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Ann Thorac Surg 1999;67:1849-1852
© 1999 The Society of Thoracic Surgeons

Recurrence of aortic insufficiency after aortic root remodeling with valve preservation

^a Division of Cardiac Surgery, University of Verona, Verona, Italy
^b Division of Pathology, University of Verona, Verona, Italy

Address reprint requests to Dr Luciani, Division of Cardiac Surgery, University of Verona, O. C. M. Piazzale Stefani 1, Verona, 37126, Italy
e-mail: Luciani{at}netbusiness.it

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

	Abstract

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Background. Aortic root remodeling (ARR) has recently been proposed for patients with aortic aneurysms and valve insufficiency (AI). To define factors associated with a favorable functional outcome, a review of the mid-term results with ARR was undertaken.

Methods. Between March 1994 and October 1997, 17 consecutive patients (11 men, 6 women), aged 57 ± 11 years (range 35–71), had elective ARR for aortic aneurysm with or without annuloaortic ectasia (13), sinus of Valsalva aneurysm (3), or chronic aortic dissection (1). Moderate or severe AI was present in 11 patients (65%). Preoperative aortic root diameter was 58 ± 5 mm (range 51–70). ARR involved replacement of all three aortic sinuses and coronary button reimplantation, using grafts with a mean diameter of 28 ± 2 mm (range 24–30).

Results. There was one early death (6%) due to multiple organ failure. Survivors were followed for 16 ± 12 months (range 1–44). Actuarial 3-year survival was 94% ± 6%. Discharge echocardiogram showed a decrease in AI in all patients: AI was absent in 11 (69%) and mild in 5 (31%). Recurrence of moderate or severe AI after a mean of 16 ± 9 months (range 9–28) was noted in 6 patients (37%), 3 of whom had no AI at discharge. Five of 6 patients required aortic valve replacement. Comparison of demographic and operative variables showed that severe preoperative AI (67% vs 20%, p = 0.06), annuloaortic ectasia (100% vs 20%, p = 0.002), and cystic medial necrosis (100% vs 20%, p = 0.002) were significantly more prevalent in patients developing severe AI at follow-up. The 10 patients (63%) with absent AI showed durable competence of the valve and relief from symptoms at follow-up.

Conclusions. Despite early restoration of valve competence, AI may recur and progress after ARR at medium-term follow-up in a proportion of patients. The severity of preoperative AI and the nature of aortic root disease may negatively influence the durability of repair. Continued observation of results with ARR appears mandatory to identify the appropriate surgical candidates.

	Introduction

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Great interest has recently grown up around operations involving aortic root replacement with preservation of the valve in cases of aortic insufficiency caused by aortic root disease [1–4]. At least three different techniques have thus far been reported with very encouraging early results [1, 2, 4]. A series of doubts remain, however, with regard to the indications for preservation of an apparently normal aortic valve, selection of specific techniques for the particular anatomy of the patient, sizing of the prosthesis, and durability of the repair. In an attempt to identify factors associated with a favorable outcome after aortic root remodeling with valve preservation, our experience was retrospectively analyzed.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Between March 1994 and October 1997, 17 consecutive patients underwent elective remodeling of the aortic root with preservation of the aortic valve. Operations involving aortic valve preservation in the context of acute aortic dissection, as well as remodeling limited to the sinotubular junction or to one or two sinuses of Valsalva, were excluded from the present study. These techniques represent radically different forms of treatment because the integrity of the aortic root is at least partly maintained. Indeed, the generally favorable outcome of these operations in terms of lasting aortic valve competence has previously been described [5].

There were 11 males and 6 females, aged 57 ± 11 years (range 35–71). Ascending aortic aneurysm with (8) or without (4) annuloaortic ectasia, sinus of Valsalva aneurysm (4), and chronic aortic dissection (1) were the indications for repair. Only 1 patient (6%) had a Marfan phenotype. The maximal diameter of the aortic aneurysm was 58 ± 5 mm (range 51–70), with mild (grade 2) aortic insufficiency in 5 patients, moderate (grade 3) in 6, and severe (grade 4) in 6. Preoperative New York Heart Association (NYHA) class was 2.6 ± 0.8 (range 2–4). All procedures were conducted under moderately hypothermic (28°C) cardiopulmonary bypass (mean duration 174 ± 43 min), during a period of aortic cross-clamping (mean duration 129 ± 32 min).

Aortic root remodeling, including the method for sizing the tubular graft, was performed in all patients using a technique described by Sarsam and Yacoub [2], which entails replacement of all three aortic sinuses, resuspension of the aortic valve leaflets, and reimplantation of the coronary artery buttons. Only one technical modification was adopted: buttressing the three suture lines on the aortic annulus with three strips of autologous glutaraldehyde-fixed pericardium. The purpose of the pericardial strips was to confer greater hemostasis and possibly prevent dilatation of the aortic annulus. The mean Dacron graft diameter was 28 ± 2 mm (range 24–30). Associated procedures were required in 2 patients: myocardial revascularization in 1, and separate Dacron graft replacement of the innominate artery in 1.

Aortic valve competence was assessed by means of intraoperative transesophageal echocardiography. Transthoracic echocardiogram was repeated before discharge and on a 6-month basis thereafter. Patients with recurrent severe aortic insufficiency underwent repeat catheterization.

	Results

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There were no operative casualties. One patient (6%), with chronic aortic dissection and chronic renal insufficiency requiring dialysis, developed postoperative multiple organ failure and died 40 days after an apparently successful operation. Perioperative complications were recorded in 3 patients (18%), and included two episodes of transient neurologic dysfunction and one reexploration for bleeding. There were no late deaths, including those patients who required reintervention at a mean follow-up of 16 ± 12 months (range 1–44), resulting in an actuarial survival of 94 ± 6% at both 1 and 3 years.

Discharge echocardiograms demonstrated a significant decrease in the degree of aortic insufficiency in all patients. There was trivial or no regurgitation in 11 (69%), and mild aortic insufficiency in 5 (31%) (Fig 1). Progressive evolution of aortic insufficiency was noted at serial echocardiographic evaluation in 6 patients, 3 of whom had absent, and 2 of whom had mild insufficiency at discharge. The remaining 2 patients with mild insufficiency at discharge had no evolution at follow-up. The mean time interval for development of severe aortic insufficiency requiring reintervention was 17 ± 10 months (range 5–28). Reoperation was necessary in 5 patients (31%): replacement of the aortic valve was carried out using a mechanical prosthesis in 4 patients, and a bioprosthesis in 1. The macroscopic finding of the aortic valve in reoperated patients was always unrewarding, with an apparently normal looking tricuspid valve and no annular dilatation. Based on these findings, early in our series, 1 of the 5 patients had an attempt at valve repair by means of aortic annuloplasty and commissure resuspension. The functional result was unsatisfactory, and the valve had to be replaced shortly thereafter. All patients survived reoperation and are well after a mean follow-up of 10 ± 8 months (range 2–24). Histology of the explanted valve showed mucoid degeneration in 4 and extensive fibrosis in 1. The last patient with recurrent insufficiency is currently in NYHA class 2 with moderate aortic regurgitation and no evidence of further progression.

View larger version (15K): [in this window] [in a new window]   Fig 1. Evolution of aortic insufficiency before repair, at discharge, and at follow-up assessment. In parenthesis are shown the relative numbers of patients with regression or progression of aortic insufficiency.

	Comment

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In spite of the evidence of ultrastructural abnormalities of aortic valve leaflets in Marfan patients that are identical to the ones found in the aortic wall [9], Marfan’s syndrome has not represented a contraindication to the procedure. Outcome of valve sparing operations in these patients has, however, been less predictable [10] and, currently, exclusion criteria such as an aortic root diameter greater than 60 mm and the presence of gross valvular insufficiency have been proposed [11]. Although the proportion of Marfan patients in our experience was smaller than in previously reported series [3, 4, 6, 7], our observations support the above findings: patients with severe preoperative valve insufficiency were more likely to develop recurrent aortic regurgitation at follow-up (Table 1).

In contrast, no apparent association with aortic root diameter was evident in our series. Annuloaortic ectasia represents the most common indication for elective aortic root remodeling procedures in Marfan and non-Marfan patients [3, 4, 6, 7]. Unfortunately, the hypothesis that the aortic valve leaflets are unaffected by the degenerative changes found in the aortic wall has never been proven. As the microscopic (ie, cystic medial necrosis) and ultrastructural findings of Marfan syndrome are by and large common to most degenerative disease processes affecting the aorta [12], the possible involvement of the aortic valve leaflets in some patients with annuloaortic ectasia cannot be excluded. Our preliminary experience with root remodeling operations shows that the presence of annuloaortic ectasia and aortic wall histology of cystic medial necrosis are more prevalent in patients who present with recurrent regurgitation at follow-up (Table 1). Furthermore, the high association with aortic valve histology compatible with mucoid degeneration, albeit in the absence of a control group, further implies that the structural properties of the leaflets of patients with annuloaortic ectasia and normal-looking aortic valves may be abnormal. Whether these findings are in any way related to failure of the repair is, at present, a matter of speculation.

Lastly, concern about extending use of valve sparing procedures to the older patient has grown, since valve repair may be less durable than replacement. Indeed, anecdotal evidence has suggested that ultrastructural changes similar to those of Marfan patients may be present in the aortic leaflets of senescent patients (older than 60 years) with no evidence of aortic aneurysm or connective tissue disorder [9]. No association between recurrent insufficiency and older age was appreciable in our series; patients without aortic insufficiency tended to be older, with a mean age close to 60 years (Table 1).

The ideal technique to restore aortic root anatomy and thus valve physiology has also not been defined. Recent work suggests that root remodeling, possibly associated with annuloplasty, may be preferable to reimplantation in annuloaortic ectasia [11]. Others have identified an additional advantage in tailoring the graft so as to confer a sinusoidal geometry ("pseudosinus" modification) to the neoaortic root [4]. Nonetheless, the general postulate that, once repaired with a graft, the root will function as a unit, remains to be verified. In the present series, a root remodeling technique similar to the one described by Sarsam and Yacoub [2], associated with an annuloplasty, was uniformly adopted. Unfortunately, the lack of gross alterations of the valves in reoperated patients (including leaflet prolapse, tear, or annular dilatation) makes it difficult to determine what proved inadequate in our series: whether the substrate (aortic valve), the repair, or both. Although the existence of a learning curve has been postulated due to the complexity of the repair [1, 2], the time distribution of unsuccessful cases in the present series suggests a limited role for technical failure due to inexperience.

In conclusion, the present work shows that a satisfactory functional outcome can be obtained in most patients early after aortic root remodeling. The result, however, may not be durable in a significant proportion of patients. The association of late recurrence of aortic incompetence with the degree of preoperative insufficiency and with histological evidence of cystic medial necrosis underscores the need for further definition of patient selection criteria and closer scrutiny of long-term results.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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