Aortic Root Aneurysms: Remodeling or Composite Replacement?

Division of Cardiovascular Surgery, Toronto Hospital, University of Toronto, Ontario, Canada.
The Annals of Thoracic Surgery (Impact Factor: 3.85). 12/1997; 64(5):1564-8. DOI: 10.1016/S0003-4975(97)01026-6
Source: PubMed


Patients with ascending aortic aneurysms often have aortic insufficiency due to dilatation of the aortic root. Although composite replacement of the aortic valve and ascending aorta has been the standard treatment, an aortic valve-sparing operation is feasible in patients with normal aortic valve leaflets.
From 1988 to 1996, 208 patients with ascending aortic aneurysms and aortic insufficiency were operated on. Aortic valve-sparing operations were performed in 101 patients: 70 men and 31 women with a mean age of 53 years (range, 14 to 82 years). Twenty-eight patients had the stigmata of Marfan's syndrome. Fifteen patients had acute and 8 had chronic type A aortic dissection. Coronary artery disease was detected in 19 patients and mitral regurgitation in 5. Two types of aortic valve-sparing operations were performed: remodeling of the aortic root with preservation of the aortic valve in 73 patients and reimplantation of the aortic valve in a tubular Dacron graft in 28. Patients were followed up from 3 to 108 months (mean, 31 months). Doppler echocardiographic studies were performed annually.
There were two operative deaths. One patient had to have aortic valve replacement because of persistent aortic insufficiency. There were five late deaths; the actuarial survival rate at 6 years was 87% +/- 5%. One patient required aortic valve replacement 2 years after the initial operation; the freedom from aortic valve replacement at 6 years was 97% +/- 2%. There have been no thromboembolic or infective complications. Only 3 patients have moderate aortic insufficiency; the remaining patients have mild or no aortic insufficiency.
The midterm results of aortic valve-sparing operations have been excellent and justify their continued use in patients with aortic root aneurysms and normal or near-normal aortic valve leaflets.

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    • "One of the causes of recurrence of AR is an unsecured aorto-ventricular junction. David et al. reported that reinforcement of the aorto-ventricular junction brought about reduced recurrence of AR [3] [4]. We have performed aortic root remodeling concomitant with aortic annuloplasty (subvalvular circular annuloplasty) in patients with annuloaortic ectasia (AAE) and AR to treat AR and prevent aortic annulus from dilation in the future. "
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    ABSTRACT: We have performed aortic root remodeling concomitant with aortic annuloplasty (subvalvular circular annuloplasty: it tightens the aortic annulus, using Gore-Tex strip (N.L. Gore and Associates, Arizona, USA)) in patients with AAE and AR. We examined morphologic changes in the aortic root during cardiac cycles, using pre- and post-operative echocardiography. Twelve patients were underwent the procedure. Their grade of AR was 3.2+/-1.0. Five adults with normal aortic roots were studied as controls. The systolic and diastolic radius of each cusp was measured at the annulus, the Valsalva and the STjunction level. The ratio of diastolic radius to systolic radius in the control, pre-operative data and post-operative data was obtained. In the controls, the rate of diameter change during the cardiac cycle was largest at the annulus level (Right coronary cusp (RCC), Left coronary cusp (RCC), Noncoronary cusp (NCC); 1.00+/-0.2, 1.12+/-0.1, 1.23+/-0.2), second largest at Valsalva level (RCC, LCC, NCC; 0.96+/-0.6, 1.07+/-0.2, 0.97+/-0.2), and smallest at the ST junction (RCC, LCC, NCC; 0.95+/-0.4, 1.03+/-0.2, 0.93+/-0.2). Pre-operative data showed that it was largest at the Valsalva level. Post-operative data showed that the rate of change at each level was not significantly different from the control data. All patients were in NYHA class I and the grade of AR was 0.4+/-0.7 at the latest follow-up. Subvalvular circular annuloplasty did not interfere with annulus motion during the cardiac cycle. Aortic root remodeling and concomitant aortic annuloplasty restored near normal cyclic aortic root motion and morphology on the short-term.
    Full-text · Article · Oct 2004 · Interactive Cardiovascular and Thoracic Surgery
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    • "The direct consequence has been extension of aortic surgical procedures to patients at the extremes of the age spectrum and to patients with mildly symptomatic or asymptomatic disease. In addition, the rising popularity of biological conduits (autografts, homografts, xenografts), as substitutes of the aortic valve or root [8], and of aortic root remodeling operations with preservation of the native valve [9] have all translated into a substantial increase in the population at risk for reoperative procedures on the proximal thoracic aorta. Since reinterventions on the ascending aorta and aortic root pose a unique surgical challenge, it has become urgent to deĀ®ne the risk and outcome connected with these procedures . "
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    ABSTRACT: Reoperations on the ascending aorta after prior aortic procedures are formidable challenges. In order to identify factors predictive of clinical outcome using a uniform surgical approach, results of a 15-year experience were reviewed. Between 1983 and 1998, 78 reoperations on the ascending aorta were performed in 71 consecutive patients. There were 56 males and 15 females, aged 54+/-13 years (10-73 years), with a mean interval to first reoperation of 60+/-76 months (5-223 months). The original operation was replacement of ascending aorta (23), aortic valve (25), aortic root (7), ascending aorta with valve preservation (9), ascending aorta and aortic valve (7). Surgical approach included femoral vessels dissection and repeat sternotomy, with femoro-femoral bypass limited to cases of traumatic reentry. Reoperation consisted in replacement of the aortic root (48), ascending aorta (15), ascending aorta and aortic valve (6), aortic root with ascending aorta and arch (6), ascending aorta and aortic arch (3). Average aortic crossclamp and cardiopulmonary bypass times were 122+/-86 and 188+/-60 min, respectively. Early deaths were five (7%), due to low output syndrome (3), hemorrhage (1) and sepsis (1). Mortality for emergent reoperation was significantly higher (38 vs. 3%, P=0.001). A total of 39 early complications were observed in 78 reinterventions (50%), including: traumatic reentry requiring emergent femoro-femoral bypass (4), reexploration for bleeding (4), respiratory failure (12), sepsis (5), transient neurologic dysfunction (4), renal failure (3), myocardial infarction (3), circulatory insufficiency requiring mechanical life support (2), and wound infection (2). Average intensive care unit stay was 4.5+/-9.7 days (0.5-40 days). Survival was 92+/-4%, 78+/-10% and 78+/-10% at 1, 5, and 10 years, respectively. At follow-up (mean 34+/-36 months, 1-170), survivors were in satisfactory clinical conditions (1.6+/-0. 8 mean NYHA class, 1-3) with no evidence of renal, respiratory or neurologic dysfunction. Multivariable analysis showed emergent reoperation (P=0.001), prior aortic valve replacement (P=0.005) and need for arch replacement (P=0.03) to be predictive of higher operative mortality. Longer duration of bypass (P=0.01) and aortic arch replacement (P=0.04) were predictive of higher prevalence of postoperative complications. Reoperations on the ascending aorta via repeat sternotomy without preventive femoral bypass are associated with low operative risk and high prevalence early complications. Emergent reintervention due to aortic dissection, particularly in patients with prior aortic valve replacement, and need for arch repair are predictive of poorer perioperative outcome. Long-term outlook of hospital survivors is satisfactory.
    Full-text · Article · Jun 2000 · European Journal of Cardio-Thoracic Surgery
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    • "Recently, the increased use of pulmonary autografts, aortic homografts, stentless porcine valves, aortic valve repair or reconstruction, and valve-sparing procedures demands a better understanding of the functional anatomy of the aortic valve complex [1] [2] [3] [4] [5] [6] [7] [8]. Although the importance of the sinuses of Valsalva (SoV) as part of the aortic valve was already intuitively shown by Leonardo da Vinci [9], aortic valve dynamics as part of the root have not been studied until recently. "
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    ABSTRACT: Objective: Although aortic root expansion has been well studied, its deformation and physiologic relevance remain controversial. Three- dimensional (3-D) sonomicrometry (200 Hz) has made time-related 4-D study possible. Methods: Fifteen sonomicrometric crystals were implanted into the aortic root of eight sheep at each base (three), commissures (three), sinuses of Valsalva (three), sinotubular junction (three), and ascending aorta (three). In this acute, open-chest model, the aortic root geometric deformations were time related to left ventricular and aortic pressures. Results: During the cardiac cycle, aortic root volume increased by mean ^ 1 standard error of the mean (SEM) 33.7 ^ 2.7%, with 36.7 ^ 3.3% occurring prior to ejection. Expansion started during isovolumic contraction at the base and commissures followed (after a delay) by the sinotubular junction. At the same time, ascending aorta area decreased (22.6 ^ 0.4%). During the first third of ejection, the aortic root reached maximal expansion followed by a slow, then late rapid decrease in volume until mid-diastole. During end-diastole, the aortic root volume re-expanded by 11.3 ^ 2.4%, but with different dynamics at each area level. Although the base and commissural areas re-expanded, the sinotubular junction and ascending aorta areas kept decreasing. At end-diastole, the aortic root had a truncated cone shape (base area . commissures area by 51.6 ^ 2.0%). During systole, the root became more cylindrical (base area . commissures area by 39.2 ^ 2.5%) because most of the significant changes occurred at commissural level (63.7 ^ 3.6%). Conclusion: Aortic root expansion follows a precise chronology during systole and becomes more cylindrical - probably to maximize ejection. These findings might stimulate a more physiologic approach to aortic valve and aortic root surgical procedures. q 2002 Elsevier Science B.V. All rights reserved.
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