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Ann Thorac Surg 2005;80:1540-1549
© 2005 The Society of Thoracic Surgeons

Review

Restitution of the Aortic Valve: What is New, What is Proven, and What is Obsolete?

Johannes M. Albes, MD, PhD * , Ulrich A. Stock, MD, PhD, Martin Hartrumpf, MD

Department of Cardiovascular Surgery, Heart Center Brandenburg, Bernau, Germany

Accepted for publication February 1, 2005.

* Address reprint requests to Dr Albes, Department of Cardiovascular Surgery, Heart Center Brandenburg, Ladeburger Strasse 17, Bernau, 16321 Germany (Email: j.albes{at}immanuel.de).


   Abstract
Top
 Abstract
Introduction
 Current Surgical Techniques
 Systematic Review: Cumulative...
 Early and Late Mortality
 Longevity of Reconstructive...
 Conclusion
 References
 
Restitution strategies of the insufficient aortic valve belong to the clinical armamentarium. To date, the accumulated body of evidence comprises 126 articles dealing with restitution strategies on the insufficient aortic valve with concomitant aortic surgery. In a cumulative analysis an almost identical number of reimplantation (506) and remodeling (489) procedures were found in the literature, whereas 357 patients underwent aortic valve resuspension. The cumulative results tend to favor the reimplantation technique in terms of longevity of the reconstruction, particularly in congenital degenerative disorders of the aortic wall, whereas remodeling appears to exhibit a more physiologic behavior of the reconstructed valve and re-suspension serves as a simplified approach particularly in acute type A dissection. Although restitution of the native aortic valve has its place in current treatment options, the accumulated worldwide numbers indicate that it is not yet routinely implemented in the vast majority of cardiac institutions.


   Introduction
Top
 Abstract
 Introduction
Current Surgical Techniques
 Systematic Review: Cumulative...
 Early and Late Mortality
 Longevity of Reconstructive...
 Conclusion
 References
 
Developments in cardiac surgery do not proceed in a neat uniform rate. Particular treatment modalities unanimously accepted for rather long periods of time may suddenly be deemed inadequate and therefore questioned. As the main focus of interest shifts towards such a topic, surgeons become more and more intrigued. As a consequence, more than one invention may emerge simultaneously. In case of almost identical solutions "who was the first" will most certainly be a matter of keen debate. If different strategies are used to solve the same problem "which is better" will surely become the subject of an ongoing discussion. Both David and Feindel [1] and Yacoub and colleagues [2] independently developed quite different operative strategies to reconstruct a dilated aortic root while replacing the aneurysmatic aorta with a prosthetic graft. After many years of rather liberal aortic valve replacement, their methods to spare a valve with morphologic intact cusps were obviously overdue. Thus they were eagerly adopted by many cardiac surgeons. Although technically very demanding, the widespread use of the procedure resulted in a variety of articles exhibiting positive early experiences. However, the pendulum regarding the "preferable" method swayed back and forth. Whereas supporters of the "David" technique claimed to offer superior prevention of annulus dilatation, the proponents of the "Yacoub" technique cited the more physiologic movement of the cusps within their native sinus basis [3–7]. Although in recent years more surgeons appear to favor the David technique, which is underlined by a larger body of studies concerning this particular method [8–10]. Some technical alterations also found their way into the literature. Additional annulus support for the Yacoub technique, facilitation of implantation of the David technique, and modalities to estimate the appropriate prosthesis diameter and the spatial alignment of the commissures within the prosthetic graft were described [11–13]. Euphemistic interpretation of the apparently promising early data resulted in an increasing incentive to perform reconstructive surgery [14]. Indications were liberally extended toward patients with bicuspid valves, Marfan patients, acute type A-dissection, endocarditis, or even small infants [15–20]. However, in recent years some concerns regarding the long-term results of valve-sparing procedures were raised by reporting a significant proportion of remaining aortic insufficiency, enlargement of the remaining root components, or even deleterious ruptures [21–26]. Currently several authors aim at a reduction of the technical challenges by suggesting simplified methods for selected patients. First clinical results appear to support the feasibility of those modalities [27, 28]. The matter of aortic valve sparing is clearly not solved and needs to be scrutinized further. At present, proven evidence for certain benefits as well as drawbacks and pitfalls intermingle with experience on a mere casuistic basis or even plain superstitious belief.


   Current Surgical Techniques
Top
 Abstract
 Introduction
 Current Surgical Techniques
Systematic Review: Cumulative...
 Early and Late Mortality
 Longevity of Reconstructive...
 Conclusion
 References
 
In an attempt to develop a systematic order for aortic restitution some authors distinguish between repair to salvage the valve and reconstruction to spare the valve. However, one should consider that during the evolution of sparing strategies in the last years, many techniques were mixed in order to respond more readily to the individual situation of the patient. Therefore neither term appears to be ideal for reparative or reconstructive measures. However, the terms remodeling, reimplantation, and re-suspension may be helpful in categorizing valve-sparing and restitution measures.

The root remodeling technique was originally inaugurated by Yacoub [2, 14]. A triple tongue graft is fashioned and serves to re-suspend the commissures, whereas the sinuses are replaced. Interestingly, David described a very similar approach known as the David II procedure. The difference is minor and lies in the shape of the tongues. Although the original Yacoub technique utilizes plain cuts of appropriate height, which renders tipped triangles to be sewn into the round remnants of the sinuses, the David II procedure utilizes round tongues that are fashioned to adapt more readily to the sinus remnants. The annulus remains untreated [29–31]. Numerous modifications have been developed thus far in order to suspend the annulus. El Khoury and colleagues [32] and later Hopkins [29] accomplished this goal by means of a narrow Teflon felt strip (DuPont, Wilmington, DE) attached around the annulus fixed with subannular U-shaped stitches. In order to maintain a larger diameter of the root at the level of the sinuses, the prosthesis was slightly tailored by means of another Teflon felt passed around the prosthesis at the sinutubular level (ie, directly above the level of the re-suspended commissures [13, 30]. The David III technique stands for a combination of annulus stabilization with Teflon felt strips, as well as sinus replacement with prosthesis tongues completed with an additional suspension of the commissural heights with teflon-pledgetted U-stitches [29].

The aortic reimplantation technique was originally inaugurated by David [1, 30, 31, 33]. The basic principle is to re-suspend the entire valve within a prosthesis. U-shaped subannular ligatures attached to the proximal edge of the prosthesis suspend the subvalvular region. The native commissures are attached inside the prosthesis and finally the edges of the trimmed sinuses are sewn into the prosthesis [1]. This technique does not prevent the cusps from coming into contact with the prosthetic wall during systole [34]. Therefore, variations of this technique aiming at an improvement of this particular drawback have been developed [35]. In a modification, the sinus walls were not resected, but instead trimmed and incorporated in the prosthesis [36]. As also inaugurated by David [31], a larger prosthesis can be chosen to provide redundant space at the sinus level. The diameter was reduced at the annular level utilizing subannular U-stitches and was reduced at the sinutubular level by anastomosing it to a smaller prosthesis that replaces the ascending aorta. In a different attempt to produce an outward bulging sinus, the Seattle technique was developed by Cochran and colleagues [37]. The basis of the prosthesis is fashioned in a tripartite scalloped fashion. When connected to the subannular suspension stitches, the diameter of the prosthesis becomes larger at its basis thereby forming a slightly bulging sinus. After first attempts to fashion a prosthesis with inherent sinus-like areas by Thubricar and Robicsek [38], a Dacron prosthesis (Vascutek, Terumo Inc, Ann Arbor, MI) recently became commercially available utilizing the outward bulging tendency of a crimped woven prosthesis when aligned in a longitudinal fashion. Connected with a conventional horizontally aligned and somewhat smaller prosthesis, this construction yields a sinus-like proximal area [39, 40].

Valve re-suspension techniques are simplified means that were developed to avoid excision and reimplantation of the coronary ostia. Redundant wall tissue of the sinus wall can be resected and the remaining halves reattached [41] or the sinuses are simply plicated in order to reduce the outward bulging area. As such measures are mostly applied to the noncoronary sinus, a modification of all three sinuses can be accomplished using U-shaped and J-shaped reduction plasty [27]. Correct positioning and stabilization of the commissures can then be secured with an appropriately sized prosthesis suspending the commissural triangle at the sinutubular level. However, the annulus remains untreated. Valve-conserving repair maneuvers for dissected components of the aortic root may also be addressed in this context [42]. Reattachment of the sinus wall with and without involvement of the particular area of the commissures or even the ostium is nowadays usually performed with Gelatine-Resorcin-Glutar Formaldehyde glue or fibrin-glue. Although Teflon strips or Teflon pledgets were exclusively used in the earlier days, they are now reserved for areas requiring particular reinforcement. The repaired aortic root can then be anastomosed with an appropriately sized prosthesis while seeing to a correct triangular positioning of the commissures. Aside from glue repair, an isolated dissection of the noncoronary sinus can be treated by means of resection and reconstruction utilizing an otherwise supracommissural graft with one single tongue fitting into the resected sinus [41].


   Systematic Review: Cumulative Surgical Results
Top
 Abstract
 Introduction
 Current Surgical Techniques
 Systematic Review: Cumulative...
Early and Late Mortality
 Longevity of Reconstructive...
 Conclusion
 References
 
In a recent comprehensive literature research of the MEDLINE database (Pub Med, National Library of Medicine) in October 2004, 126 articles were retrieved dealing with restitution strategies on the aortic valve with concomitant aortic surgery. Forty-four publications dealt with clinical results of aortic root reconstruction techniques on more than a casuistic basis (cohorts > 10 patients) [1, 5, 6, 8–10, 15, 20, 21, 25, 26, 30, 32, 33, 43–60]. Five publications provided clinical experience with commissural suspension [28, 42, 49, 50, 59]. For the purpose of an objective and unbiased analysis they were evaluated according to evidence based principles.

Interestingly, thus far, none of the existing publications was performed on a prospective or randomized basis. All publications are retrospective studies enrolling a more or less adequate number of patients. In nearly all of the larger studies, the statistical analysis comprised Kaplan-Meier curves, whereas only a minority utilized more sophisticated analyses such as the Cox proportional hazard model. Some studies aimed at a comparative analysis of different operative measures or important subgroups. Therefore the articles were ranked according to the size of the cohorts.

The currently available results can be extrapolated from the literature but need to be interpreted cautiously because of quite a large number of publications by institutions that utilized identical patients in consecutive studies. In the case of consecutive articles by a single group or center, the dates for enrollment of the patients as well as the particular type of procedure were analyzed. It was assumed that in case of an identical enrollment period the most recent publication comprised the entire number of patients submitted to the particular procedure.

Only a few groups can be named that have written more than one article on clinical aortic valve-sparing results. To date, the largest number of articles were accumulated by David and colleagues (Toronto, Canada, 11 articles) [1, 30, 31, 33], as well as the Hannover (Germany) group (12 articles) [10, 26, 47, 48, 52, 53]. Seven studies were published by Schäfers and colleagues [54–56] (Homburg/Saar/Germany) [5, 6, 51] and four articles were retrieved and compiled by Leyh, Erasmi, and colleagues (Luebeck, Germany) [20, 43, 46]. Two clinical studies were published by Yacoub and coworkers (Harefield, UK) [15, 60] and by Burkhart, Zehr, and colleagues (Rochester, USA), respectively [44, 61]. Bethea and coworkers (Baltimore, MD) [9] have published a study with a medium-sized cohort; whereas two other groups, Aybeck and colleagues, [8] (Frankfurt, Germany) and Bassano and colleagues [21] (Rome, Italy) have published original articles with smaller clinical numbers [8, 21]. Casselman and coworkers [42] (Nieuwegein, Netherlands) reported experience with quite a large number of 121 valve re-suspensions in acute type A dissection.

To date, the accumulated body of evidence concerning valve reconstruction according to David and Feindel [1] (reimplantation) or Yacoub and colleagues [2] (remodeling) comprise approximately 1,000 patients entered into the literature. In contrast, simplified valve re-suspension measures were performed and published in approximately 400 patients (Table 1). These are rather small cohorts in terms of a sufficient statistical power to derive valuable long-term results but beginning with interesting numbers.


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  		Table 1. Cumulative Results of Aortic Restitution
 

   Early and Late Mortality
Top
 Abstract
 Introduction
 Current Surgical Techniques
 Systematic Review: Cumulative...
 Early and Late Mortality
Longevity of Reconstructive...
 Conclusion
 References
 
All large studies revealed that early and late mortality depended on the extent of the underlying disease as well as the urgency of the procedure, whereas the restitution modalities did not exhibit a considerable influence. In fact, the results of the elective cohorts were exceptionally good in the majority of the large studies (Tables 2, 3). Go These results correspond with those found in the literature concerning composite graft replacement in elective and emergent aortic surgery [62–65].


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  		Table 2. Valve Reimplantation and Remodeling: Clinical Results of the Largest Available Studies
 

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  		Table 3. Valve Resuspension: Clinical Results of the Largest Available Studies
 

   Longevity of Reconstructive Measures
Top
 Abstract
 Introduction
 Current Surgical Techniques
 Systematic Review: Cumulative...
 Early and Late Mortality
 Longevity of Reconstructive...
Conclusion
 References
 
In an attempt to elucidate the long-term quality of the three different methods, the available actuarial rates of freedom from reoperation of the latest studies of the respective groups were retrieved. Thus, extrapolated data from 31 studies could be compiled (Fig 1). It became evident that 5-year freedom from reoperation was available from all relevant studies. In order to directly compare the longevity of the three different methods, robust nonparametrical statistical methods were applied [66, 67]. Indeed the Kruskal-Wallis test revealed significant differences between reimplantation and re-suspension (p = 0.034), whereas the differences between reimplantation and remodeling (p = 0.537), as well as between remodeling and re-suspension (p = 0.249) were not significant (Table 4).



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  		Fig 1. Freedom from reoperation. Cumulative actuarial freedom from reoperation and cumulative patients at risk of all three investigated methods of reimplantation (diamonds), remodeling (boxes) and resuspension (triangles). Data are extrapolated from 31 studies.

 

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  		Table 4. Influence of Procedure, Underlying Disease, and Learning Curve on Long-Term Quality of Restitution: 5-Year Freedom From Reoperation and Cumulative Analysis
 
Underlying Disease and Longevity of the Procedure
With increasing experience, several important subgroups were analyzed. Patients with Marfan syndrome, patients with acute type A aortic dissection, patients presenting with leaflet prolapse at the time of surgery, and patients in whom a bicuspid valve was reconstructed. It was assumed that the underlying degenerative disease of the aortic media of Marfan patients may affect the long-term results of aortic reconstruction. Indeed, some studies indicated that reimplantation may be more appropriate in terms of longevity of the reconstructed aortic valve and avoidance of recurrent aneurysm than remodeling or re-suspension. It was also shown that aortic root reconstruction is a reasonable option in acute dissection. However, the urgency of these patients impaired the short-term and long-term clinical course of the patients. Obviously valve prolapse could be successfully corrected while re-suspending the valve. Mid-term results after 5 years demonstrated a slight decrease of freedom from reoperation compared with patients without leaflet prolapse. Reconstruction of bicuspid valves also showed acceptable mid-term results, although the entire numbers of this particular subgroup were small (Tables 2, 3).

However, comparison of the cumulative numbers of 5-year freedom from reoperation concerning the underlying diseases did not exhibit a particularly negative influence of Marfan syndrome nor the presence of an acute type A dissection. Because of sufficient numbers, it was possible to analyze the type of procedure within the patients operated on with acute type A dissection. Reimplantation appeared to provide superior 5-year freedom from reoperation when compared with both other measures, although exceptional results were obtained only in the three smaller studies, whereas the only large incorporated study indicated numbers in the vicinity of both the other surgical measures (Table 3).

Neurological Events
As neurological problems are considered to contribute significantly to mortality and morbidity in aortic surgery, many authors analyzed their cohorts regarding the occurrence of neurologic complications. Fortunately it appeared that adverse neurologic events are definitely not frequent in the elective patients. However, in cohorts submitted to aortic arch surgery or those who were submitted with acute aortic dissection, significant numbers of postoperative major neurological events such as stroke were detected albeit obviously independent of the particular valve restitution maneuver. In contrast, first evidence was given by Notzold and colleagues [68] that restitution of the native valve was indeed beneficial in terms of avoidance of cerebral perfusion deficits by demonstrating less microembolization in patients after valve-sparing procedures compared with composite replacement (Tables 2, 3).

Learning Curve
As the sample sizes of the respective studies obtained for this survey differed a great deal, one may argue that a learning curve rather than the particular technique may account for the observed differences in 5-year freedom from reoperation. Therefore, sample size and 5-year freedom from reoperation of the retrieved clinical studies were correlated. However, a strong correlation was not observed (0.228; Pearson product-moment correlation coefficient) (Fig 2). In contrast, a division of the studies into smaller and larger trials (arbitrarily subdivided into sample sizes smaller and larger than 60) did reveal significantly higher 5-year freedom from reoperation in the larger trials (Mann-Whitney U test) (Table 4), thereby supporting the assumption of a learning curve. However, only the larger studies provided 5-year freedom from reoperation data on a regular basis, whereas these numbers were often elusive in the very small studies. Therefore learning curves may be even more pronounced than observed in this review.



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  		Fig 2. Correlation between sample size and 5-year freedom from reoperation; observed (boxes) and linearized (dashed line). Pearson product-moment correlation coefficient obtained from 31 studies.

 
It is for certain that the aforementioned comparisons must be interpreted with utmost care. Particularly if the patient's individual situation is taken into account. A rather moderate aortic insufficiency can very well be treated successfully with the reimplantation or the remodeling approach, as well as simpler means. In contrast, a most severe valve insufficiency involving all components of the valve definitely requires comprehensive measures. Because none of the articles referred to in this article provided accurate information regarding the dependency of a chosen technique on the extent of the disease (ie, involvement of the aortic root's components), one cannot truly arrive at an evidence-based conclusion concerning the correlation of technique and severity of disease. However, it appears that reimplantation (ie, valve re-suspension within a prosthesis that replaces the aortic root [David I and derivatives]) guarantees the most complete restitution of all currently known strategies, particularly in patients with profound degenerative disease and highly abnormal aortic wall morphology [69].

When looking at the recommendations of the authors of larger clinical studies, strategies emerge that may help to properly assign one of the currently available and accepted modalities to restitute the aortic valve in the given individual situation of the patient.

Patients with a normal annulus but significant sinus enlargement and sinutubular junction (funnel shaped) may be best served with a remodeling technique (14, 70) (Fig 3). For elderly patients without profound aortic wall degeneration, such as Marfan or Ehlers-Danlos syndrome, simplified sinus reduction maneuvers accompanied by commissural re-suspension with an appropriate supracommissural prosthesis may be adequate (Fig 4). In cases of an acute type A dissection in the presence of a normal annulus, these techniques may also be entirely sufficient with the glue repair of a dissected sinus wall provided.



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  		Fig 3. Remodeling technique: computerized rendering of an aortic root (translucent view) prepared for a remodeling or reimplantation maneuver. (a) All sinuses including the coronary ostia are excised yielding a "quasi-stentless" valve, whereas the basis remains in place. The prosthesis is fashioned with three tongues that are attached to the sinus edges with non-absorbable 5-0 or 4-0 polypropylene running sutures. (b) Both previously excised coronary ostia are anastomosed to the prosthesis at the appropriate level within the "neo-sinus" (4-0 or 5-0 polypropylene).

 


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  		Fig 4. Resuspension technique: (a, b) U-shaped (4-0 polypropylene) sutures are passed through the aortic wall at the level of the commissures from inside to outside, passed through the edge of an appropriately sized prosthesis in an isosceles fashion, knotted, and used as running sutures to complete the anastomosis. (c) In addition, a reinforcement plasty of an isolated enlarged annulus can be performed. The diameter is reduced by means of a Hegar obturator of appropriate diameter (typically 24 to 28 mm) passed through the native annulus while the Teflon-strip (DuPont, Wilmington, DE) reinforced mattress suture (4-0 polypropylene) is tightened around the stick. Alternatively U-shape sutures and a Teflon strip of defined length can be used.

 
Patients with a dilated annulus, an aneurysm extending down to the sinuses, and dilated sinutubular junction (barrel shaped) require a root replacement and valve reimplantation with an appropriately sized prosthesis [1] (Fig 5). If this yields a rather small neo-root, one of the techniques that provides a bulging neo-sinus may be applied (beveled prosthesis, prosthesis reshaping, and so forth) [37, 40]. However, current evidence regarding sculpted sinuses is not yet sufficient for an evidence-based decision.



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  		Fig 5. Reimplantation technique: (a) a tubular graft is placed upon the prepared root. (b) U-shaped, non-absorbable 3-0 polypropylene sutures are placed in a transannular fashion from inside to outside while forming a horizontal plane just below the native annulus. Optionally, these sutures can be reinforced with Teflon-pledgets (DuPont, Wilmington, DE). The prosthesis is thereafter connected with these sutures. (c) The commissures are positioned inside the prosthesis ensuring proper height and alignment. Thereafter the sinus edges are anastomosed to the prosthesis wall with 5-0 or 4-0 non-absorbable polypropylene running sutures. Reimplantation of both coronary ostia is then performed.

 
Patients with a dilated annulus but normal sinutubular junction (pear shaped) may very well be treated with simple strategies such as annulus-reduction plasty and reinforcement [71–73]. In case of significant enlargement of the sinuses, a sinus-reduction plasty or remodeling can be added [14, 27].


   Conclusion
Top
 Abstract
 Introduction
 Current Surgical Techniques
 Systematic Review: Cumulative...
 Early and Late Mortality
 Longevity of Reconstructive...
 Conclusion
References
 
After more than 10 years of aortic root reconstruction, modalities have evolved into reasonable and useful surgical measures. Short-term and long-term results match those of aortic composite replacement, which is still believed to be the gold standard in terms of safety, efficacy, and longevity [50, 62–65]. As a consequence, reconstruction is unequivocally recommended, although some euphemistic and hence biased interpretation should be considered when looking at the clinical results [50, 74]. Root replacement with valve reimplantation, root remodeling, and commissural re-suspension are successfully utilized. However, the accumulated body of worldwide published evidence is still small when compared with other novel technologies such as off-pump coronary bypass surgery. Considerable cross-clamping times of reimplantation and remodeling procedures (Table 2) indicate high technical challenges that are a hindrance for a truly widespread application. From a more defensive standpoint, reconstructive surgery of the aortic root appears to be the playground for the able and experienced surgeon. We still have to wait for definite guidelines regarding the appropriate method of restitution required to best serve the patient's individual situation. Perhaps we will never gain this knowledge because of the anatomical complexity. However, the surgeon's ideal to pursue the most physiologic result by those means he excels in, truly stands in line with the medieval geniuses (Leonardo Da Vinci and Michelangelo Buonarotti) attempts to find nature's truths through their arts.


   References
Top
 Abstract
 Introduction
 Current Surgical Techniques
 Systematic Review: Cumulative...
 Early and Late Mortality
 Longevity of Reconstructive...
 Conclusion
 References
 

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