertion have been used: subcoronary (free-hand) valve implantation, mini- or inclusion-root implantation, and aortic root replacement. Thirty-day mortality for elective operations with all of these techniques has not exceeded 5%. Thromboembolic episodes have been rare, and endocarditis has occurred infrequently. Early hemodynamic performance has been excellent, without significant gradients or valve regurgitation in the majority of patients.

Methods and Results. Progressive aortic regurgitation has been observed with continued follow-up, and is the most important complication of both types of valves. Leaflet failure and technical problems are the major causes of reoperation for patients receiving aortic allografts. There is some evidence to suggest that the prevalence of these complications is lower with the root replacement technique than with the intraaortic implantation methods.

Conclusions. Reoperation for regurgitation of the neo-aortic valve is the major complication of the pulmonary autograft procedure. The incidence of reoperation appears to be lowest with the root replacement technique. Certain conditions (acute rheumatic fever, juvenile rheumatoid arthritis, systemic lupus, ankylosing spondylitis, Libman-Sachs endocarditis, and possibly a dilated aortic root) may be contraindications to the use of a pulmonary autograft. Reoperation on the pulmonary allograft that is used to replace the autograft may be necessary in up to 20% of patients at 20 years.