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Ann Thorac Surg 2007;83:S732-S735
© 2007 The Society of Thoracic Surgeons

Supplement

Aortic Valve Preservation in Patients With Aortic Root Aneurysm: Results of the Reimplantation Technique

Tirone E. David, MD*, Christopher M. Feindel, MD, Gary D. Webb, MD, Jack M. Colman, MD, Susan Armstrong, MSc, Manjula Maganti, MSc

Divisions of Cardiovascular Surgery and Cardiology of Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada

Accepted for publication October 17, 2006.

* Address correspondence to Dr David, 200 Elizabeth St. 4N-457, Toronto, Ontario M5G 2C4, Canada. (Email: tirone.david{at}uhn.on.ca).

Presented at Aortic Surgery Symposium X, New York, NY, April 27–28, 2006.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
BACKGROUND: A study was conducted to determine the long-term results of aortic valve reimplantation to treat aortic root aneurysm.

METHODS: Prospective follow-up with clinical assessments and echocardiography was done of 167 consecutive patients who had reimplantation of the aortic valve as treatment of aortic root aneurysm. Their mean age was 45 ± 15 years, 78% were men, 38% had Marfan syndrome, 14% had aortic dissection, and 7% had bicuspid aortic valve. The aortic valve was reimplanted into a straight Dacron (Dupont, Wilmington, DE) tube in 89 patients and in a Dacron tube with creation of neoaortic sinuses in 78. Aortic cusp repair was performed in 66 patients, and the free margin was reinforced with a fine Gore-Tex suture (W.L. Gore & Assoc, Flagstaff, AZ) in 36. The mean follow-up was 5.1 ± 3.8 years and was 100% complete.

RESULTS: There were two operative and six late deaths. Survival at 10 years was 92% ± 3%. Moderate aortic insufficiency developed in 3 patients, and severe developed in 2. Freedom from moderate or severe aortic insufficiency was 94% ± 4% at 10 years. Two patients required aortic valve replacement. Freedom from aortic valve replacement was 95% ± 4% at 10 years. At the latest follow-up, 90% of the patients were in New York Heart Association functional class I and 10% were in class II.

CONCLUSIONS: Reimplantation of the aortic valve to treat patients with aortic root aneurysm is associated with excellent long-term survival and low rates of valve-related complications. Reimplantation of the aortic valve is a durable type of aortic valve repair.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Composite replacement of the aortic valve and ascending aorta with a conduit containing a tissue or a mechanical valve has been considered the standard operation to treat patients with aortic root aneurysm [1, 2]. Aortic valve–sparing operations were introduced to treat a subset of these patients whose aortic cusps are normal or who have minimal anatomic abnormality [3, 4]. These operations are not yet widely done largely because of lack of long-term data [5].

The two basic types of aortic valve–sparing operations to treat patients with aortic root aneurysm are remodeling of the aortic root and reimplantation of the aortic valve. In our hands, the technique of reimplantation of the aortic valve is more durable than the remodeling of the aortic root, particularly in patients with Marfan syndrome [6, 7]. For this reason, we have used it almost exclusively during the past 6 years. This report describes our clinical experience with reimplantation of the aortic valve in patients with aortic root aneurysm.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
A review of the Cardiac Surgery Database of Toronto General Hospital disclosed 329 patients who had aortic valve–sparing operations from May 1988 to June 2005. Of these, 167 had reimplantation of the aortic valve for aortic root aneurysm; 162 had remodeling of the aortic root, 53 for aortic root aneurysm, and 109 for ascending aortic aneurysm. This study examined the clinical and echocardiographic outcomes of patients who had reimplantation of the aortic valve. The Research Ethics Board of the University Health Network approved this retrospective study. Table 1 summarizes the clinical profile of the patients. Sixty-four patients (38%) had Marfan syndrome according to Gent criteria.


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  		Table 1. Clinical Profile and Preoperative Hemodynamic Data
 
Operative Technique
Aortic valve reimplantation was performed by dissecting the aortic root circumferentially down to a level just below the nadir of the aortic annulus, detaching the coronary arteries from their sinuses, excising the aortic sinuses except for a few millimeters, and placing the aortic cusps, annulus, and subcommissural triangles of the noncoronary cusp inside a tubular Dacron (DuPont, Wilmington, DE) graft. The normal scallop-shaped aortic annulus was restored with two suture lines, one with interrupted, horizontal mattress sutures through the left ventricular outflow tract along a single horizontal plane on its fibrous portion and scalloped along the muscular septum, and the second with a continuous suture line in a scalloped fashion immediately above the insertion of the aortic cusps [4].

The first 89 patients had the valve implanted inside a straight tubular graft. This technique was modified in mid-1990, and slightly larger grafts were used with a diameter that was approximately twice the average heights of the aortic cusps. The neoaortic sinuses were created by plicating the graft in the spaces between the commissures of the reimplanted aortic valve. The mean diameter of the graft was 28.6 mm (range, 26 to 30 mm) in the first 89 patients and 32.1 mm (range, 28 to 34 mm) in the 78 patients with neoaortic sinuses. Elongated aortic cusps were shortened by plicating the free margin along the nodulus Arantii [8]. Aortic cusps with stress fenestration near the commissures were reinforced with a double layer of 6-0 Gore-Tex suture (W.L. Gore & Assoc, Inc, Flagstaff, AZ) [8]. Table 2 summarizes the operative data.


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  		Table 2. Operative Data
 
Patients were followed up by the referring cardiologists and were contacted by us annually. The mean follow-up was 5.1 ± 3.8 years (range, 0 to 16 years). No patient was lost to follow-up. Doppler echocardiographic examinations were obtained annually. All patients had an echocardiographic study during the last year of follow-up, which was closed on December 31, 2005. Postoperative aortic insufficiency (AI) was graded as none, trace, moderate, or severe. If the echocardiographic report was read as "trace-to-mild AI," it was entered as mild; if "mild-to-moderate," it was entered as moderate, and so on.

Statistical Analysis
All data analyses were performed with SAS 8.1 software (SAS Institute, Cary, NC). Categoric variables are reported as frequencies, and all continuous variables are reported as mean ± standard deviation. The Kaplan-Meier method was used to calculate estimates for long-term survival and for freedom from morbid events. All preoperative variables with a univariate p < 0.25 or those with known biologic significance but failing to meet this critical {alpha} level underwent multivariable model for Cox regression analysis to determine the independent multivariable predictors of late outcomes. Variables retention criteria in the model were set at a p = 0.05.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
There were two operative and six late deaths. The causes of operative death were stroke in 1 patient and complications of low cardiac output syndrome in another. The causes of late death were cardiac in 2 patients (1 each from sudden death and acute type B dissection) and noncardiac in 4 (cancer, 2; chronic renal failure, 1; and chronic obstructive pulmonary disease, 1). The survival at 10 years was 92% ± 3% (Fig 1). No independent predictors of death could be identified.


Figure 1
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  		Fig 1. Survival of patients after aortic valve sparing operations.({blacktriangleup} = event.)

 
The latest echocardiographic study before death or reoperation in all 167 patients revealed trace or no AI in 125 patients, mild in 37, moderate in 3, and severe in 2. The freedom from moderate or severe AI was 94% ± 4% at 10 years (Fig 2). Marfan syndrome, creation of neoaortic sinuses, cusp shortening, reinforcement of the free margin of the cusp with Gore-Tex suture, or the severity of AI before surgery had no effect in the development of late AI by univariate or multivariate analysis.


Figure 2
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  		Fig 2. Freedom from moderate or severe aortic insufficiency.({blacktriangleup} = event.)

 
The 2 patients in whom severe AI developed required aortic valve replacement: one on the second postoperative day and the other in the ninth postoperative year. Both patients survived reoperation. The freedom from aortic valve replacement was 95% ± 3% at 10 years.

Echocardiographic studies during follow-up also revealed new moderate or severe mitral regurgitation in 2 patients and a small ventricular septal defect in 1.

Three patients had reoperations for other reasons than the aortic root: mitral valve repair for severe mitral regurgitation owing to advanced myxomatous degeneration in a patient with Marfan syndrome 8 years after aortic valve reimplantation, and replacement of the thoracic aorta (1 patient) or entire aorta (1 patient) because of expansion of the false lumen. These 3 patients survived reoperation.

During follow-up, one patient sustained a stroke and completely recovered. Fourteen patients were receiving oral anticoagulation therapy for atrial fibrillation or a previous stroke. A major hemorrhagic complication occurred in 1 patient.

At the most recent follow-up contact, 157 patients were alive with the preserved aortic valve: 142 were in New York Heart Association functional class I, 11 in class II and 2 in class III.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
We have performed various types of aortic valve sparing operations during the past 18 years [9, 10]. AI often develops in older patients with ascending aortic aneurysm because of dilation of the sinotubular junction and minimal or no dilation of the aortic sinuses [11]. Correction of AI in these patients is relatively simple and consists of reducing the diameter of sinotubular during replacement of the ascending aorta. If only one aortic sinus is dilated, it can be replaced with a graft that is tailored to recreate the sinus [10]. If two or three sinuses are dilated, as it is often the case in patients with aortic root aneurysm, all three aortic sinuses can be replaced with a tailored graft containing three neoaortic sinuses [10]. This operative procedure is referred to as "remodeling of the aortic root" [9].

Patients in whom all three aortic sinuses are dilated are usually younger and many have Marfan syndrome [6]. In our experience, supraannular reconstruction of the aortic root in these patients does not prevent delayed dilation of the aortic annulus with consequent AI. We have documented this problem in patients with the Marfan syndrome [7].

Reimplantation of the aortic valve prevents the aortic annulus from dilating because it is entirely supported by the Dacron graft used to reconstruct the aortic root [4]. Although remodeling of the aortic root is a simpler and physiologically sounder operation than reimplantation of the aortic valve [12, 13], we stopped using it in young patients with aortic root aneurysm but continue using it in older patients with an ascending aortic aneurysm in which one or two sinuses are dilated. Thus, the present study focused only our experience with reimplantation of the aortic valve in patients with aortic root aneurysm.

Patients with aortic root aneurysm are younger than those with ascending aortic aneurysm [11]. The long-term survival after reimplantation of the aortic valve for aortic root aneurysm is excellent in our experience, and indeed, in a previous publication we showed that it was similar to that of the general population matched for age and sex [6].

The development of AI is the Achilles’ heel of aortic valve–sparing operations, but if one considers that this series included all patients since its development, the results are exceptionally good. AI developed in only 5 patients in our series (2 with severe, 4 with moderate), and these patients were operated on during the first few years of our experience. We have not had a single case of moderate or severe AI in patients operated on during the past decade. Moreover, many patients operated on recent years had aortic cusp prolapse or stress fenestrations in the commissural areas, or both, and a number had bicuspid aortic valve, pathologies that used to be exclusion criteria to performing aortic valve–sparing operations.

Reimplantation of the aortic valve is a complex operation because the entire aortic annulus and the two fibrous subcommissural triangles have to be sutured inside a tubular graft. In addition, it may be desirable to create neoaortic sinuses [14, 15], further complicating the operation.

Sizing of the graft is also difficult. Despite numerous studies on geometric relationships of various components of the normal aortic root [16, 17], determining the most appropriate diameters for the aortic annulus and sinotubular junction remains a challenge during this operation. We use the height of the aortic cusp as the measurement to estimate the desirable diameter of the aortic annulus in patients with aortic root aneurysm because the cusp height cannot be surgically altered without resecting or adding cusp tissue. The slope of the curvature of the base of the cusp and the length of its free margin can be adjusted during the reimplantation procedure but the height cannot.

Our experience suggests that by using grafts with a diameter approximately twice that of the average heights of the cusps, the reconstructed annulus acquires an ideal diameter for the size of the cusps. When this approach is used, the sinotubular junction becomes larger than needed, which allows for creation of neoaortic sinuses by plicating the spaces in between the commissures of the valve.

We do not believe that commercially available grafts with neoaortic sinuses [18] are appropriate for aortic valve reimplantation because the sinuses in those grafts are spherical and alter the symmetry of the aortic annulus, which is supposed to be along a single plane. This alteration in geometry may shorten the durability of the repair.

An important issue regarding this operation is whether it is better than the Bentall procedure with mechanical valves [2]. These two procedures for the treatment of aortic root aneurysm have not been compared in a randomized clinical trial, but retrospective studies in patients with Marfan syndrome suggest that the outcomes may be similar [7, 19]. The long-term survival and the freedom from morbid events in our series of aortic valve reimplantation are exceptionally good, however, and certainly better than those reported for aortic root replacement with mechanical and tissue valves [2, 20].

We believe that aortic valve sparing operations offer an ideal method to treat young patients with aortic root aneurysm and normal or minimally diseased aortic cusps. When correctly performed, they provide excellent results and are associated with very low rates of valve-related complications.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Bentall H, De Bono A. A technique for complete replacement of the ascending aorta Thorax 1968;23:3388-3389.
  2. Hagl C, Strauch JT, Spielvogel D, et al. Is the Bentall procedure for ascending aorta or aortic valve replacement the best approach for long-term event free survival? Ann Thorac Surg 2003;76:698-703.[Abstract/Free Full Text]
  3. Yacoub MH, Fagan A, Stessano P, Radley-Smith R. Results of valve conserving operations for aortic regurgitation[abstract] Circulation 1983;68:311.
  4. 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;103:617-622.[Abstract]
  5. Albes JM, Stock UA, Hartrumpf M. Restitution of the aortic valve: what is new, what is proven, and what is obsolete? Ann Thorac Surg 2005;80:1540-1549.[Abstract/Free Full Text]
  6. David TE, Feindel CM, Webb GD, et al. Long term results of aortic valve sparing operations for aortic root aneurysms J Thorac Cardiovasc Surg 2006;132:347-354.[Abstract/Free Full Text]
  7. de Oliveira NC, David TE, Ivanov J, et al. Results of surgery for aortic root aneurysm in patients with Marfan syndrome J Thorac Cardiovasc Surg 2003;125:789-796.[Abstract/Free Full Text]
  8. David TE. Surgery of the aortic valve Curr Probl Surg 1999;36:421-504.
  9. 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;109:345-352.[Abstract/Free Full Text]
  10. David TE. Remodeling of the aortic root and preservation of the native aortic valve Op Tech Cardiac Thorac Surg 1996;1:44-56.
  11. David TE, Armstrong S, Ivanov J, Feindel CM, Omran A, Webb G. Results of aortic valve sparing operations J Thorac Cardiovasc Surg 2001;122:39-46.[Abstract/Free Full Text]
  12. Leyh RG, Schmidtke C, Sievers HH, Yacoub MH. Opening and closing characteristics of the aortic valve after different types of valve-preserving surgery Circulation 1999;100:2152-2160.
  13. Erasmi A, Sievers HH, Scharfschwerdt M, Eckel T, Misfeld M. In vitro hydrodynamics, cusp-bending deformation, and aortic root distensibility for different types of aortic valve-sparing operations: remodeling, sinus prosthesis, and reimplantation J Thorac Cardiovasc Surg 2005;130:1044-1049.[Abstract/Free Full Text]
  14. Grande-Allen KJ, Cochran RP, Reinhall PG, Kunzelman KS. Re-creation of sinuses is important for sparing the aortic vale: a finite element study J Thorac Cardiovasc Surg 2000;119:753-763.[Abstract/Free Full Text]
  15. Kvitting JP, Ebbers T, Wigstrom L, Engwall J, Olin CL, Bolger AF. Flow patterns in the aortic root and the aorta studied with time-resolved, 3-dimensional, phase-contrast magnetic resonance imaging: implications for aortic valve-sparing surgery J Thorac Cardiovasc Surg 2004;127:1602-1607.[Abstract/Free Full Text]
  16. Swanson M, Clark RE. Dimensions and geometric relationships of the human aortic valve as a function of pressure Circ Res 1974;35:871-882.[Abstract/Free Full Text]
  17. Kunzelman KS, Grande J, David TE, Cochran RP, Verrier E. Aortic root and valve relationships: impact on surgical repair J Thorac Cardiovasc Surg 1994;107:162-170.[Abstract/Free Full Text]
  18. De Paulis R, De Matteis GM, Nardi P, Scaffa R, Buratta MM, Chiarello L. Opening and closing characteristics of the aortic valve after valve-sparing procedures using a new aortic root conduit Ann Thorac Surg 2001;72:487-494.[Abstract/Free Full Text]
  19. Karck M, Kallenbach K, Hagl C, Rhein C, Leyh R, Haverich A. Aortic root surgery in Marfan syndrome: comparison of aortic valve-sparing reimplantation versus composite grafting J Thorac Cardiovasc Surg 2004;127:391-398.[Abstract/Free Full Text]
  20. Sioris T, David TE, Ivanov J, Armstrong S, Feindel CM. Clinical outcomes after separate and composite replacement of the aortic valve and ascending aorta J Thorac Cardiovasc Surg 2004;128:260-265.[Abstract/Free Full Text]



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