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Ann Thorac Surg 1998;66:1269-1272
© 1998 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Residual aortic valve regurgitation after aortic root remodeling without a direct annuloplasty

^a Department of Cardiac Surgery, Tor Vergata University, European Hospital, Rome, Italy

Accepted for publication April 28, 1998.

Address reprint requests to Dr Bassano, Cardiochirurgia, Università Tor Vergata, European Hospital, Via Portuense 700, 00149 Roma, Italy

	Abstract

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Background. Aortic insufficiency secondary to degenerative aneurysms of the ascending aorta can be surgically treated with replacement of the valve or with remodeling of the aortic root.

Methods. In 15 patients who underwent aortic root remodeling from January 1994 to December 1996, we evaluated the postoperative aortic regurgitation and correlated it with several anatomic and functional variables. Operative success was defined as a residual aortic regurgitation less than or equal to 1 on a scale of 0 to 4.

Results. Root dimensions and aortic incompetence decreased significantly after the operation (p < 0.0001). The difference between preoperative and postoperative root diameters (p = 0.0006) and the presence of Marfan’s syndrome (p < 0.0001) were independently predictive of persisting significant aortic insufficiency. Operative success was obtained in patients with a difference between preoperative and postoperative root diameters smaller than 30 mm.

Conclusions. Aortic root remodeling is effective in reducing aortic regurgitation. Severe aortic root dilatation may result in excessive geometric alteration, leading to suboptimal results. The choice of a larger graft contributes to avoiding excessive geometric constraint of a profoundly diseased aortic root. Indication to undergo root remodeling should be evaluated cautiously in patients with Marfan’s syndrome.

	Introduction

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Secondary aortic insufficiency (AI) in patients with aneurysm of the ascending aorta is often well treated with different types of valve-sparing operation: remodeling of the aortic root [1] and reimplantation of the aortic valve [2]. These operations provide good early results and avoid the use of a prosthesis when the native valve is not diseased [3]. Remodeling has been suggested in the case of dilatation limited to the aortic root and the sinotubular junction and reimplantation in the presence of marked annular dilatation [3]. Recently, David [4] suggested a modified remodeling technique, which includes a direct aortic annuloplasty: this technique overcomes the disadvantages of the reimplantation, while correcting the annular ectasia. We retrospectively tried to validate these orientations and define the appropriate indications for root remodeling.

	Material and methods

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Patients
From January 1994 to December 1996, 15 patients with degenerative, expansive aneurysm of the ascending aorta, secondary AI, and tricuspid aortic valve with apparently normal leaflets underwent an aortic valve–sparing operation, following the technique first described by Yacoub and associates [5]. Patients’ characteristics are described in Tables 1 and 2.

Echocardiographic variables
Direct measurements
Preoperative and postoperative (day 5) transthoracic echocardiography was performed in all patients. We measured the grade of AI (grade 0 = absent or trivial, grade 1 = mild, grade 2 = mild to moderate, grade 3 = moderate, grade 4 = severe) and the annular (An) and root (R) diameters at the level of the upper part of the left ventricular outflow tract and at the largest site of the sinuses of Valsalva, respectively. As expected, it has been impossible to identify a definite sinotubular junction [6].

Calculated variables
The differences between postoperative and preoperative echocardiographic values have been calculated for the annulus diameter (An) and for root diameter (R). The gain in aortic insufficiency grade (AIG), defined as (AI_pre - AI_post)/AI_pre, was determined to evaluate the relative improvement of AI in each patient. The other calculated variables were (1) the preoperative annulus-to-root diameters ratio (an index of annuloaortic ectasia [An_pre/R_pre]), whose value should be approximately 0.97 in normal hearts [5]; (2) the postoperative annulus-to-root (An_post/R_post) and annulus-to-tube (An_post/T) diameters ratios, which are an index of the theoretical geometric adequacy of the correction, and whose values should be approximately 0.97 and 1.15, respectively [7, 8], assuming that they should be similar to those found in normal hearts; and (3) the ratio between the preoperative annulus diameter and the caliber of the prosthetic graft (An_pre/T), an index of the adequacy of the graft dimensions.

Statistical analysis
Directly measured echocardiographic values were compared with a two-tailed t test for paired data. The association of postoperative AI and AIG with the independent variables considered in our study was univariately tested by means of simple linear regression for continuous variables and a two-tailed t test for unpaired data for dichotomous variables. Multivariate analysis was performed on independent variables found to be significantly associated (p < 0.10) with postoperative AI or AIG, by means of logistic stepwise regression analysis. A p value less than 0.05 was considered to identify variables independently predictive of residual postoperative AI and AIG.

	Results

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Patient outcome
One patient died of aortic rupture at the site of aortic cannulation 10 days after the operation. The hospital mortality was therefore 6.7%. The postoperative course of the other patients was free from major complications. No patient required reoperation for severe residual AI during the same hospital stay. Mean postoperative AI was 1.3 ± 1.0 (p < 0.0001 versus preoperative AI); (see Table 1). The mean AI (the difference between AI_pre and AI_post) was 1.9 ± 1.1 (see Table 1), leading to a mean AIG of 0.61 ± 0.29. Five patients with suboptimal results (AI_post 2) were discharged and entered a close-interval follow-up protocol.

Direct echocardiographic measurements
All variables varied significantly after the operation and their values are recorded in Table 1. Aortic insufficiency behavior has already been described. Root diameter decreased from 55.3 ± 8.7 to 30.5 ± 2.0 mm (p < 0.0001) and An decreased from 27.8 ± 2.6 to 26.2 ± 2.4 mm (p = 0.0040). The remodeling of the root proved to be effective in reducing both the two diameters and the amount of AI.

Univariate analysis
With linear regression analysis AI_post correlated significantly with R_pre, R_post, An, R, and An/R. A similar result, with the exception of An, was obtained for AIG. The correlation factor r and the relative p value are shown in Table 2. The presence of Marfan’s syndrome (p = 0.04) and a history of arterial hypertension (p = 0.04) were found to be significantly associated with AI_post by t test for unpaired data. Among the three dichotomous variables, only Marfan’s syndrome (p = 0.05) was linked to a low AIG value (Table 3).

View larger version (23K): [in this window] [in a new window]   Fig 1. Plot of postoperative aortic incompetence (AIpost) compared with the difference between preoperative and postoperative largest diameter of the aortic root (R). In patients with R greater than or equal to 30 mm, the outcome, in terms of persisting AI, is somewhat disappointing. The use of a larger graft contributes to keeping the R in the desired range.

	Comment

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Aortic root remodeling has proved to be effective in correcting aortic valve regurgitation. By simply remodeling the aortic root, a slight, although statistically significant, reduction in the annulus diameter was also obtained. This was probably caused by the reduced wall stress, but obviously not an actual anatomic modification of the annulus. In fact, the postoperative annular diameter, although reduced, still did not reach a normal value. It is still possible that an additional direct procedure to reduce annular dimensions may be useful in some instances [3, 4]. Actually, in our small series both preoperative annular dimensions and the ratio An/R (an index of annuloectasia degree) are not correlated with the success of the operation; therefore, we are not able to support or refute this hypothesis.

Marfan’s syndrome is an independent risk factor for AI_post: these patients are at risk for macroscopically undetectable leaflet dysfunction. Moreover, an improper evaluation of leaflet dimensions can result in the erroneous sparing of the valve. Once the centrifugal traction of the commissures, because of the sinotubular junction dilatation, is repaired, the aortic valve leaflets become redundant and prolapse. For this reason, 3 patients with Marfan’s syndrome in our series underwent aortic valve replacement a few months after aortic root remodeling.

The other variable independently predictive of a favorable operative result is R. This variable implements the anatomic severity of the disease (R_pre) and the dimensions of the prosthetic graft, the latter being the most important determinant of R_post. The ideal ratio between annulus and root diameters and annulus and sinotubular junction diameters are estimated to be 0.97 [7] and 1.15 [7, 8], respectively. The theoretical goal of the conservative surgical approach is to reestablish a normal geometric relationship among all the components of the aortic root, without unnecessary use of prosthetic heart valves. Facing a preoperative An/R ratio of 0.51 ± 0.10 (range, 0.4 to 0.8), the mean An_post/R_post was 0.86 ± 0.10 (range, 0.8 to 1.1), which approaches the ideal ratio. The graft diameter, T, was supposed to be equal to the rebuilt sinotubular junction. Therefore, the An_post/T ratio should be approximately 1.15 to achieve an "anatomically correct" reconstitution of the aortic root outlet. The mean value obtained in our series was 0.94 ± 0.12 (range, 0.85 to 1.25), slightly smaller than the optimal one. Although these two postoperative measurements were very close to the mean values of normal hearts, they were not correlated with operative success. This suggests that the geometrically appropriate reconstruction of the aortic root is a somewhat more puzzling matter. Even in normal hearts there is a great variability among the relative dimensions of the three aortic sinuses and leaflets [9]. The differences may be enhanced and stabilized by enlargement and rotation of the aortic root that invariably occur in aneurysmal disease. A small tube graft may be responsible for a coarse adaptation of the graft itself to the residual aortic root, forcing the commissures in the radial direction at the level of the rebuilt sinotubular junction plane. The entity of central displacement of the commissures is indicated by R, which is an index of both disease severity and discrepancy between preoperative anatomy and graft dimension. The choice of a larger graft, neglecting annular surgery, is dictated by the belief that geometric constraint of a profoundly diseased root is unnecessary and potentially detrimental, as excessive distortion might cause residual regurgitation. In our opinion, the ideal An_post/T ratio should be smaller than the ratio between annulus and sinotubular junction observed in normal hearts [7, 8]. This can be easily obtained with the use of a larger graft. With this approach R would more often be in the desired range. This is especially true in patients with Marfan’s syndrome, whose valve cusp growth is expected to be more intense and may lead to relative oversizing and prolapse of the leaflet. Actually, we have been able to identify a R cutoff value to predict the success of the operation, defined as AI_post less than or equal to 1 (see Fig 1): patients with a R larger than 30 mm had the worst results with this type of surgical approach. The change in root diameter is an independent predictive factor for success, and therefore we believe that this variable is of relevant importance in selecting patients to undergo simple root remodeling.

Our results are consistent even when the AI_post is corrected for AI_pre, because AIG is independently associated with the same variables as AI_post: this assures that the relationship between AI_post and R and Marfan’s syndrome can be demonstrated, regardless of the baseline grade of aortic regurgitation. Indeed, from a clinical standpoint, the crucial aspect is the mere presence of residual AI, regardless of preoperative conditions. Whatever the extent of preoperative valve disease, our goal is to cure it as completely as we can. That is why we believe that the postoperative AI is the most reliable index of the operation’s effect.

It must be noted that the fact that other variables could not be identified as independent predictors of AIG or postoperative AI might be related to the small sample size and consequent relatively poor statistical power.

Aortic root remodeling is a powerful surgical tool to correct aneurysms of the ascending aorta with secondary aortic incompetence. Annuloectasia is not a contraindication to this technique, as an appreciable annular reduction is often obtained. Of note is the fact that an annular diameter of about 26 mm, as obtained in our series, can still be considered a bit too large, although R_post was not correlated with AI_post. In patients with suspected or demonstrated annular overstretching, with an advanced-stage disease, either a direct annuloplasty [4] or a larger graft might contribute to improve root reconstruction. The first technique deals simultaneously with both the annulus and the sinotubular junction, trying to reestablish an aortic root anatomy close to normal, whereas the use of a larger graft adapts to the consequences of a long-lasting disease.

Finally, because the primary lesion in these patients is the diseased aortic wall, a complete excision of the latter should reestablish a "closer-to-normal" spatial relationship among the aortic valve commissures, once they are set free from the sinus wall traction.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Sarsam M.A.I., Yacoub M. Remodeling of the aortic valve anulus. J Thorac Cardiovasc Surg 1993;105:435-438.[Abstract]
2. 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]
3. 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]
4. David T.E. An anatomic and physiologic approach to acquired heart disease. Eur J Cardiothorac Surg 1995;9:175-180.[Medline]
5. Yacoub M., Fagan A., Stassano P., Radley-Smith R. Results of valve conserving operations for aortic regurgitation. Circulation 1983;68(Suppl 3):321.[Abstract/Free Full Text]
6. Yacoub M. Valve conserving operation for aortic root aneurysm or dissection. Oper Tech Cardiac Thorac Surg 1996;1:57-67.
7. Kunzelmann K.S., Grande K.J., David T.E., Cochran R.P., Verrier E.D. Aortic root and valve relationships: Impact on surgical repair. J Thorac Cardiovasc Surg 1994;107:162-170.[Abstract/Free Full Text]
8. Reid K. The anatomy of the sinus of Valsalva. Thorax 1970;25:79-85.[Abstract/Free Full Text]
9. Vollebergh F.E.M.G., Becker A.E. Minor congenital variations of cusp size in aortic valve: Possible link with isolated aortic stenosis. Br Heart J 1977;39:1006-1011.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Carlo Bassano Ruggero De Paulis Alessandro Ricci Luigi Chiariello Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bassano, C. Articles by Chiariello, L. Search for Related Content PubMed PubMed Citation Articles by Bassano, C. Articles by Chiariello, L.