OBJECTIVE: We investigated long-term outcomes of bicuspid aortic valve (BAV) repair, with external annuloplasty, according to aorta phenotype. METHODS: Between 2003 and 2020, all patients with BAV operated on for aortic insufficiency (AI) and/or aneurysm were included. Repairs included isolated AI repair with subvalvular with or without sinotubular junction (STJ) (single or double) annuloplasty, supracoronary aorta replacement (with or without hemiroot remodeling), and root remodeling with external subvalvular ring annuloplasty. RESULTS: Among 343 patients operated, reparability rate was 81.3% (n = 279; age 46 ± 13.3 years). At 10 years (median follow-up: 3.42 years; interquartile range, 1.1, 5.8), survival was 93.9% (n = 8 deaths, similar to general population), cumulative incidence of reoperation was 6.2% (n = 10), AI grade >2 was 5.8% (n = 9), and grade >1 was 23.0% (n = 30). BAV repair stabilizing both the annulus and STJ with annuloplasty, compared with nonstabilized STJ repair (single annuloplasty), had lower incidence of reoperation (2.6% vs 22.5%, P = .0018) and AI grade >2 (1.2% vs 23.6%, P < .001) at 9 years. Initial commissural angle <160° was not a risk factor for reoperation, compared with angle ≥160° if symmetrical repair was achieved (2.7% and 4.1%, respectively, at 6 years, P = .85). Multivariable model showed that absence of STJ stabilization (odds ratio, 6.7; 95% confidence interval, 2.1-20, P = .001) increased recurrent AI, but not initial commissural angle <160° (odds ratio, 1.01; 95% confidence interval, 0.39-2.63, P = .98). Commissures adjusted symmetrically led to lower transvalvular gradient, compared with nonsymmetrical repair (8.7 mm Hg vs 10.2 mm Hg, P = .029). CONCLUSIONS: BAV repair, tailored to aorta phenotype, is associated with excellent durable outcomes if both annulus and STJ are reduced and stabilized with external ring annuloplasty. Commissural angle <160° is not associated with reoperation if symmetrical repair is achieved.
- MeSH
- Cardiac Valve Annuloplasty * adverse effects mortality methods MeSH
- Aortic Aneurysm surgery diagnostic imaging mortality MeSH
- Aortic Valve surgery abnormalities diagnostic imaging physiopathology MeSH
- Aortic Valve Insufficiency * surgery physiopathology diagnostic imaging mortality MeSH
- Bicuspid Aortic Valve Disease * surgery physiopathology MeSH
- Time Factors MeSH
- Heart Valve Prosthesis Implantation adverse effects instrumentation MeSH
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Postoperative Complications etiology MeSH
- Reoperation statistics & numerical data MeSH
- Retrospective Studies MeSH
- Risk Factors MeSH
- Treatment Outcome MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
OBJECTIVES: Both aortic root remodelling and aortic valve (AV) reimplantation have been used for valve-sparing root replacement in patients with aortic root aneurysm with or without aortic regurgitation. There is no clear evidence to support one technique over the another. This study aimed to compare remodelling with basal ring annuloplasty versus reimplantation on a multicentre level with the use of propensity-score matching. METHODS: This was a retrospective international multicentre study of patients undergoing remodelling or reimplantation between 2010 and 2021. Twenty-three preoperative covariates (including root dimensions and valve characteristics) were used for propensity-score matching. Perioperative outcomes were analysed along with longer-term freedom from AV reoperation/reintervention and other major valve-related events. RESULTS: Throughout the study period, 297 patients underwent remodelling and 281 had reimplantation. Using propensity-score matching, 112 pairs were selected and further compared. We did not find a statistically significant difference in perioperative outcomes between the matched groups. Patients after remodelling had significantly higher reintervention risk than after reimplantation over the median follow-up of 6 years (P = 0.016). The remodelling technique (P = 0.02), need for decalcification (P = 0.03) and degree of immediate postoperative AV regurgitation (P < 0.001) were defined as independent risk factors for later AV reintervention. After exclusion of patients with worse than mild AV regurgitation immediately after repair, both techniques functioned comparably (P = 0.089). CONCLUSIONS: AV reimplantation was associated with better valve function in longer-term postoperatively than remodelling. If optimal immediate repair outcome was achieved, both techniques provided comparable AV function.
- MeSH
- Cardiac Valve Annuloplasty methods MeSH
- Aortic Valve * surgery MeSH
- Aortic Valve Insufficiency * surgery MeSH
- Heart Valve Prosthesis Implantation methods MeSH
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Reoperation statistics & numerical data MeSH
- Replantation * methods MeSH
- Retrospective Studies MeSH
- Aged MeSH
- Propensity Score * MeSH
- Treatment Outcome MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Multicenter Study MeSH
- Comparative Study MeSH
Aortic stenosis in patients with previous valve-sparing root replacement represents a challenge, given the substantial morbidity and mortality rates in case of reoperation. Here, we present the case of a patient with late severe aortic stenosis 12 years after valve-sparing aortic root replacement. He was successfully treated by transapical aortic valve implantation. External ring annuloplasty, by reducing the native annuloaortic ectasia, allows transcatheter aortic valve replacement in case of stenotic deterioration of the native valve after valve-sparing aortic root replacement.
- MeSH
- Aortic Valve surgery MeSH
- Aortic Valve Insufficiency * surgery MeSH
- Aortic Valve Stenosis * surgery MeSH
- Heart Valve Prosthesis Implantation * MeSH
- Humans MeSH
- Heart Valve Prosthesis * MeSH
- Transcatheter Aortic Valve Replacement * MeSH
- Treatment Outcome MeSH
- Check Tag
- Humans MeSH
- Male MeSH
- Publication type
- Case Reports MeSH
BACKGROUND: Current guidelines recommend root replacement when diameter of the sinuses of Valsalva are superior to 45 mm particularly for bicuspid valve. However, in case of tubular aorta aneurysms with moderate root dilatation (40-45 mm diameter), the approach is still debated regarding the increased risk of coronary reimplantation. We present a modified hemi-remodeling aortic repair technique that includes the replacement of the noncoronary sinus, ascending aorta, and valve repair with external ring annuloplasty in patients with bicuspid aortic valve (BAV) and moderately dilated aortic root. METHODS: Between 2003 and 2017, 18 patients presenting with left-right BAV and an aortic root diameter at 42.3+/-3.3 mm underwent hemi-root and ascending aorta replacement and aortic valve repair with external annuloplasty. RESULTS: Postoperatively, 16 (88.9%) had no aortic insufficiency (AI) and 2 (11.1%) had grade I AI, no patients had grade III or grade IV AI. Overall survival and freedom from grade II AI at 4 years and freedom from aortic valve-related reoperation were 100%. CONCLUSION: The standardized modified hemi-remodeling technique we present is a safe and reproducible procedure, with satisfactory durability at follow-up. This technique represents an interesting alternative to full valve sparing root replacement, as it avoids the operative risk of coronary reimplantation, allows shorter cross-clamping time and a better exposition on the valve for a symmetrical repair, placing the commissure at 180°, compared with valve sparing root replacement.
- MeSH
- Cardiac Valve Annuloplasty methods MeSH
- Aortic Valve abnormalities surgery MeSH
- Heart Valve Diseases surgery MeSH
- Publication type
- Journal Article MeSH
OBJECTIVES: Aortic valve (AV) insufficiency with normal root and ascending aorta is most frequently treated by valve replacement with significant prosthetic-related complications and reduced life expectancy. We compared the outcomes of a new standardized isolated AV repair approach using an external aortic annuloplasty ring at the subvalvular level (single ring annuloplasty) and the role of an additional supravalvular ring at the sinotubular junction (double ring annuloplasty). METHODS: Single centre data were collected from the Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (AVIATOR) between 2003 and 2017. A total of 93 patients (56 single ring and 37 double ring) underwent isolated AV repair. RESULTS: The overall 30-day mortality rate and the need for a permanent pacemaker were 1% and 2%, respectively. The overall survival rate at 6 years was similar for sex- and age-matched members of the general population (89% vs 95%; P = 0.1) and did not differ between the double and single ring groups (82% vs 93%; P = 0.4) at 6 years. There were no thromboembolic or bleeding events in the entire cohort. However, at 6 years, the cumulative incidence of valve-related reintervention was 26% in the single ring annuloplasty group compared to 3% in the double ring annuloplasty (P = 0.02) group. Similarly, at 6 years, the cumulative incidence of moderate-to-severe (>2) aortic insufficiency was 30% in the single ring annuloplasty group compared to 0% in the double ring annuloplasty group (P = 0.007). CONCLUSIONS: Standardized AV repair with external ring annuloplasty has a survival rate similar to that of the general population. The additional stabilization of the sinotubular junction with a second supravalvular ring (double ring annuloplasty) is associated with better outcomes compared to single subvalvular annuloplasty. It can be considered as a first line intervention for patients with isolated aortic insufficiency and pliable leaflets.
- MeSH
- Cardiac Valve Annuloplasty * adverse effects MeSH
- Aortic Aneurysm * MeSH
- Aortic Valve diagnostic imaging surgery MeSH
- Aortic Valve Insufficiency * surgery MeSH
- Humans MeSH
- Aged, 80 and over MeSH
- Heart Valve Prosthesis * MeSH
- Treatment Outcome MeSH
- Check Tag
- Humans MeSH
- Aged, 80 and over MeSH
- Publication type
- Journal Article MeSH
- Research Support, Non-U.S. Gov't MeSH
OBJECTIVES: Ring annuloplasty reduces the septal-lateral diameter (SLD) indirectly by circumferential annular cinching and frequently results in the recurrence of mitral regurgitation (MR) in patients with functional MR (FMR). Our goal was to report the results from the trial and the 2-year post-trial surveillance data. We evaluated whether direct reduction of the SLD with a transannular mitral bridge could achieve significant and durable MR reduction in patients with FMR. METHODS: In a prospective trial, 34 consecutive patients with FMR had a mitral bridge implanted surgically. Primary end points were MR ≤1+ at 1, 3 and 6 months postimplant and freedom from subsequent surgical mitral valve repair or replacement. RESULTS: Thirty-two of 34 (94.1%) patients met the primary end points with MR ≤1+ at 6 months. At 2 years, there were no strokes or device-related adverse events. At 2 years, MR was reduced from 3.32 ± 0.47 to 0.50 ± 0.83 (P ≤ 0.001) with ≤1+ MR in 33/34 patients, including 4 reinterventions for periprosthetic recurrent MR ≥3 without mitral bridge explants or conventional mitral repair or replacement. At 2 years, the mean mitral gradient was 2.15 ± 0.82 mmHg; the mitral annular SLD decreased from 40.4 ± 2.91 mm to 28.9 ± 1.55 mm (P ≤ 0.001). The left ventricular ejection fraction increased (57.9 ± 10.4-62.4 ± 9.7%; P ≤ 0.001). The New York Heart Association functional class improved (2.19 ± 0.76-1.41 ± 0.61; P ≤ 0.001). CONCLUSIONS: The single-centre trial data indicate that direct reduction in the SLD with a mitral bridge is feasible, safe and efficacious in patients with FMR. Validation in a larger population of patients and comparison to conventional annuloplasty ring are necessary. CLINICAL TRIAL REGISTRATION NUMBER: NCT03511716.
- MeSH
- Mitral Valve Annuloplasty * adverse effects instrumentation mortality statistics & numerical data MeSH
- Middle Aged MeSH
- Humans MeSH
- Mitral Valve physiopathology surgery MeSH
- Mitral Valve Insufficiency physiopathology surgery MeSH
- Prospective Studies MeSH
- Recurrence MeSH
- Aged MeSH
- Heart Valve Prosthesis MeSH
- Treatment Outcome MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Observational Study MeSH
Záchovné operace a plastiky aortální chlopně představují možnost chirurgicky obnovit kompetenci nedomykavé aortální chlopně a vyhnout se rizikům, která provázejí nemocné v případě náhrady chlopně. Úspěšné provedení rekonstrukce vyžaduje plné porozumění statické i dynamické geometrii aortální chlopně a aortálního kořene. Aortální regurgitace vychází z malpozice patologicky změněných chlopenních cípů, současně je velmi často spojena s dilatačním postižením aortálního kořene a vzestupné aorty. Technika chirurgických intervencí pro aortální nedomykavost prošla historickým vývojem a v současné době spěje ke zjednodušení a standardizaci jednotlivých kroků aortální plastiky. Základním principem je normalizace morfologického nálezu na úrovni aortálního kořene, tj. bazálního prstence, sinotubulární junkce a vlastních cípů aortální chlopně. Tyto operace jsou v současnosti jasně podporovány evropskými doporučenými postupy v třídě I, a to i u pacientů s bikuspidální aortální chlopní. Oproti náhradě aortální chlopně jsou rovněž spojeny s lepší kvalitou života. Proto by měly být považovány za metodu volby. Velmi důležitá je centralizace těchto výkonů ve specializovaných centrech, které mají s touto technikou dostatečné zkušenosti.
Aortic valve repair and valve sparing procedures enable restoration of competence in a regurgitant aortic valve, thus avoid therisks related to valve replacement. Successful aortic valve repair requires profound understanding of static and dynamic geometryof the aortic valve and aortic root. Aortic regurgitation originates from a malposition of the aortic leaflets and is also frequentlyassociated with dilation of the aortic root and ascending aorta. The surgical techniques for aortic regurgitation have evolvedhistorically and are currently moving toward simplification and standardization. The basic principles involve morphological normalizationat the level of the basal ring, sinotubular junction, and valve leaflets. These procedures are currently supported by theEuropean guidelines (Class I), even in patients with a bicuspid aortic valve. In comparison with aortic valve replacement, they resultin better quality of life. Therefore, they should be considered to be the method of choice. Of great importance is centralizationof these procedures in dedicated centers where a cumulative experience in this surgery has been gained.
- MeSH
- Cardiac Valve Annuloplasty methods trends utilization MeSH
- Aorta surgery physiopathology pathology MeSH
- Aortic Valve * physiopathology pathology MeSH
- Aortic Valve Insufficiency * diagnosis surgery complications MeSH
- Aortic Valve Stenosis diagnosis surgery complications MeSH
- Cardiac Care Facilities organization & administration trends utilization MeSH
- Cardiac Surgical Procedures * methods trends utilization MeSH
- Humans MeSH
- Meta-Analysis as Topic MeSH
- Replantation methods trends utilization MeSH
- Practice Guidelines as Topic MeSH
- Heart Valve Prosthesis utilization MeSH
- Statistics as Topic MeSH
- Tricuspid Valve surgery physiopathology pathology MeSH
- Outcome and Process Assessment, Health Care MeSH
- Check Tag
- Humans MeSH
- Publication type
- Review MeSH
Cíl: Zhodnotit střednědobé až dlouhodobé výsledky záchovných operací aortální chlopně a identifikovat rizikové faktory selhání těchto výkonů. Metodika: V období od 11/2007 do 10/2017 bylo na našem pracovišti provedeno 198 záchovných operací aortální chlopně. Průměrný věk operovaných byl 48,4 let ± 13,5. Průměrný stupeň aortální regurgitace před operací byl 3,4 ± 1,1. Aortální regurgitace způsobená dilatací aortálního kořene byla u 106 nemocných, prolaps cípu byl u 92 pacientů. Výsledky: Z celkového počtu 198 operací byla provedena 24× suprakoronární náhrada ascendentní aorty, 11× reimplantace aortální chlopně, 71× remodelace aortálního kořene (66× spolu s implantací zevního anuloplastického prstence) a 92 pacientům byl proveden výkon na cípech aortální chlopně. 30denní mortalita byla 0 %. Ve sledování je 194 operovaných pacientů, zemřeli čtyři nemocní, přežívání je 98 %. Střední doba sledování je 2,8 roku. Reoperováno bylo 19 pacientů (9,5 %); 15 pro recidivu aortální regurgitace, 1 pro rozvoj aortální stenózy, 2 pro infekci cévní protézy a 1 pro pseudoaneuryzma kořene aorty. Z provedených reoperací byla provedena 1× replastika aortální chlopně, 1× náhrada bioprotézou, 14× mechanickou protézou (z toho 1× s uzávěrem pseudoaneuryzmatu) a 2× náhrada aortálního kořene homograftem. Hlavními důvody recidivy aortální regurgitace bylo obnovení prolapsu cípu a redilatace aortálního anulu při selhání anuloplastiky (9×). Dalšími příčinami selhání aortální plastiky byla restrikce a retrakce cípů (6×). Závěr: Záchovné operace aortální chlopně lze v současnosti považovat za metodu volby u vybraných pacientů. Echokardiografie správně rozliší nálezy vhodné k záchovnému výkonu, určí optimální typ výkonu, zhodnotí jeho výsledek a odhalí přítomnost rizikových faktorů selhání rekonstrukce aortální chlopně.
Aim: To evaluate medium to long-term outcomes of aortic valve – sparing procedures and identify risk factors for procedure failure. Methods: From 11/2007 to 10/2017, a total of 198 aortic valve sparing operations were performed at our department. The meanage of patients was 48.4±13.5 years. Preoperatively, the mean grade of aortic regurgitation was 3.4±1.1. Aortic root dilation andcusp prolapse were main causes of aortic regurgitation (in 106 and 92 cases, respectively). Results: Out of a total of 198 operations, supracoronary aortic root replacement (24), reimplantation of the aortic valve (11), remodelingof the aortic root (71) combined in 66 patients with implantation of the external annuloplasty ring, and 92 aortic cuspinterventions were performed. Thirty-day mortality was 0 %. The median follow-up is 2.8 years (194 patients). During this period, 4 patients died. Nineteen patients were reoperated (9.5 %); 15 for recurrent aortic regurgitation, 1 for development of aorticstenosis, 2 for vascular graft infection and 1 for aortic root pseudoaneurysm. At reoperation 1 valve repair, 14 replacements witha mechanical prosthesis and 1 with a bioprosthesis (1 with pseudoaneurysm closure), and 2 aortic root replacements with a homograftwere performed. The leading cause of aortic regurgitation recurrence was cusp reprolapse and aortic annulus redilation(9 cases). Aortic valve restriction and retraction were other causes of repair failure (6 cases). Conclusion: Aortic valve-sparing operations should be considered the method of choice in selected patients. Echocardiographycorrectly distinguishes the anatomy suitable for aortic valve repair, determines the optimal type of procedure, evaluates its outcome,and identifies the presence of risk factors for failure of aortic valve reconstruction.
OBJECTIVE: An aortic annuloplasty ring could be useful for aortic valve repair. This trial evaluated intermediate-term outcomes of internal geometric ring annuloplasty for repair of trileaflet and bicuspid aortic insufficiency associated with ascending aortic and/or aortic root aneurysms. METHODS: Under regulatory supervision, 47 patients with aortic insufficiency and ascending aortic (n = 22) and/or aortic root (n = 25) aneurysms were managed with aortic valve repair and aneurysm resection. Valve repair was performed using trileaflet (n = 40) or bicuspid (n = 7) internal geometric rings, together with leaflet reconstruction. Ascending aortic and/or remodeling root replacements were accomplished with Dacron grafts 5 to 7 mm larger than the rings. An Echo Core Lab provided independent echocardiographic assessments, and changes over time were evaluated by Friedman tests. RESULTS: Mean ± SD age was 60 ± 14 years, 57% (27/47) were male, 15% (7/47) had bicuspid valves, 87% (41/47) had moderate-to-severe aortic insufficiency, and 13% (6/47) had mild aortic insufficiency. All patients had annular dilatation, with a mean ± SD of 26.5 ± 2.6 mm before repair, and mean ± SD ring sizes were 21.7 ± 1.7 mm. Follow-up was 42 months (mean = 27 months). No operative mortality or valve-related complications occurred. Two patients died beyond 1 year from nonvalve-related causes. One patient required valve replacement for repair failure. Survival free of complications or valve replacement was 94% at 2 years. Significant reduction in aortic insufficiency and New York Heart Association class were observed (P < 0.0001), and valve gradients remained low. No heart block or direct ring complications occurred. CONCLUSIONS: In preliminary regulatory studies, aortic ring annuloplasty seemed safe and effective during aortic aneurysm surgery. This approach could help standardize aortic valve repair.
- MeSH
- Cardiac Valve Annuloplasty * adverse effects instrumentation mortality statistics & numerical data MeSH
- Aortic Aneurysm mortality surgery MeSH
- Aortic Valve surgery MeSH
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Postoperative Complications MeSH
- Prosthesis Design MeSH
- Reoperation MeSH
- Aged MeSH
- Heart Valve Prosthesis adverse effects MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
Záchovné operace a plastiky aortální chlopně představují možnost chirurgicky obnovit kompetenci nedomykavé aortální chlopně a vyhnout se rizikům, která provázejí nemocné v případě náhrady chlopně. Úspěšné provedení rekonstrukce vyžaduje plné porozumění statické i dynamické geometrii aortální chlopně a aortálního kořene. Aortální regurgitace vychází z malpozice patologicky změněných chlopenních cípů, současně je velmi často spojena s dilatačním postižením aortálního kořene a vzestupné aorty. Technika chirurgických intervencí pro aortální nedomykavost prošla historickým vývojem a v současné době spěje ke zjednodušení a standardizaci jednotlivých kroků aortální plastiky. Základním principem je normalizace morfologického nálezu na úrovni bazálního prstence, sinotubulární junkce a vlastních cípů aortální chlopně. Remodelace aortálního kořene a reimplantace aortální chlopně zůstávají standardem rekonstrukce v případě dystrofi cky dilatovaného aortálního kořene.
Aortic valve repair and valve sparing procedures enable restoration of competence in regurgitant aortic valve, and thus to avoid the risks related to valve replacement. Successful aortic valve repair requires deep understanding of the static and dynamic geometry of the aortic valve and aortic root. Aortic regurgitation originates from malapposition of the aortic leafl ets and frequently is also connected to dilation the aortic root and ascending aorta. Techniques of surgical procedures for aortic regurgitation have been subject of historical development and currently tend to simplifi cation and standardization. Basic principles stand upon morphological normalization at the level of the basal ring, sinotubular junction and valve leafl ets. Remodelation of the aortic root and reimplantation of the aortic valve keep to be standard procedures in case of a dystrophic dilation of the aortic root.
