Aortic valve sparing operations

Aortic valve sparing operations were developed to preserve the aortic valve in patients with ascending aortic aneurysm and aortic insufficiency or patients with aortic root aneurysm. There are 2 types of aortic valve sparing operations, remodeling of the aortic root and reimplantation of the aortic valve. The author believes that remodeling of the aortic root is more appropriate for older patients with ascending aortic aneurysm, dilated aortic sinuses, and normal aortic annulus, whereas reimplantation of the aortic valve is more appropriate for young patients with aortic root aneurysm in whom dilation of the aortic annulus is commonly associated. Although remodeling of the aortic root has been extensively used in patients with aortic root aneurysm, the long-term results are somewhat inferior to reimplantation in most series. The late results of aortic valve sparing operations have been excellent, and these operations have become an important addition to the surgical armamentarium to treat patients with proximal aortic aneurysms.     

Aortic valve sparing operations: a review

Aortic valve sparing operations were developed to preserve the native aortic valve during surgery for aortic root aneurysm as well as surgery for ascending aortic aneurysms with associated aortic insufficiency. There are basically two types of aortic valve sparing oprations: remodeling of the aortic root and reimplantation of the aortic valve. These operations have been performed for over two decades and the clinical outcomes have been excellent in experienced hands. Although remodeling of the aortic root is physiologically superior to reimplantation of the aortic valve, long-term follow-up suggests that the latter is associated with lower risk of developing aortic insufficiency. Failure of remodeling of the aortic root is often due to dilatation of the aortic annulus. Thus, this type of aortic valve sparing should be reserved for older patients with ascending aortic aneurysm and normal aortic annulus whereas reimplantation of the aortic valve is more appropriate for young patients with inherited disorders that cause aortic root aneurysms. This article summarizes the published experience with these two operations. They are no longer experimental procedures and should be part of the surgical armamentarium to treat patients with aortic root aneurysm and ascending aortic aneurysms with associated aortic insufficiency.     

Aortic flow after valve sparing root replacement with or without neosinuses reconstruction

Objectives

This study applied advanced 4-dimensional flow magnetic resonance imaging processing to assess differences in aortic flow dynamics after valve sparing root replacement, with and without reconstruction of the Valsalva sinuses.

Prosthetic valve sparing aortic root replacement: an improved technique

We describe a modified surgical technique to treat patients with a previous history of isolated aortic valve replacement who now require aortic root replacement for an aneurysmal or dissected aorta. This technique consists of replacing the aortic root with a Dacron conduit, leaving intact the previously implanted prosthesis, and re-implanting the coronary arteries in the Dacron graft. Our technique differs from other techniques in that we do not leave behind any aortic tissue remnant and also in that we use a felt strip to obliterate any gap between the old sewing ring and the newly implanted graft. In our opinion, this promotes better hemostasis. We demonstrate that this technique is safe, feasible, and results in acceptable outcomes.     

Aortic valve leaflet sparing and salvage surgery: evolution of techniques for aortic root reconstruction

Over the past 20 years, a series of procedures have been designed to reconstruct the aortic root of patients with aortic insufficiency, in whom the pathology and hence the surgery spares the valve leaflets. Such techniques have various names. Usually ‘valve sparing’ is used in context with chronic aortic dissection or aortic root aneurysm as in patients with Marfan's syndrome. ‘Aortic valve salvage’ tends to be the term of choice for similar surgical reconstruction in the setting of aortic dissection. ‘Aortic valve repair’ is often chosen when direct surgical procedures are performed on the leaflets themselves. All of the techniques have evolved based upon an increased understanding of the functional anatomy of the aortic root complex. The different technical approaches, their applications and results need to be understood by the cardiology community. The failure modes for such techniques are specific and different from prosthetic valve failure modes, but are adequately followed with echocardiography. Over two-thirds of patients remain free of re-development of significant aortic insufficiency at 8–10 years following surgery. The overall patient survival is more dependent upon the underlying cardiovascular status of the patient than the surgical technique itself. Perioperative mortalities vary between 0 and 6% and are comparable to composite valve+graft techniques and isolated aortic valve replacement, in which the operative mortality approximates 3.3–4%. Long-term results are good to excellent and spare the patient anticoagulation and prosthetic valve disease.     

Aortic valve stenosis and regurgitation: an overview of management

There are few cardiovascular disease entities that have as an impressive contribution to improved quality and duration of life as aortic valve disease correction. Although aortic valve stenosis is fairly common, particularly in elderly patients, between one third and two thirds go untreated, despite operative survival rates with the minimal invasive J incision approach of 99%. For those patients with high risk co-morbidity or technical inoperable reasons, the percutaneous transfemoral or transapical approaches are now available with good initial RESULTS: For younger patients with tricuspid valves or bicuspid valves and aortic regurgitation, aortic valve repair should be the first choice procedure and with careful selection of the appropriate approach based on analysis of the patients CLASS (Commissure, Leaflet, Annulus, Sinotubular junction, and Sinuses) anatomy. Excellent results can be obtained with better than 90% freedom from reoperation at 10 years. The scope of procedures for aortic valve disease has increased markedly over the last 10 years and patients and cardiovascular physicians need to be aware of these newer options.     

Parenchymal sparing operations for bronchogenic carcinoma

By the end of the 1950s, the principles of tracheobronchial and pulmonary artery (PA) reconstruction had been established, and their successful clinical application had taken place. It was not until very recently, however, that these techniques aroused widespread interest among thoracic surgeons as a means to achieve complete cancer resection while preserving functioning lung parenchyma. At the present time, sleeve resection of the bronchus and/or PA has a definite role in the surgical management of lung cancer. Growing interest in this field is evidenced by an increasing number of technical variations intended to adapt the basic technique to the different anatomical settings. Also pitfalls, complications, and their prevention and treatment are being extensively described. Last but not least, functional and oncological long-term results, comparing favorably with those of more extended resections, are being reported by many groups. This demonstrates that sleeve lobectomy is no longer reserved only for particularly skillful surgeons. Sleeve lobectomy has achieved its rightful position among the techniques commonly used in thoracic surgery after 40 years of improving understanding and alternating enthusiasm and legitimate doubts.     

Papillary muscle rupture: an unusual complication of chordal sparing mitral valve replacement

An adult patient with advanced rheumatic heart disease undergoing chordal sparing mitral valve replacement as well as aortic valve replacement is presented. The patient developed an unusual complication of an infarction of the retained head of the anterolateral papillary muscle with subsequent spontaneous rupture 72-hours postoperatively. The ruptured head of the papillary muscle was successfully resected via an aortotomy through the aortic valve prosthesis. The patient made an uneventful recovery. Care to avoid excessive tension on the preserved chordae during mitral valve replacement, especially in the setting of chronic rheumatic carditis, is stressed.     

Aortic valve replacement in predominant aortic stenosis: What is an appropriate size valve?

Objective This is a retrospective analysis of 94 patients who underwent aortic valve replacement for predominant aortic stenosis between January 1998 and December 2004. Patients and Methods Age ranged from 16 to 70 years (mean 43.2±13.2 years). 73 were male (77.7%). Etiology was rheumatic in 71 (75.5%) and degenerative in 23 (24.5%) patients. On transthoracic echocardiography, the diameter of the aortic annulus ranged from 19 mm to 36mm (mean 28.5±3.0 mm) and the peak systolic gradients ranged from 54 mm to 174 mm of Hg (mean of 109.8±28.8 mmHg). Aortic regurgitation was absent or mild in 76 patients (80.8%) and moderate in rest. A mechanical valve was implanted in 66 patients (70.2%) and a tissue valve in 28 patients (29.8%). Valves of size 23 mm or more were implanted in 75 patients (80%). A valve of 25 mm or larger was implanted in 55 patients (54.3%). Results There were no early deaths. Two patients required permanent pacemaker implantation for complete heart block in the immediate postoperative period. Prosthetic valve thrombosis in one patient was relieved by thrombolysis. Anticoagulant related hemorrhage was seen in two patients. One patient underwent homograft aortic valve replacement for prosthetic valve endocarditis nine months after surgery. Conclusion Isolated aortic valve replacement in patients with predominant aortic stenosis can be performed safely by implanting an adequately large sized prosthesis, without root enlargement in a large majority of patients.     

Delayed sternal closure for life-threatening complications in cardiac operations: an update

Over a 7-year-period, 25 patients had delayed sternal closure after open heart operations out of 34 patients whose sternum was not closed. The indications were extreme cardiac dilatation and uncontrollable mediastinal hemorrhage. This represented a 1.79% incidence in the overall open heart surgical experience at our unit. Sternal closure was performed at a mean of 2.64 days after the initial operation. Eighteen patients (52.9%) left the hospital alive and well, representing a 72% survival rate among patients undergoing delayed sternal closure. No mediastinal or fatal infection developed and only 1 patient had late superficial wound infection after delayed sternal closure. We conclude that delayed sternal closure is an effective method to treat severe complications after cardiac operations.