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Ann Thorac Surg 1999;67:1840-1842
© 1999 The Society of Thoracic Surgeons

Aortic valve sparing operations: an update

^a Division of Cardiovascular Surgery, The Toronto Hospital, University of Toronto, Toronto, Ontario, Canada

Address reprint requests to Dr David, 200 Elizabeth St, 13EN219, Toronto, ON, Canada M5G 2C4
e-mail: aats{at}torhosp.toronto.on.ca

Presented at the Aortic Surgery Symposium VI, April 30–May 1, 1998, New York, NY.

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Aortic valve sparing operations in patients with ascending aorta and/or aortic root aneurysms have been performed for a decade in our institution. Initially only patients with normal aortic valve leaflets had these operations, but more recently we utilized them in patients with prolapse of a single leaflet and in those with a bicuspid aortic valve. This article is an update on the clinical results of these operations.

Methods. From May 1988 to December 1997, 126 patients with ascending aorta and/or aortic root aneurysms and aortic insufficiency underwent replacement of the ascending aorta with reconstruction of the aortic root and preservation of the native aortic valve. There were 85 men and 41 women, with a mean age of 54 years (range, 14 to 84). Thirty-two patients had the Marfan syndrome; 17 patients had acute and 10 had chronic type A aortic dissection; 23 had a transverse arch aneurysm; 26 had coronary artery disease, and 8 had mitral regurgitation. The aortic valve sparing operation consisted of simple adjustment of the sinotubular junction in 33 patients, adjustment of the sinotubular junction and replacement of one or more aortic sinuses in 60, and reimplantation of the aortic valve in a tubular Dacron (C.R. Bard, Haverhill, PA) graft in 33. Fifteen patients also had repair of aortic leaflet prolapse. Only 4 patients had a bicuspid aortic valve.

Results. There were 3 operative deaths due to cardiac failure. Patients were followed from 2 to 117 months, with a mean of 31. There were 11 late deaths: 7 cardiovascular and 4 from unrelated causes. The actuarial survival was 72 ± 8% at 7 years. Two patients required aortic valve replacement; the freedom from aortic valve replacement was 97 ± 2% at 7 years. Doppler echocardiography revealed absent, trivial or mild aortic insufficiency in most patients; only 9 patients had moderate aortic insufficiency.

Conclusions. Aortic valve sparing operations are feasible in most patients with ascending aorta and/or aortic root aneurysms who have normal or near normal aortic leaflets. The functional results of the repaired aortic valve are excellent, and the repair appears to be durable.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Aortic valve sparing operations in patients with aortic root and/or ascending aorta aneurysms have been performed for almost a decade in our institution, and the results have been most gratifying [1–4]. These operations were done initially in patients who had normal or near-normal aortic valve leaflets, but more recently we have performed them in patients who have prolapse of one of the 3 aortic leaflets, and in those with a bicuspid aortic valve. This paper summarizes our current experience with various types of aortic valve sparing operations [1–3].

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
From May 1988 to December 1997, 126 patients with ascending aorta/aortic root aneurysm and aortic insufficiency (AI) underwent replacement of the ascending aorta and reconstruction of the aortic root with preservation of the native aortic valve (AV). Table 1 summarizes the clinical profile of the patients.

Mild-to-moderate prolapse of a leaflet was corrected by passing a 6-0 Gore-Tex suture (WL Gore & Associates, Inc, Flagstaff, AZ) in and out of the free margin of the leaflet and adjusting its length to shorten the free margin as shown in Figure 1. More severe prolapse was corrected by plication of the free margin of the leaflet in one of its commissures if a fenestration was present in this area, or by a triangular resection of its mid-portion, and reinforcement of the free margin with a 6-0 Gore-Tex suture as described above.

View larger version (37K): [in this window] [in a new window]   Fig 1. Repair of prolapsing aortic leaflet with 6-0 Gore-Tex suture.

Statistical analysis
Actuarial survival and freedom from aortic valve replacement were estimated by the Kaplan-Meier method. Values are expressed as means and standard errors of the means.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
There were 3 operative deaths, all due to cardiac failure (myocardial infarction in 1 and low output syndrome in 2). Postoperative complications were common: re-exploration for bleeding was required in 14 patients, and a permanent pacemaker in 1; myocardial infarction occurred in 2 patients (1 died); stroke occurred in 6 (all of whom had either an atherosclerotic transverse arch aneurysm or an acute type A aortic dissection), and sternal infection occurred in 1.

Operative survivors were followed from 2 to 117 months, with a mean of 31. There were 11 late deaths: 7 cardiovascular (myocardial infarction in 2, sudden in 1, stroke in 1, and problems related to the false lumen in dissecting aneurysms in 3), and 4 non-cardiovascular (cancer in 2, pneumonia in 1, Lou Gehrig’s disease in 1). The actuarial survival for all patients was 72 ± 8% at 7 years. The survival for patients with the Marfan syndrome was 100% at 7 years.

Two patients required AV replacement: one soon after surgery, and the other 2 years later. The freedom from AV replacement was 97 ± 2% at 7 years. It was the same for patients with the Marfan syndrome. Two patients who had aortic dissection required replacement of the entire thoracic and abdominal aorta; 1 became paraplegic.

Doppler echocardiographic studies were performed yearly. The latest study showed absent or trivial AI in 54 patients, mild AI in 47, and moderate AI in 9.

Functional inquiry revealed that most patients are asymptomatic from a cardiac viewpoint. Of 109 patients available for follow-up, 82 are in New York Heart Association functional class I, 18 in class II, 8 in class III, and 1 in class IV.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Elderly patients with ascending aortic aneurysms frequently have AI secondary to dilatation of the sinotubular junction. The AV leaflets are often normal for age, and reduction of the sinotubular junction with an appropriate tubular Dacron graft is all that is needed to restore valve competence. The diameter of this graft should not exceed that of the average length of the free margins of the AV leaflets [3]. However, if the average length of the free margins of the leaflets is less than 24 mm, it is preferable to use a larger graft and reduce its diameter in the area where it is anastomosed to the aortic root, because grafts with small diameters in the ascending aorta can increase left ventricular afterload and cause heart failure.

Younger patients with degenerative disease of the aorta frequently have all three aortic sinuses dilated. Remodeling of the aortic root or reimplantation of the aortic valve is needed to re-establish AV function in these patients [2]. Long-term follow-up revealed that the function of the AV remains normal in most patients regardless of the type of reconstructive procedure used. The hypothesis that elimination of the sinuses of Valsalva adversely affects durability of the AV may be correct [5], but this problem has not become apparent after 5 to 10 years of follow-up in our patients.

Approximately one-fourth of our patients had the Marfan syndrome. Some investigators have expressed concerns regarding the appropriateness of preserving the AV in these patients because of abnormal fibrillin [6]. However, our experience suggests that AV repair in patients with the Marfan syndrome is durable and that the long-term results may be similar to those obtained with mitral valve repair in this patient population. The stabilization of the aortic annulus and sinotubular junction with a properly tailored Dacron graft may prevent the deterioration of the connective tissue in the leaflets. The functional results in these patients have been so gratifying that we now recommend surgery if the leaflets are echocardiographically normal and the diameter of the aortic root reaches 50 mm.

In conclusion, our experience suggests that AV sparing operations are a valid surgical therapy for patients with ascending aorta and/or aortic root aneurysms and aortic insufficiency if the aortic valve leaflets are normal.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. David T.E., Feindel C.M. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992;103:617-622.[Abstract]
2. David T.E., Feindel C.M., Bos J. Repair of the aortic valve in patients with aortic insufficiency and aortic root aneurysm. J Thorac Cardiovasc Surg 1995;109:345-352.[Abstract/Free Full Text]
3. David T.E. Remodeling of aortic root and preservation of the native aortic valve. Op Tech Cardiac Thorac Surg 1996;1:44-56.
4. David T.E. Aortic root aneurysms: Remodeling or composite replacement?. Ann Thorac Surg 1997;64:1564-1568.[Abstract/Free Full Text]
5. Cochran R.P., Kunzelman K.S., Eddy A.C., Hofer B.O., Verrier E.D. Modified conduit preparation creates a pseudosinus in an aortic valve-sparing procedure for aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1995;109:1049-1058.
6. Gott V.L., Laschinger J.C., Cameron D.E., et al. The Marfan syndrome and the cardiovascular surgeon. Eur J Cardiothorac Surg 1996;10:149-158.[Abstract]

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