Abstract
Objective
To analyze our long-term experience with valve-sparing reimplantation technique in treating aortic root aneurysm, aortic regurgitation, and aortic dissection in patients with tricuspid aortic valve.
Methods
Between March 1998 and October 2018, 303 consecutive patients underwent valve-sparing reimplantation in our institution. The mean age of this cohort was 52.9 ± 15 years. Time to event analysis was performed with the Kaplan-Meier method. Risk of death, reoperation, and aortic regurgitation (AR) recurrence were analyzed using the cox-regression method.
Results
In-hospital mortality was 1% (n = 3) of which two were admitted for acute aortic dissection. Median follow-up was 5.81 years ([IQR]: 2.8–10 years). Thirty-nine patients (14.4%) died during follow-up. At 5 and 10 years, overall survival was 92 ± 2%and 75 ± 4.9%, respectively. Seventeen patients required late aortic valve reoperation. Freedom from valve reoperation was 95 ± 2% and 90 ± 3%. Freedom from AR > 2+ and AR > 1+ at 10 years was 91 ± 4% and 71.5 ± 4.6%, respectively. Significant multivariate predictors of death included age, New York Heart Association dyspnea class (NYHA), type A acute dissection (TAAD), and preoperative left ventricular end-diastolic diameter (LVEDD). Significant multivariate predictors of AR recurrence included indication for surgery, previous cardiac surgery, and presence of preoperative AR. Freedom from events like major bleeding, thromboembolic events, and infective endocarditis at 10 years were 97%, 98%, and 96%, respectively.
Conclusions
Aortic valve-sparing with the reimplantation technique has been performed for over two decades in our institution, and the results in patients with tricuspid aortic valve (TAV) are excellent in terms of survival and freedom from valve-related adverse outcomes including valve reoperation. These results continue supporting the use of valve sparing root replacement using the reimplantation technique (VSRR) in patients with aortic aneurysm, irrespective of whether they have preoperative AR or not. VSRR is safe, durable, and reproducible, but further follow-up, well into the second decade is still necessary.
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References
David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg. 1992;103:617–21.
David TE, Feindel CM, Bos J. Repair of the aortic valve in patients with aortic insufficiency and aortic root aneurysm. J Thorac Cardiovasc Surg. 1995;109:345–51.
Sarsam MA, Yacoub M. Remodeling of the aortic valve anulus. J Thorac Cardiovasc Surg. 1993;105:435–8.
David TE. Tirone on Tirone David operation and types. Gen Thorac Cardiovasc Surg. 2019;67:66–9.
David TE. The aortic valve–sparing operation. J Thorac Cardiovasc Surg. 2011;141:613–5.
David TE. Remodeling the aortic root and preservation of the native aortic valve. Oper Tech Card Thorac Surg. 1996;1:44–56.
De Paulis R, De Matteis GM, Nardi P, Scaffa R, Buratta MM, Chiariello L. Opening and closing characteristics of the aortic valve after valve-sparing procedures using a new aortic root conduit. Ann Thorac Surg. 2001;72:487–94.
Price J, De Kerchove L, Glineur D, Vanoverschelde JL, Noirhomme P, El Khoury G. Risk of valve-related events after aortic valve repair. Ann Thorac Surg. 2013;95:606–12.
Price J, Magruder JT, Young A, et al. Long-term outcomes of aortic root operations for Marfan syndrome: a comparison of Bentall versus aortic valve-sparing procedures. J Thorac Cardiovasc Surg. 2016;151:330–6.
Ouzounian M, Rao V, Manlhiot C, et al. Valve-sparing root replacement compared with composite valve graft procedures in patients with aortic root dilation. J Am Coll Cardiol. 2016;68:1838–47.
Mastrobuoni S, Tamer S, Navarra E, de Kerchove L, El Khoury G. Aortic valve repair in patients with Marfan syndrome-the ‘Brussels approach. Ann Cardiothorac Surg. 2017;6:704–8.
de Kerchove L, Boodhwani M, Glineur D, et al. Valve sparing-root replacement with the reimplantation technique to increase the durability of bicuspid aortic valve repair. J Thorac Cardiovasc Surg. 2011;142:1430–8.
Erbel R, Aboyans V, Boileau C, et al. ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2014;35:2873–926.
Falk V, Baumgartner H, Bax JJ, et al. ESC/EACTS guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg. 2017;52:616–64.
de Kerchove L, Mosala Nezhad Z, Boodhwani M, El Khoury G. How to perform valve sparing reimplantation in a tricuspid aortic valve. Ann Cardiothorac Surg. 2013;2:105–12.
Boodhwani M, de Kerchove L, El Khoury G. Aortic root replacement using the reimplantation technique: tips and tricks. Interact Cardiovasc Thorac Surg. 2009;8:584–6.
de Kerchove L, Boodhwani M, Glineur D, Noirhomme P. El Khoury G. A new simple and objective method for graft sizing in valve-sparing root replacement using the reimplantation technique. Ann Thorac Surg. 2011;92:749–51.
de Kerchove L, Glineur D, Poncelet A, et al. Repair of aortic leaflet prolapse: a ten-year experience. Eur J Cardiothorac Surg. 2008;34:785–91.
Schäfers HJ, Bierbach B, Aicher D, et al. A new approach to the assessment of aortic cusp geometry. J Thorac Cardiovasc Surg. 2006;132:436–8.
le Polain de Waroux JB, Pouleur AC, Robert A, et al. Mechanisms of recurrent aortic regurgitation after aortic valve repair. Predictive value of intraoperative transesophageal echocardiography. JACC Cardiovasc Imaging. 2009;2:931–9.
Kunihara T, Aicher D, Rodionycheva S, et al. Preoperative aortic root geometry and postoperative cusp configuration primarily determine long-term outcome after valve-preserving aortic root repair. J Thorac Cardiovasc Surg. 2012;143:1389–95.
Akins CW, Miller DC, Turina MI, et al. Guidelines for reporting mortality and morbidity after cardiac valve interventions. J Thorac Cardiovasc Surg. 2008;135:732–8.
De Paulis R, Chirichilli I, Scaffa R, et al. Long-term results of the valve reimplantation technique using a graft with sinuses. J Thorac Cardiovasc Surg. 2016;151:112–9.
de Kerchove L, Boodhwani M, Glinuer D, et al. Effects of preoperative aortic insufficiency on outcome after aortic valve-sparing surgery. Circulation. 2009;120:S120–6.
de Kerchove L, Mastrobuoni S, Boodhwani M, et al. The role of annular dimension and annuloplasty in tricuspid aortic valve repair. Eur J Cardiothoracic Surg. 2016;49:428–37.
Martens A, Beckmann E, Kaufeld T, et al. Valve-sparing aortic root replacement (David I procedure) in Marfan disease: single-Centre 20-year experience in more than 100 patients. Eur J Cardiothorac Surg. 2019;55:476–83.
Mastrobuoni S, Tamer S, de Kerchove L, El Khoury G. Valve sparing: aortic root replacement with the reimplantation technique. Multimed Man Cardiothorac Surg. 2015. https://doi.org/10.1093/mmcts/mmv012.
Shrestha ML, Beckmann E, Abd Alhadi F, et al. Elective David I procedure has excellent long-term results: 20-year single-center experience. Ann Thorac Surg. 2018;105:731–8.
Cameron D, Vricella L. Valve-sparing aortic root replacement with the valsalva graft. Oper Tech Thorac Cardiovasc Surg. 2009;14:297–308.
David TE, David CM, Feindel CM, Manlhiot C. Reimplantation of the aortic valve at 20 years. J Thorac Cardiovasc Surg. 2017;153:232–8.
David TE, David CM, Manlhiot C, Colman J, Crean AM, Bradley T. Outcomes of aortic valve-sparing operations in Marfan syndrome. J Am Coll Cardiol. 2015;66:1445–53.
Benedetto U, Melina G, Takkenberg JJ, Roscitano A, Angeloni E, Sinatra R. Surgical management of aortic root disease in Marfan syndrome: a systematic review and meta-analysis. Heart. 2011;97:955–8.
Schneider U, Hofmann C, Aicher D, Takahashi H, Miura Y, Schäfers HJ. Suture annuloplasty significantly improves the durability of bicuspid aortic valve repair. Ann Thorac Surg. 2017;103:504–10.
Arabkhani B, Mookhoek A, Di Centa I, et al. Reported outcome after valve-sparing aortic root replacement for aortic root aneurysm: a systematic review and meta-analysis. Ann Thorac Surg. 2015;100:1126–31.
De Paulis R, Scaffa R, Salica A, Weltert L, Chirichilli I. Biological solutions to aortic root replacement: valve-sparing versus bioprosthetic conduit. J Vis Surg. 2018;4:94. https://doi.org/10.21037/jovs.2018.04.12.
Lee H, Cho YH, Sung K, et al. Clinical outcomes of root reimplantation and Bentall procedure: propensity score matching analysis. Ann Thorac Surg. 2018;106:539–47.
Kvitting JP, Kari FA, Fischbein MP, et al. David valve-sparing aortic root replacement: equivalent mid-term outcome for different valve types with or without connective tissue disorder. J Thorac Cardiovasc Surg. 2013;145:117–26.
Schäfers HJ, Raddatz A, Schmied W, et al. Reexamining remodeling. J Thorac Cardiovasc Surg. 2015;149:S30–6.
Mastrobuoni S, De Kerchove L, Navarra E, Astarci P, Noirhomme P, El Khoury G. Valve sparing—aortic root replacement with the reimplantation technique in acute type a aortic dissection. Ann Cardiothorac Surg. 2016;5:397–400.
Leshnower BG, Myung RJ, McPherson L, Chen EP. Midterm results of David V valve-sparing aortic root replacement in acute type a aortic dissection. Ann Thorac Surg. 2015;99:795–800.
Miyahara S, Matsueda T, Izawa N, et al. Mid-term results of valve-sparing aortic root replacement in patients with expanded indications. Ann Thorac Surg. 2015;100:845–51.
David TE, Feindel CM, David CM, Manlhiot C. A quarter of a century of experience with aortic valve-sparing operations. J Thorac Cardiovasc Surg. 2014;148:872–9.
Giebels C, Aicher D, Kunihara T, Rodionycheva S, Schmied W, Schäfers HJ. Causes and management of aortic valve regurgitation after aortic valve reimplantation. J Thorac Cardiovasc Surg. 2013;145:774–80.
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Tamer, S., Mastrobuoni, S., Momeni, M. et al. Long-term experience with valve-sparing root reimplantation surgery in tricuspid aortic valve. Indian J Thorac Cardiovasc Surg 36 (Suppl 1), 71–80 (2020). https://doi.org/10.1007/s12055-019-00842-x
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DOI: https://doi.org/10.1007/s12055-019-00842-x