Longer-term Outcomes after Bicuspid Aortic Valve Repair in 142 Patients

Background The aim of this study was to evaluate the longer-term results of bicuspid aortic valve (BAV) repair with or without aortic root replacement. Methods From 1999 to 2017, 142 patients with or without aortic root dilatation who underwent repair of a regurgitant BAV were included in the study. Ninety-four patients underwent isolated BAV repair (Group 1; mean age 45±14 years) and 48 patients underwent valve-sparing aortic root replacement plus BAV repair (aortic valve reimplantation – Group 2; mean age 49±13 years. Median follow-up time was 5.9 years (range 0.5-15) in Group 1 and 3 years (range 0.5-16) in Group 2, respectively. Results In-hospital mortality was 1% in group 1, and 2% in Group 2 (p=0.6). The 5- and 10-year survival was 93±2.9% and 81±5.8% in Group 1 and 96±3.1% and 96±3.1% in Group 2, respectively (p=0.31). Eleven patients of Group 1 (1.7% /patient-year) and 5 patients of Group 2 (2.2%/patient-year) underwent reoperation of the aortic valve (p=0.5). The 5- and 10-year freedom from reoperation were 93.0±2.1% and 77.1±7.1% in Group 1 and 93.0±5.0% and 76.7±9.6% in Group 2 (p=0.83), respectively. At latest follow-up only 2 patients of Group 1 and 1 patient of Group 2 had AR=2° (p=0.7). The cumulative linearized incidence of all valve-related complications (bleeding, stroke, endocarditis, reoperation) was 2.9%/patient-year in Group 1 and 4%/patient-year in Group 2, respectively (p=0.6). Conclusions Isolated BAV repair and combined aortic valve reimplantation plus BAV repair provide good clinical longer-term outcomes with relatively low reoperation rate and durable valve function.

Valve-sparing operations on the aortic valve and the ascending aorta: radical correction of congenital and acquired heart diseases. Immediate outcomes

This paper presents the immediate outcomes of valve-sparing operations on the aortic valve and ascending aorta in radical correction of congenital and acquired heart disease. Materials and methods. The study enrolled 50 patients with aortic insufficiency who were operated upon at Shumakov National Medical Research Center of Transplantology and Artificial Organs from 2011 to 2019. The mean age was 48 ± 16 years, 64% of them were men (n = 32). The study included patients with tricuspid (n = 36, 72%) and bicuspid (n = 14, 28%) aortic valves. Aortic valve reimplantation was performed in 32 (64%) patients, aortic root remodeling - in 1 (2%). 17 (34%) patients had no aortic root reconstruction or remodeling. Aortic valve reimplantation was done in 4 (8%) cases in combination with coronary artery bypass grafting, and in 4 (8%) with mitral and tricuspid valve repair. Results. Thirty-day mortality was 0%. In 1 case (2%), a permanent pacemaker was installed due to complete atrioventricular block. There were no neurological and coronary events, and cases of endocarditis. In all patients (100%), aortic valve insufficiency after surgical correction did not exceed grade 1 according to echocardiographic follow-up examination. On aortic valve mean and peak gradients were 8 ± 6 and 15 ± 7 mm Hg, respectively. Findings. Type I and II valve-sparing reconstructive surgery (for bicuspid and tricuspid aortic valves) is an excellent alternative to prosthetic repair with great postoperative outcomes, low valve-associated complications and low mortality.

Assessment of long-term outcomes: aortic valve reimplantation versus aortic valve and root replacement with biological valved conduit in aortic root aneurysm with tricuspid valve

OBJECTIVES We compared the long-term outcomes between aortic valve reimplantation [David V (DV)] and aortic valve and root replacement with biological valved conduit [Bentall–De Bono (BD)] for the patients with aortic root aneurysm with tricuspid valve. METHODS Among 876 patients who underwent aortic root replacement in our institution between 2005 and 2018, 371 patients who underwent DV (n = 199) or BD (n = 172) for aortic root aneurysm with tricuspid valve were retrospectively reviewed. Exclusion criteria included aortic stenosis, infective endocarditis, previous prosthetic aortic valve, bicuspid aortic valve, aortic dissection and mechanical Bentall procedure. Propensity score matching was performed based on the patient characteristics, matching 90 patients in each group. The primary end point was all-cause mortality. Secondary end points were reoperation for any cause and specifically for aortic valve-related cause. RESULTS After propensity score matching, DV and BD groups each had 1 in-hospital mortality (1.1%). Survival at 10 years was 95.3% [95% confidence interval (CI) 85.8–98.5] in DV and 98.6% (95% CI 90.8–99.8) in BD (P = 0.345). The cumulative incidences of reoperation at 10 years in DV versus BD were 3.9% (95% CI 0.7–11.8) vs 18.1% (95% CI 6.9–33.4) for any cause (P = 0.046) and 1.9% (95% CI 0.1–8.8) vs 15.9% (95% CI 5.5–31.4) for aortic valve-related causes (P = 0.032). The reasons for valve-related reoperation were aortic insufficiency (3/5 in DV vs 5/10 in BD), aortic stenosis (0/5 vs 2/10) and infective endocarditis (2/5 vs 3/10). CONCLUSIONS Both DV and BD procedures for patients with aortic root aneurysm with tricuspid valve resulted in excellent 10-year survival. All-cause and aortic valve-related reoperations were significantly less frequent with valve-sparing root replacement, suggesting an advantage of DV over biological BD.

Current trends in aortic valve-preserving surgery

The natural history of aortic regurgitation is not as benign as once believed, even in asymptomatic patients with preserved left ventricular function. Aortic valve surgery can prolong survival in these patients. However, both mechanical and biological aortic valve replacement have major disadvantages, especially in young patients. Aortic valve-preserving surgery has attracted a great deal of attention because it has a significant survival benefit over replacement. Nonetheless, aortic valve-preserving surgery has not been widely adopted due to the complexity of the technique and assessment (i.e., long learning curve). With recent technical and theoretical advances, aortic valve-preserving surgery has increasingly been performed with better outcomes, and therefore earlier surgical intervention in cases of aortic regurgitation has been considered. Recent advances in aortic valve-preserving surgery include repair-oriented classification of the etiology of aortic regurgitation, objective assessment of the cusp configuration (i.e., effective height and geometric height), use of aortic annuloplasty, introduction of two reproducible valve-sparing root replacement procedures (i.e., aortic valve reimplantation and aortic root remodeling techniques), standardization of aortic valve-preserving surgery, and assessment of cusp configuration with aortoscopy. A number of prospective multicenter studies are currently underway and will clarify the role of aortic valve-preserving surgery in the treatment of aortic regurgitation in the near future.

Morphological modification of the aortic annulus in tricuspid and bicuspid valves after aortic valve reimplantation: an electrocardiography-gated computed tomography study†

OBJECTIVES: Aortic valve-sparing operations have been shown to produce fewer valve-related complications than valve replacement. The aortic root is a morphological and functional unit in which the annulus plays an important role on dynamism, shape and geometry of the valve with different results in bicuspid aortic valves (BAVs) or tricuspid aortic valves (TAVs). The aim is to evaluate the differences in the size and shape of the aortic annulus between native BAVs and TAVs using ECG-gated computed tomography (CT) after a reimplantation procedure. METHODS: We selected 35 patients scheduled for aortic valve reimplantation who underwent good-quality preoperative and postoperative ECG-gated contrast-enhanced CT scan of the aortic root. Twenty-three patients had TAV, 8 patients type 1 BAV and 4 patients type 0 BAV. Major diameter and minor diameter, perimeter (P) and area (A) were measured. The shape of the aortic annulus was considered ‘circular’ or ‘elliptic’ according to the Ellipticity Index. We also selected a subgroup of 18 patients (9 TAVs and 9 BAVs) to evaluate annular shape and size variations through the cardiac cycle and to study the expansibility both in the preoperative and in the postoperative phases. RESULTS: Preoperative CT scans showed an elliptic shape of TAVs (Ellipticity Index 1.3 ± 0.1), a circular shape of type 0 BAVs (1.1 ± 0.1) and an intermediate behaviour of type 1 BAVs, suggesting a possible gradual spectrum of circularity from TAVs to type 1 BAVs to type 0 BAVs. Postoperative CT scans did not show any significant difference in annular shape among the 3 groups, which demonstated a similar roundness, obviating the preoperative differences. Analysing the expansibility of the aortic annulus during the cardiac cycle, we observed that it was completely absent in the preoperative phase in BAVs, while in the postoperative phase, both TAVs and BAVs showed a small but similar expansibility after the annular reduction. CONCLUSIONS: There is a possible gradual spectrum in terms of shape, from native TAVs, to type 1 BAVS to type 0 BAVs. These differences are eliminated in the postoperative phase, suggesting an active role of the annuloplasty on the geometry of the aortic annulus. The preoperative analysis showed a complete inelasticity of BAVs, which was partly restored in the postoperative phase.

Predictors of Outcome for Aortic Valve Reimplantation Including the Surgeon—A Single-Center Experience

Introduction Aortic valve reimplantation is considered technically demanding. We searched for predictors of long-term outcome including the surgeon as risk factor. Methods We selected all aortic valve reimplantations performed in our department between December 1999 and January 2017 and obtained a complete follow-up. The main indications were combined aortic aneurysm plus aortic valve regurgitation (AR), 69% and aortic dissections (15%). In 14%, valves were bicuspid. Cusp repair was performed in 27% of patients. One-third received additional procedures (coronary artery bypass grafting, mitral, or arch surgery). We performed multivariable analyses for independent risk factors of short- and long-term outcomes, including “surgeon” as variable. Twelve different surgeons operated on 193 patients. We created three groups: surgeons A and B with 84 and 64 procedures, respectively, and surgeon C (10 surgeons for 45 patients). Results Cardiopulmonary bypass and clamp times were 176 ± 45 and 130 ± 24 minutes, respectively. In-hospital mortality was 2%. Postoperatively, 5% had mild and 0.5% had moderate AR. Kaplan–Meier's survival estimates, freedom from reoperation, and freedom from severe AR at 12 years were 97 ± 1, 93 ± 2, and 91 ± 3%, respectively. Age and chronic obstructive pulmonary disease appeared as risk factors for perioperative complications by univariate analysis. Age, coronary artery disease, and duration of cardiopulmonary bypass, but not surgeon, presented as risk factors by multivariable analysis. Conclusion The results suggest that if a David procedure is performed successfully, long-term durability may be excellent. They also suggest that good and durable results are possible even with limited experience of the operating surgeon.