Aortic root motion remodeling after aortic valve replacement--implications for late aortic dissection

Aortic root motion was previously identified as an additional risk factor for aortic dissection. This study analyzed if the magnitude of aortic root motion changed in patients after aortic valve replacement (AVR) and acute proximal aortic dissection. An institutional database (1984-2005) was used to measure the downward motion of the aortic root (perpendicular to the plane of the sinotubular junction) in contrast injections in 48 patients with aortic insufficiency (AI), aortic stenosis (AS) and proximal aortic dissection pre- and postoperatively, when available. Postoperative aortic root motion was significantly reduced after AVR for AI, while it was significantly increased after AVR for AS. By contrast, aortic root motion was unchanged when functional AI due to paravalvular leak was present post-AVR for AI. In patients with acute aortic dissection, both aortic root motion and aortic diameter were unchanged from pre-dissection. However, in patients who dissected again, aortic root motion was significantly smaller than pre-dissection, and the aortic diameter was significantly less than at first dissection. Removal of aortic stenosis was associated with increased aortic root motion, theoretically heightening the threat of dissection posed to the aortic wall by mechanical stress, although this was not confirmed by our study of dissection patients. Yet, mechanical principles command to include higher magnitude of aortic root motion during follow-up of patients after AVR as an additional risk factor for dissection.     

The Florida sleeve: a new technique for aortic root remodeling with preservation of the aortic valve and sinuses

Aortic valve salvage remains the procedure of choice for patients with incompetent valves and normal leaflet morphology. Here my colleagues and I describe a new technique for aortic root remodeling with preservation of the aortic valve.     

Aortic root reconstruction with preservation of native aortic valve and sinuses in aortic root dilatation with aortic regurgitation.

BACKGROUND: We assessed the results of a modified technique for aortic root reconstruction including preservation of the native aortic valve and sinuses. METHODS: A modified technique for reconstruction of the aortic root was devised in which the native aortic sinuses are preserved and remodeled, the diameter of the sinotubular junction is reduced, the ventriculoaortic junction is reinforced with a Dacron prosthesis, and the coronary ostia are reimplanted. Since January 1995, this modified operative technique was performed in 13 patients with a mean age of 54 +/- 21 years. The median grade of aortic regurgitation was 3; in 10 patients it was caused by dilatation of the sinotubular junction, and 3 had additional annuloaortic ectasia. RESULTS: The aortic crossclamping time was 61 +/- 18 minutes. In-hospital mortality was 2 of 13 (15. 3%) patients, both deaths being related to complications of aortic dissection. In 1 patient aortic regurgitation increased to grade 3, necessitating aortic valve replacement. At a mean follow-up of 2.1 years, the remaining 10 patients had stable aortic valve function with a median grade of regurgitation of 1. The mean New York Heart Association functional class was 1.2. CONCLUSIONS: Aortic root reconstruction with preservation of the native aortic valve and sinuses allows symmetric reconstruction of the aortic sinuses and adaptation of the diameters of the sinotubular and ventriculoaortic junctions, thus optimizing aortic valve function. Moreover, it prevents contact of the aortic valve leaflets with the Dacron graft, which may enhance the durability of the repair.     

Severe aortic insufficiency after transapical aortic valve implantation

We report the dislocation of a stented aortic valve prosthesis two weeks after the uneventful transapical implantation in a female who had underwent mitral valve replacement and CABG six years before. The initial implantation of the Edwards Sapien aortic valve prosthesis (Edwards Lifesciences, Irvine, CA), as well as the postoperative recovery, was uneventfully. At the sixth postoperative day, the patient developed a progressive heart failure due to a severe aortic insufficiency. During conventional aortic valve replacement, the dislocated prosthesis was found in the left ventricle. After uncomplicated postoperative recovery, the patient could be discharged in a good physical condition. Preexisting mitral valve prosthesis seems to be an important, complicating goal for transcatheter aortic valve implantation.     

Complete aortic root reimplantation facilitates preservation of the aortic valve.

The optimal technique for preservation of a retainable aortic valve is yet to be defined. We present a new facilitated procedure allowing for reimplantation of the complete aortic root in selected patients with acute type A aortic dissection or ascending aortic aneurysm.     

David Ⅰ手术治疗主动脉根部病变致主动脉瓣关闭不全的效果

目的 评价David Ⅰ术式治疗主动脉根部病变导致主动脉瓣关闭不全的治疗效果.方法 2005年8月至2011年5月,采用David Ⅰ手术治疗24例主动脉根部病变导致主动脉瓣关闭不全患者.男21例,女3例;年龄24 ～ 69岁,平均(47.0±12.3)岁.主动脉夹层13例,主动脉根部瘤7例,马方综合征2例,单纯主动脉瓣环扩张并主动脉瓣关闭不全2例.术前心功能Ⅰ级20例,Ⅱ级3例,Ⅲ级1例;主动脉瓣反流中度13例,重度11例.David Ⅰ手术采用直人工血管9例,带Valsalva窦人工血管15例.同期行冠状动脉旁路移植手术6例,主动脉弓置换11例,室间隔缺损修补术1例,房间隔缺损修补术1例,二尖瓣成形+三尖瓣成形1例.1例术中食管超声提示主动脉瓣大量反流,瓣叶脱垂,即刻决定使用带瓣人工血管行Bentall手术.术后观察患者心功能和主动脉瓣反流情况.结果 围术期死亡2例,分别于术后第9天死于感染性休克并多脏器功能衰竭和术后第22天死于肺部感染;近期死亡1例,术后第54天死于肺部感染.本组体外循环(235.9±58.5) min,主动脉阻断(182.7±35.8) min.术后1周超声心动图复查,主动脉瓣无反流11例,轻度反流11例,轻至中度反流1例;所有患者心功能均为Ⅰ级.术后20例(不包括3例死亡和1例行Bentall术者)随访3～74个月.主动脉瓣无反流3例;轻度反流15例,其中3例半年后再次复查提示主动脉瓣无反流;中度反流2例,其中1例3个月后复查提示反流转为轻度,1例采用直人工血管的马方综合征患者术后55个月复查提示反流转为重度.结论 保留主动脉瓣的主动脉根部再植入术(David Ⅰ术式)是治疗主动脉瓣叶及瓣环结构大致正常的主动脉根部病变引起的主动脉瓣关闭不全的一种理想手术方式,同时应用带Valsalva窦血管能提供更稳定的手术效果.     

Outcome of aortic valve repair in children with congenital aortic valve insufficiency

OBJECTIVE: Surgical aortic valvotomy has a long history of providing excellent palliation for aortic stenosis in infancy and childhood. The fate of aortic valve repairs for dominant aortic regurgitation in this same age group is considerably less clear. METHODS: From 1990 to 2000, a total of 21 patients underwent aortic valve repair for aortic regurgitation at our institution. Seventeen patients were younger than 17 years at the time of repair (3-17 years, mean 8.1 +/- 3.7 years). Of these 17 children, 6 (35%) had bicuspid valves and 11 (65%) had tricuspid valves. Type of repair varied with valve type, but repair generally consisted of commissure resuspension, partial commissure closure, triangular resection of redundant leaflets, or some combination. RESULTS: There were no deaths. Follow-up ranged from 1 to 11 years (mean 5.3 +/- 2.4 years). At present 3 of 17 (17.6%) have mild aortic regurgitation according to echocardiography and 6 (35.2%) have moderate aortic regurgitation. In 8 of 17 cases (47.1%) the repair clearly failed, requiring reoperation from 0.5 to 73 months after the original operation (mean 18.9 months). Reoperation consisted of 6 Ross procedures and 2 mechanical aortic valve replacements. There were no deaths at the secondary operation. CONCLUSION: Aortic valve repair in children with a dominant feature of aortic insufficiency tended to fail progressively and at a high rate. Leaflet thickening was associated with higher risk of repair failure in this series. The threshold for aortic valve replacement should remain low.     

Durability of aortic valve preservation and root reconstruction in acute type A aortic dissection

BACKGROUND: The aim of this study was to determine the durability of aortic valve preservation and root reconstruction in type A aortic dissection with involvement of the aortic root. METHODS: From November 1976 to February 1999, 246 patients underwent surgical treatment for acute type A aortic dissection at our institution. In 121 patients (49%), all with acute type A dissection and aortic root involvement, the aortic valve was preserved and one or more of the sinuses of Valsalva were reconstructed. The mean age of this group was 59 +/- 11 years and 70 (58%) were men. Thirty patients (25%) were operated in cardiogenic shock. Criteria for aortic root reconstruction were technical feasibility and surgeon preference. Techniques used for reconstruction were valve resuspension in all patients and additional reinforcement of the aortic root with Teflon (L.R. Bard, Tempe, AZ) felt (n = 21), gelatin-resorcinol-formaldehyde-glue (GRF-glue, Fii, Saint-Just-Malmont, France) (n = 103), or fibrinous glue (Tissu-col, Immuno AG, Vienna, Austria) (n = 5). Mean follow-up was 43.5 +/- 46 months. RESULTS: The operative mortality was 21.5% (n = 26). Actuarial survival was 72% +/- 4%, 64% +/- 5%, and 53% +/- 6% at 1, 5, and 10 years, respectively. Median aortic regurgitation in patients with retained native aortic valve at follow-up was 1+. All root reoperations included aortic valve replacement (n = 12). Freedom from aortic root reoperation was 95% +/- 2% at 1 year, 89% +/- 4% at 5 years, and 69% +/- 9% at 10 years. The incidence of aortic root reoperation was 23%, 11%, and 40%, respectively, when Teflon felt, GRF-glue, and fibrinous glue were used for root reconstruction. Multivariate Cox proportional hazard analysis revealed the use of fibrinous glue (RR = 8.7; p = 0.03) as well as the presence of an aortic valve annulus more than 27 mm (RR = 4.2; p = 0.04) as independent risk factors for aortic root reoperation. CONCLUSIONS: Aortic valve preservation in acute type A dissection provides relatively durable results. The use of fibrinous glue for root reconstruction seems to compromise the long-term durability of the repair compared with Teflon felt and GRF-glue. A dilated aortic annulus requires a more extensive root procedure.     

Aortic root remodeling for root aneurysm with a uni-commissural aortic valve: report of a case.

A 23-year-old man was admitted for an aortic root aneurysm with mild aortic valve regurgitation (AR) and a small pressure gradient. At surgery, findings of aortic valve, one normal left posterior commissure and very rudimentary right anterior commissure, was compatible with the uni-commisural aortic valve. Aortic root replacement with valve-sparing technique was performed. Four years later no residual AR was observed.     

Two decades of experience with root remodeling and valve repair for bicuspid aortic valves

Objective

Bicuspid aortic valve anatomy is associated with ascending aortic aneurysm in approximately 50% of individuals and may lead to severe aortic regurgitation with aortic dilatation. Both entities may be treated by valve repair and root remodeling. The objective was to review the cumulative experience of 20 years.

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.