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Ann Thorac Surg 2002;73:29-33
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Aortic valve reimplantation in ascending aortic aneurysm: risk factors for early valve failure

^a Department of Thoracic and Cardiovascular Surgery, Division of Surgery, Hannover Medical School, Hannover, Germany

Accepted for publication August 31, 2001.

* Address reprint requests to Dr Pethig, Department of Thoracic and Cardiovascular Surgery, Division of Surgery, Hannover Medical School, D-30623 Hannover, Germany
e-mail: klaus.pethig{at}t-online.de

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Aortic root reconstruction by reimplantation of the native valve represents a new therapeutic option for ascending aortic aneurysms. Information about long-term follow-up is limited, and possible predictors for failure of reconstruction have not been evaluated so far.

Methods. After aortic valve reimplantation 101 patients were followed in a prospective observational study. From this cohort the first 75 consecutive patients with a complete 1-year follow-up were chosen for further analysis. Clinical and echocardiographic data were obtained preoperatively, intraoperatively, and early postoperatively, as well as after 1 year of follow-up.

Results. No mortality was observed within the first 30 days. There were 52 male patients, mean age was 49.1 ± 20.6 years, observation period was 35.6 ± 20.6 months, and Marfan’s syndrome was present in 22 patients. Although in 67 patients a stable valve function could be demonstrated, 5 patients presented with mild aortic insufficiency or had to be operated on again for secondary valve failure (n = 3). Analyzing possible demographic, disease-related, and procedure-related risk factors in a multivariable approach, only level of coaptation within the graft (as assessed by echocardiography) could be identified as being related to the subsequent development of aortic insufficiency. Coaptation level within the tube graft (type A) resulted in a mean aortic regurgitation grade of 0.3 ± 0.5 as compared with a mean grade of 2.5 ± 0.6 for a coaptation type C (below the prosthesis; p < 0.001).

Conclusions. Aortic valve reimplantation is a promising alternative to alloprosthetic composite replacement. A level of coaptation within the tube graft is essential to achieve valve competence.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Aortic insufficiency (AI) caused by dilatation of the aortic root is a frequent finding in ascending aortic aneurysms [1]. Dilatation of the sino-tubular junction with distraction of the commissures, with or without annular ectasia, is the major cause of valvular regurgitation. Combined replacement of aortic valve and ascending aorta with a composite graft can be regarded as standard therapy [2–5]. Despite low mortality rates, however, implantation of a mechanical prosthesis is associated with a relevant valve-related morbidity in the form of thromboembolic events, anticoagulation-associated bleeding, and a systolic pressure gradient across the artificial valve [6, 7]. Therefore, sparing of the intact and native leaflets is believed to be a promising alternative [8–10].

At least two reconstructive procedures have been developed in recent years. The therapeutic principle of both is a repair by narrowing of the sino-tubular junction, allowing for an adequate recoaptation of the aortic leaflets. This can be achieved by downsizing and remodeling of the aortic sinuses as described by Sarsam and Yacoub [10] or, as the more extensive approach, by a complete replacement of the aortic root with reimplantation of the valve as published by David and Feindel in 1992 [8]. Using clinical and echocardiographic examinations, feasibility of repair could be shown by several groups [10–15]. Encouraging early results were published for both techniques. Beyond feasibility, however, scientific and clinical interest is directed now into more advanced questions. Optimal selection of patients, possible contraindications (eg, in Marfan’s syndrome), risk factors for early valve failure, and, finally, long-term results will be the major upcoming issues during the following years.

Since 1993 aortic root reconstruction has been performed at our institution. In an ongoing prospective observational study we are following clinical and echocardiographic results in a series of 101 patients undergoing the David-type aortic root reconstruction. Although valve function continues to be stable in the majority of patients, secondary valve failure with increasing AI was observed in some individuals. To optimize early results, the aim of our present analysis was to identify possible patient or procedure-related risk factors leading to an impaired valve function within the first year after reconstruction.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Since July 1993, 101 patients underwent aortic root reconstruction using the technique as described by David and Feindel [8] (for details see below). No patient was lost to follow-up. From this patient cohort the first consecutive 75 patients completed the chosen observation period of 1 year or more (with the rest of the patients followed for less than 1 year). There were 52 male and 23 female patients, mean age was 49.1 ± 20.6 years (range, 12.2 to 76.3 years). Diagnostic features of Marfan’s syndrome were present in 22 patients. Mean diameter of the aortic root was 62 ± 14 mm, an extension of the aneurysm to the aortic arch was seen in 19 patients. Echocardiography revealed a mean grade of AI of 2.5 ± 0.9. Aortic dissection was present in 8 patients (acute, n = 4; chronic, n = 4); owing to coronary artery disease 7 patients required coronary artery bypass grafting, and 2 patients had an additional mitral valve prolapse.

Diagnostic procedure
All patients underwent a complete invasive and noninvasive cardiac evaluation comprising left heart catheterization, a computed tomographic scan or magnetic resonance imaging, and echocardiography preoperatively. Intraoperative transesophageal echocardiography was routinely used to control valve competence and to define characteristics of resuspension and coaptation. Postoperative evaluation was performed according to The Society of Thoracic Surgeons and the American Association for Thoracic Surgery guidelines [16], comprising clinical examination and questionnaire (thromboembolic or bleeding complications), as well as transthoracic echocardiography before discharge and at 12-month intervals during follow-up. Examinations were focused on valve morphology, type of coaptation, and the degree of aortic regurgitation. Valve morphology was graded as 0, normal leaflets; 1, hyperreflexibility of the leaflets; 2, more extensive or circumscript thickening, normal cusp motion; 3, calcifications and structural defects resulting in a reduced separation of cusps; and 4, severely degenerated valve with restricted separation and closure.

Initial observations suggested surgically adjusted height of coaptation to impact on valvular stability. Therefore, morphology of coaptation was assessed by echocardiography (Fig 1). A classification was used as type A, coaptation point greater than or equal to 2 mm above the lower prosthetic rim; type B, coaptation close to the lower border of the woven Dacron (Meadox Medicals, Inc, Oakland, NJ) graft; and type C, coaptation greater than or equal to 2 mm below the prosthesis.

View larger version (71K): [in this window] [in a new window]   Fig 1. Type of coaptation of the aortic valve as assessed by echocardiography. Type A has the coaptation point 2 mm within the prosthesis. Type B has coaptation close to the lower border of the Dacron graft. Type C has coaptation 2 mm below the prosthesis.

Surgical technique
Extracorporeal circulation was established after cannulation of the aortic arch or the femoral artery, and blood cardioplegic solution was administered repetitively in an antegrade or retrograde way. After inspection of the aortic valve and decision for root reconstruction, all three aortic sinuses were excised down to a 5-mm rim of the remaining aortic wall attached to the valve. Then the aortic root was dissected circumferentially down to the base of the sinuses, and a Dacron graft, adapted to the free height of the leaflets, was fixed through the annulus underneath the valve using multiple horizontal mattress sutures. As the most essential step, reimplantation of the aortic valve was performed avoiding valve distortion and aiming at a tight coaptation within the graft. Ideal valve coaptation was considered when 30% to 50% of cusp area was involved. If required, a second prosthesis was added for replacement of downstream segments of the aorta. Replacement of the aortic arch was performed using hypothermic cardiac arrest. After removal of air, intraoperative echocardiography was performed immediately after weaning from cardiopulmonary bypass to assess characteristics of repair and valve competence.

Characteristics of coaptation
In the early experience, resuspension was performed maintaining geometry of the aortic valve and avoiding any tension of the leaflets. Depending on the patient’s individual anatomy and surgical decision, different heights of coaptation within the Dacron graft resulted (Fig 1). Early postoperative assessment revealed type A coaptation in 56 (74.6%), type B in 13 (17.3%), and type C in 6 patients (8.0%).

Statistics
Statistical analysis was performed using a computer-assisted software package (SPSS, version 6.1.3; SPSS, Inc, Chicago, IL). Continuous data are presented as mean ± standard deviation. A p value less than 0.05 was considered to be statistically significant.

Comparisons of demographic, disease-related, and procedure-related factors for failing versus nonfailing valves were performed using the Student’s t test for continuous variables and the ² test for noncontinuous data; for multivariable analysis a logistic regression was performed in addition.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Perioperative data
Aortic root reconstruction was initially successful in all 75 patients. A total of 19 patients required partial or total arch replacement, 7 patients underwent aortocoronary bypass grafting, and 2 patients had a mitral valve reconstruction in addition. Intraoperative bypass and cross-clamp times were 154 ± 31 minutes (range, 102 to 252 minutes) and 121 ± 24 minutes (range, 81 to 203 minutes), respectively. Hypothermic cardiac arrest for arch replacement ranged from 7 to 45 minutes (mean, 17 ± 8 minutes). There was no perioperative death; all patients remained in stable sinus rhythm. Perioperative complications were observed in the form of four episodes of reexploration for bleeding and one transitory ischemic attack without any residual attacks within the first 24 hours (most probably caused by an early embolic event).

Valve function and structure
Intraoperatively and before hospital discharge all patients presented with a functional good result. Echocardiography revealed no regurgitation in 55 patients (73.3%), minimal insufficiency (usually eccentric) in 19 (25.3%), and moderate in 1 (1.3%) (Table 1). A minimum of 1 year of follow-up is complete in the whole cohort of 75 patients. Mean observation period is now 35.6 ± 20.6 months (range, 12.2 to 76.3 months) with a cumulative follow-up time of 219.3 years.

Early postoperative assessment of valve structure revealed normal leaflets without increased echogenicity in 55 patients (grade 0, 73.3%), a hyperreflexibility of the cusps in 19 patients (grade 1, 25.3%), and a more extensive and circumscript thickening in 1 (grade 2, 1.3%). After 1 year of follow-up or at reoperation, 49 patients still presented with a complete normal appearance of the valve (grade 0). In 5 patients a slight increase in cusp echogenicity was observed, resulting in a total of 25 patients presenting with grade 2. The patient with the preexisting moderate structural abnormality of the valve (Wegener’s granulomatosis as underlying disease) initially showed a type C reconstruction and underwent reoperation 10.8 months postoperatively.

As assessed by continuous-wave Doppler, hemodynamics presented as being favorable when compared with a mechanical valve replacement. Early gradients across the resuspended valves were 5.2 ± 2.1 mm Hg and 8.8 ± 3.9 mm Hg (mean and maximal gradient) without a significant increase during the first year of follow-up (1 year, 5.9 ± 2.5 and 10.0 ± 3.9 mm Hg, respectively).

Valve failure and late death
Reoperations had to be performed in the 3 patients with increasing AI (9.3, 10.8, and 13.7 months after repair). Mechanical valve replacement within the previously placed Dacron graft could be performed without any difficulties or complications.

There were 3 postoperative deaths. One patient died suddenly on postoperative day 33 (out of hospital during rehabilitation) with an intact reconstruction, presumably because of an arrhythmic event. One patient had mitral valve endocarditis 5.3 months postoperatively including infection of the ascending graft (with the resuspension being structurally intact) and died of septic circulatory failure after reoperation. The third event was again a sudden cardiac death in a 75-year-old woman with known coronary artery disease, 20.4 months postoperatively. At her last visit, aortic root reconstruction was intact with an AI grade 1.

Risk factors for valve failure
Stimulated by the observation of a deteriorating valve function during early follow-up in some patients, several demographic, disease-related, and surgery-related risk factors (age, sex, preoperative size of aneurysm, preoperative grade of AI, Marfan’s syndrome, diameter of prosthesis, and height of coaptation) were compared between stable and failing subgroups. Univariate analysis revealed sex (p = 0.05) and type of coaptation (p < 0.001) as significant risk factors. By multivariable evaluation (logistic regression), only type of coaptation was identified as the most important factor for development of AI greater than or equal to grade 2, with type C (cusp coaptation 2 mm below the lower rim of the prosthesis, Fig 1) being at highest risk to develop AI (p < 0.001, for details see Table 2). Although no patient with a type A coaptation developed significant AI, all patients with type C presented with AI greater than or equal to grade 2 one year postoperatively, with 3 patients requiring reoperation (p < 0.001; Fig 2; Tables 1 and 2).

View larger version (16K): [in this window] [in a new window]   Fig 2. Aortic insufficiency (AI) after 1 year of follow-up in relation to the type of coaptation (A, B, or C). A significantly higher (**p < 0.001) degree of regurgitation early as well as 1 year later was found in type C. (post-OP = postoperatively.)

	Comment

Top Abstract Introduction Patients and methods Results Comment References

Since the first attempts of aortic root reconstruction, several groups have published their experience with this technique [11–13, 20]. A few cases of valve failure, including the need for reoperation, were reported in all series [11–13]. These observations raise the question of an inadequate patient selection, possible contraindications, or an inadequate surgical technique.

In general, development of a progressive AI can be influenced by structural degeneration of the valve or by functional failure owing to suboptimal geometry of coaptation. Main factors addressing the structural aspect are age of the patient, preexisting AI with possible sheer stress-induced injury of the leaflets [21], and, finally, the presence of Marfan’s syndrome. In particular, the question of valve-sparing surgical procedures in Marfan’s patients has been discussed controversially in recent years [22–24]. The presence of fibrillin in the stroma of the aortic leaflets [23] might be a risk factor for a late structural valve failure. On the other hand, anticoagulation-free repair of the aortic root in patients prone to dissection and reoperation in further downstream parts of the diseased aorta could be regarded as major benefits. Supporting the clinical and published experience with good coaptation of the usually large aortic leaflets [25, 26], neither the presence of Marfan’s syndrome nor age or preexisting AI as other structural risk factors could be identified to predispose to an early dysfunction after aortic root repair in our series.

Focusing on more functional variables, we chose initial diameter of ascending aneurysm, the size of the Dacron prosthesis, and height of coaptation of the leaflets for analysis. Basic work in recent years has been performed to clarify the complex functional relationship of the anatomic structures located in the aortic root: annulus, leaflets, commissures, and the sino-tubular junction [9, 27, 28]. Aortic root reconstruction in the technique by David and Feindel [8] affects all of them. On the one hand, this may carry the risk of disturbing essential parts of geometry; on the other hand, however, it provides the surgeon with the option to correct selectively pathologic abnormalities (for example, asymmetric enlarged sinuses and prolapsing commissures). Adding to the knowledge about geometry of the aortic root, height of coaptation could be identified as one of the most essential factors to achieve good functional results after aortic valve reimplantation. A reduced coaptation area as well as ballooning of the unsupported valve may be postulated as the most probable cause for the rapid deterioration of the valve function in type C reconstruction.

Interestingly, a similar risk factor analysis for valve failure in aortic root remodeling (the Yacoub-type of repair without stabilizing the annulus) has been published by Bassano and colleagues [29]. Severe aortic root dilatation before repair and the presence of Marfan’s syndrome were found to predict early valve failure. Valve prolapse after correction of the sino-tubular junction was suggested to be the underlying pathognomic mechanism. Although difficult to compare, we would conclude that this observation emphasizes the superiority of the David-type reimplantation technique by stabilizing the annulus and correcting prolapsing leaflets with the height of coaptation.

The observations made in our study will certainly have an impact on further strategies in aortic root repair. There are two major messages from this analysis: (1) in aortic valve reimplantation (David-type) there are no patient subgroups with a higher risk for an early valve failure (like Marfan’s syndrome), and (2) adequate height of coaptation (aiming for type A or B) will result in excellent intermediate results.

At least two limitations have to be discussed. First, although this is one of the largest series published yet, the study population is still comparably small regarding the heterogeneity of this patient cohort. Analysis with larger patient populations will allow for a more accurate assessment of risk factor profiles. Second, long-term results are essential to assess quality of valvular operations. Therefore, 5- and 10-year results are needed to qualify this type of repair as an equal or better alternative to composite replacement in aortic root ectasia.

In conclusion, valve-sparing aortic root reconstruction presents with favorable early and intermediate results in ascending aortic aneurysm with or without AI. Early outcome seems to be improved by achieving an adequate height of coaptation, allowing for coaptation within the tube graft. Further follow-up is needed to define the long-term results of this type of repair.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Olson L.J., Subramanian R., Edwards W.D. Surgical pathology of pure aortic insufficiency: a study of 225 cases. Mayo Clinic Proc 1984;59:835-841.[Medline]
2. Bentall H., DeBono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338-339.[Abstract/Free Full Text]
3. Gott V.L., Cameron D.E., Pyeritz R.E., et al. Composite graft repair of Marfan aneurysm of the ascending aorta: results in 150 patients. J Card Surg 1994;9:482-489.[Medline]
4. Kouchoukos N.T., Wareing T.H., Murphy S.F., Perrillo J.B. Sixteen-year experience with aortic root replacement. Results of 172 operations. Ann Surg 1991;214:308-318.[Medline]
5. Mingke D., Dresler C., Stone C.D., Borst H.G. Composite graft replacement of the aortic root in 335 patients with aneurysm or dissection. Thorac Cardiovasc Surg 1998;46:12-19.[Medline]
6. Edmunds L.H. Thrombotic and bleeding complications of prosthetic heart valves. Ann Thorac Surg 1987;44:430-445.[Abstract]
7. Horstkotte D., Schulte H., Bircks W., Strauer B. Unexpected findings concerning thromboembolic complications and anticoagulation after complete 10 year follow up of patients with St. Jude Medical prostheses. J Heart Valve Dis 1993;2:291-301.[Medline]
8. 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;103:617-621.[Abstract]
9. Kunzelman K.S., Grande K.J., David T.E., Cochran R.P., Verrier E.D. Aortic root and valve relationships. J Thorac Cardiovasc Surg 1994;107:162-170.[Abstract/Free Full Text]
10. Sarsam M.A., Yacoub M. Remodeling of the aortic valve annulus. J Thorac Cardiovasc Surg 1993;105:435-438.[Abstract]
11. Pethig K., Schäfers H.J., Borst H.G. Functional results after aortic valve repair in aortic root ectasia. J Heart Valve Dis 1996;5:247-250.[Medline]
12. Simon P., Moritz A., Moidl R., et al. Aortic valve resuspension in ascending aortic aneurysm repair with aortic insufficiency. Ann Thorac Surg 1995;60:176-180.[Abstract/Free Full Text]
13. David T.E. Aortic valve-sparing operations in patients with ascending aortic aneurysms. Curr Opin Cardiol 1997;12:391-395.[Medline]
14. Schäfers H.-J., Fries R., Langer F., Nikoloudakis N., Graeter T., Grundmann U. Valve-preserving replacement of the ascending aorta: remodeling versus reimplantation. J Thorac Cardiovasc Surg 1998;116:990-996.[Abstract/Free Full Text]
15. Harringer W., Pethig K., Hagl C., Meyer G.P., Haverich A. Ascending aortic replacement with aortic valve reimplantation. Circulation 1999;100(Suppl 2):II24-II28.
16. Edmunds L.H., Jr, Clark R.E., Cohn L.H., Grunkemeier G.L., Miller C., Weisel R.D. Guidelines for reporting morbidity and mortality after cardiac valvular operations. The American Association for Thoracic Surgery, Ad Hoc Liaison Committee for Standardizing Definitions of Prosthetic Heart Valve Morbidity. Ann Thorac Surg 1996;62:932-935.[Abstract/Free Full Text]
17. Dolan M.S., Castello R., St Vrain J.A., Aguirre F., Labovitz A.J. Quantification of aortic regurgitation by Doppler echocardiography: a practical approach. Am Heart J 1995;129:1014-1020.[Medline]
18. Nishimura R., Vonk G., Remberger J., Tajik J. Semiquantification of aortic regurgitation by different Doppler echocardiographic techniques and comparison with ultrafast computed tomography. Am Heart J 1992;124:995-1001.[Medline]
19. Wilkenshoff U., Kruck I., Gast D., Schröder R. Validity of continuous wave Doppler and colour Doppler in the assessment of aortic regurgitation. Eur Heart J 1994;15:1227-1234.[Abstract/Free Full Text]
20. Pethig K., Harringer W., Haverich A. Aortic valve regurgitation in aneurysm of the ascending aorta: functional results after valve sparing reconstruction. Dtsch Med Wochenschr 1998;123:1263-1268.[Medline]
21. Deck J.D., Thubrikar M.J., Schneider P.J., Nolan S.P. Structure, stress, and tissue repair in aortic valve leaflets. Cardiovasc Res 1988;22:7-16.[Medline]
22. Safi H.J., Vinnerkvist A., Bharma J.K., Miller C.C., Koussayer S., Haverich A. Aortic valve disease in Marfan syndrome. Curr Opin Cardiol 1998;13:91-95.[Medline]
23. Fleischer K.J., Nousari H.C., Anhalt G.J., Stone C.D., Laschinger J.C. Immunohistochemical abnormalities of fibrillin in cardiovascular tissues in Marfan’s syndrome. Ann Thorac Surg 1997;63:1012-1017.[Abstract/Free Full Text]
24. David T.E. When, why, and how should the native aortic valve be preserved in patients with annuloaortic ectasia or Marfan syndrome?. Semin Thorac Cardiovasc Surg 1993;5:93-96.[Medline]
25. Pethig K., Harringer W., Schaefers H.J., Fraund S., Haverich A. Functional results after valve sparing aortic root replacement in Marfan’s syndrome. Eur Heart J 1997;18:S414.
26. Yacoub M.H., Birks E.J., Child A.H., Radley-Smith R.R. Early and long term results of a valve sparing operation for Marfan syndrome. Circulation 1998;98(Suppl 1):I337.
27. Roman M.J., Devereux R.B., Kramer-Fox R., O’Loughlin J. Two-dimensional echocardiographic aortic root. Dimensions in normal children and adults. Am J Cardiol 1989;64:507-512.[Medline]
28. Sutton J.P., Ho S.Y., Anderson R.H. The forgotten interleaflet triangles: a review of the surgical anatomy of the aortic valve. Ann Thorac Surg 1995;59:419-427.[Abstract/Free Full Text]
29. Bassano C., De Paulis R., Penta de Peppo A., et al. Residual aortic valve regurgitation after root remodeling without direct annuloplasty. Ann Thorac Surg 1998;66:1269-1272.[Abstract/Free Full Text]

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