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Ann Thorac Surg 1995;60:176-180
© 1995 The Society of Thoracic Surgeons

Aortic Valve Resuspension in Ascending Aortic Aneurysm Repair With Aortic Insufficiency

Department of Cardio-Thoracic Surgery, University of Vienna, Vienna, Austria

Accepted for publication March 27, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. The known complications of prosthetic valve replacement in patients with an ascending aortic aneurysm and secondary aortic regurgitation who frequently have a morphologically normal aortic valve have prompted interest in valve-sparing aneurysm repair procedures. The aim of this study was to define the echocardiographic criteria for identifying suitable candidates for ascending aortic aneurysm repair that spares the aortic valve. We also examined the perioperative and intermediate-term results of this innovative procedure.

Methods. Fifteen patients underwent ascending aortic replacement with resuspension of the native valve within a vascular prosthesis and reimplantation of the coronary ostia. Echocardiography was performed preoperatively and intraoperatively, before discharge, and during follow-up. Thirteen patients had nondissecting aneurysms, and 2 patients had a Stanford type A aortic dissection. The mean age of the patients was 48 ± 18 years. Only patients with morphologically normal aortic leaflets and leaflets of similar size were selected.

Results. There was one death perioperatively, and this was due to sepsis. The procedure failed in 1 patient, and a valved conduit was implanted during the same operation. In the 13 others the aortic annulus diameter was significantly reduced from 27.1 ± 2.2 mm preoperatively to 22.2 ± 1.9 mm postoperatively (p < 0.05). The severity of aortic insufficiency decreased from 2.9 ± 0.7 to 0.6 ± 0.4 (p < 0.05). The peak aortic gradient increased from 11.5 ± 6.5 to 20.3 ± 16 mm Hg. A slight increase in the aortic annulus diameter to 24.3 ± 1.0 mm and normalization of the peak aortic gradient to 9.8 ± 7.8 mm Hg were noted at follow-up. There was no significant increase in aortic insufficiency.

Conclusions. In selected patients undergoing ascending aortic aneurysm repair who have normal aortic leaflets but secondary aortic regurgitation, the native valve can be spared through this novel operation. The aortic annulus size is reduced significantly, thereby effectively eliminating hemodynamically significant aortic regurgitation. The intermediate-term results are promising, but the long-term durability of this type of repair needs to be determined.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Isolated aortic regurgitation can be caused by a variety of pathologic states involving the leaflets, the aortic annulus, or the aortic root, or a combination thereof [1–4]. Annuloaortic ectasia has been identified as the most common cause [4, 5]. The progressive dilation of the aortic root may be idiopathic or secondary to Marfan's syndrome, its form fruste, or other disorders causing weakness of the aortic wall such as aortitis, the Ehlers-Danlos syndrome, and other rare causes [1–5]. These patients require surgical treatment to eliminate progressive dilation of the aortic root both to prevent aortic rupture or dissection and to treat secondary aortic regurgitation. In most of these patients the aortic leaflets are initially normal and valve incompetence occurs as a result of leaflet malcoaptation stemming from annuloaortic dilatation. As a consequence the leaflets themselves may become altered such that the changes resemble those affecting the aortic wall, with progressive structural loss and leaflet thinning making repair impossible. The current operative strategy in patients with annuloaortic ectasia is to replace the valve and the ascending aorta with a valved conduit [6]. Excellent long-term results have been obtained using the composite graft technique [7, 8]. However, many patients with isolated aortic insufficiency resulting from annuloaortic ectasia have normal valve leaflets. This and the known complications of mechanical prostheses [9] have prompted attempts to preserve the aortic valve in select patients [10, 11].

David and Feindel [12] have described a surgical technique in which the aortic valve is resuspended within a tubular graft and the coronary ostia are reimplanted.

The purpose of this study was first to establish the echocardiographic criteria for identifying suitable candidates for an ascending aneurysm repair using the technique of David and Feindel and secondly to determine intraoperatively the immediate adequacy of the procedure using transesophageal echocardiography as well as the stability of the repair before the patient was discharged and at follow-up.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Patients
Based on echocardiographic criteria, 15 patients (9 men and 6 women) with an ascending aortic aneurysm were chosen to undergo this valve-sparing aneurysm repair procedure. One patient in whom the procedure failed was excluded from further analysis. The patients ranged in age from 20 to 70 years (mean, 48 ± 18 years). The echocardiographic criteria for valve preservation were the presence of three semilunar aortic leaflets with a normal morphologic appearance, no gross leaflet prolapse, and symmetrical leaflets of similar size. The presence of aortic dissection is not a contraindication to this procedure at our institution. Thirteen patients had a nondissecting and 2 patients a dissecting aneurysm of the ascending aorta. Four patients had Marfan's syndrome.

Echocardiography
In all patients transthoracic echocardiography was performed preoperatively and postoperatively, before discharge, and at follow-up during the first year of operation. In addition, transesophageal echocardiography was done intraoperatively before and after the repair procedure to assess the adequacy of the repair. All examinations were performed using standard echocardiographic equipment (Sonos 1000 and Sonos 1500; Hewlett-Packard). A 5-MHz biplane or omniplane transesophageal transducer was used for the intraoperative studies.

A complete cardiac assessment that focused on the aorta was carried out in all patients, in particular the ascending aortic segment (Fig 1). Measurements obtained included the diameter of the aortic annulus, the sinus of Valsalva, and the ascending aorta. Frequently the sinus could not be clearly discerned from the proximal part of the ascending aorta because of the aneurysmal dilatation of this segment with accompanying loss of the sinotubular junction. The diameter of the aortic annulus was measured in transthoracic studies in the parasternal long-axis view at the insertion of the semilunar leaflets from the trailing to the leading edge. We have found that this ``inner'' diameter measurement of the annulus most closely approximates the size found at operation. In the transesophageal echocardiographic studies, the longitudinal view of the ascending aorta was obtained to measure this inner diameter of the annulus. This measurement represents the so-called surgical annulus, corresponding to the diameter at the leaflet base used for the sizing of prosthetic valves. It does not correspond to the anatomic annulus, which follows the concave attachment line of the semilunar leaflets. We also measured the commissural distances (Fig 2) in a cross-sectional view of the aortic root in an attempt to account for the complex geometric characteristics and functioning of the aortic annulus, leaflets, and sinus of Valsava and also to quantitatively describe the leaflets and the degree of their symmetry [13]. The severity of aortic insufficiency was graded semiquantitatively from 0 to 4+ on the basis of color-flow Doppler criteria, using both the width of the jet in the left ventricular outflow tract and its extension into the left ventricle [14].

View larger version (70K): [in this window] [in a new window]   Fig 1. . Transgastric view of the entire ascending aorta obtained by transesophageal echocardiography. The aortic annulus, sinus of Valsalva (SV) and sinotubular junction are dilated markedly, the classic appearance of annuloaortic ectasia. The arrow marks the level of the aortic valve. (LV = left ventricle.)

View larger version (85K): [in this window] [in a new window]   Fig 2. . Cross-sectional view of the aortic root (A) before aneurysm repair obtained by transesophogeal echocardiography. Measurement of the commissural distances shows considerable distention. The aortic leaflets do not appear to be thickened and are symmetrical. This is crucial for appropriate patient selection. The measurement between the left and noncoronary commissure is shown.

View larger version (186K): [in this window] [in a new window]   Fig 3. . The native valve is suspended within the vascular prosthesis, similar to the homograft technique.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
There was one death perioperatively. This was due to sepsis and occurred in a patient who had an acute Stanford type A aortic dissection and who also underwent arch replacement during the same operation. The procedure failed in 1 patient because of considerable aortic insufficiency after cardiopulmonary bypass. This patient was the second one in this series who had Marfan's syndrome and was included even though the leaflets were asymmetrical in size. A valved conduit was placed during the same operation, and the patient recovered uneventfully.

All patients had significant annuloaortic dilatation before operation, with the maximum diameter of the ascending aortic aneurysm being 58 ± 12 mm and that of the aortic annulus being 27.1 ± 2.2 mm. The aortic root was symmetrical in all patients, and the aortic valve was tricuspid and appeared morphologically normal in all patients. The commissural distance before and after repair are given in Table 1. There was at least 2+ aortic regurgitation in all but 1 patient, a young woman with Marfan's syndrome who had only trivial aortic insufficiency at the time of operation. The mean severity of the aortic regurgitation was 2.9 ± 0.7. The mean end-diastolic diameter of the left ventricle was mildly increased at 62 ± 7 mm. The left ventricular function, measured as the percentage of the fractional shortening of the left ventricular diameter at the midcavity level, ranged from normal to severely depressed, with the mean percentage of the fractional shortening being 27.8% ± 12.3%. The mean diameter of the aortic annulus was successfully reduced to 22.2 ± 1.9 mm (p < 0.01 versus the preoperative diameter). This and the decrease in the commissural distances (Table 1) reestablished aortic valve competence, with a mean severity of 0.6 ± 0.4 after repair. There was, however, a slight increase in the aortic flow velocities and gradients after operation. These abnormalities had resolved by the time of follow-up (Table 2). Follow-up data are available for 12 patients, with the mean follow-up time being 12 ± 9 months and ranging from 1 to 33 months. The aortic annulus showed a trend toward slight dilatation, 24.3 ± 1.0 mm, but the change was not statistically significantly different from the discharge measurement and was possibly due to remodeling. However, in only 1 patient was there an increase in aortic regurgitation by one grade compared with the predischarge assessment; this was graded as 2+ at follow-up. In all other patients the valve remained competent and the mean severity of the aortic insufficiency was 0.8 ± 0.5 (p = not significant versus the discharge valve).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Noninflammatory aortic root dilatation has become the most common cause of isolated aortic regurgitation now that the prevalence of rheumatic fever has declined [4, 5]. The recommended surgical treatment in patients who have an aortic aneurysm with aortic insufficiency has been composite graft replacement of the aortic valve and the ascending aorta, as described by Bentall and DeBono [6]. This technique has yielded excellent long-term results [7, 8], but the known complications of prosthetic valve replacement [9] make an effective technique for preserving the native valve a superior alternative. Several authors have described operative techniques for ascending aortic replacement and preservation of the aortic valve, but these have yielded mixed results. Excellent long-term results can be achieved in patients with aortic dissection who undergo resuspension of a detached commissure [15]. Carpentier [10], on the other hand, noted a high rate of reoperation in patients undergoing some of the procedures used by him for the reduction of annular dilatation. More recently Sarsam and Yacoub [11] and David and Feindel [12] have described techniques of aortic replacement with aortic valve preservation that have shown very promising short-term results, but there have been little data on the echocardiographic criteria for selecting patients for the David operation. We also used transesophageal echocardiography intraoperatively and transthoracic echocardiography subsequently to determine the hemodynamic outcome of the repair and its durability within the first postoperative year.

The patients were selected solely on the basis of the morphologic criteria of the aortic root. Patients with grossly asymmetrical leaflet sizes, with bicuspid leaflets, with leaflet prolapse, or with considerable thickening of the leaflet edges resulting from myxomatous degeneration were excluded and received composite grafts. Neither Marfan's syndrome nor aortic dissection was reason for exclusion. We have found a high prevalence of aneurysms of the sinus of Valsalva during follow-up in patients with Stanford type A dissections and extensive destruction of the sinus when only an ascending aortic tube graft has been used for repair [16]. In the future these patients may benefit from the type of operation used in the patients we describe here. Currently the surgical aim in patients with Marfan's syndrome is to resect all of the ascending aorta if they have a nondissecting aneurysm or an acute aortic dissection and to implant a composite graft even in the absence of aortic regurgitation because of the high recurrence rate of aneurysms in the nonresected aortic segment. Our data have demonstrated that these patients generally have a combined disorder of the aortic annulus and the aortic wall, that is, annuloaortic ectasia. The repair effectively reduces the annular size and the commissural distances and reestablishes valvular competence. It also shows promising results within the first year, with satisfactory stability of the aortic annulus and consistently good valve function. However, the number of patients in this series is small, as is the number of patients in other series, with David and associates [17] reporting on 19 patients at the 1994 meeting of the American Association of Thoracic Surgery. In addition, the follow-up periods are still short and the long-term durability of this type of repair has yet to be established. Thus the merits and demerits of the procedure are not fully known. The procedure should at this point be performed only in centers where the staff has extensive experience in aneurysm repair and reconstructive valve procedures. There is also a definite learning curve. The only failure in our series occurred early in our experience in a patient who was selected to undergo the procedure even though the leaflets were asymmetrical. The prospect of extending the David operation for use in patients with bicuspid valves and in patients requiring reconstruction of the leaflets themselves needs careful consideration.

In conclusion, the results of our study are encouraging. We have found the aortic valve can be effectively preserved with good valve competence and excellent hemodynamic performance in properly selected patients with secondary aortic insufficiency who undergo ascending aortic aneurysm repair using this innovative operation.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Simon, Department of Cardio-Thoracic Surgery, University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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