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Ann Thorac Surg 2002;74:S1758-S1761
© 2002 The Society of Thoracic Surgeons
a Divisions of Cardiovascular Surgery and Cardiology, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada
* Address reprint requests to Dr David, 200 Elizabeth St, 13EN219, Toronto, Ontario, Canada M5G 2C4
e-mail: tirone.david{at}uhn.on.ca
Presented at the Aortic Surgery Symposium VIII, May 2–3, 2002, New York, NY.
Abstract
BACKGROUND: Aortic valve-sparing operations are an alternative to aortic root replacement in patients with aortic root aneurysms, or aortic valve replacement and supracoronary replacement of the ascending aorta in patients with ascending aorta aneurysms and dilated sinotubular junctions with consequent aortic insufficiency.
METHODS: From 1988 to 2001, 230 patients underwent aortic valve-sparing operations for aortic root aneurysms (151 patients) or ascending aortic aneurysms with aortic insufficiency (79 patients). Two types of aortic valve-sparing operations were performed in patients with aortic root aneurysms: reimplantation of the aortic valve and remodeling of the aortic root. Mean follow-up was 3.8 ± 2.8 years.
RESULTS: Patients with aortic root aneurysms were younger, had less severe aortic insufficiency, less extensive vascular disease, and better left ventricular function than patients with ascending aorta aneurysms. The 8-year survival was 83% ± 5% for the first group and 36% ± 14% for the second. The freedom from aortic valve reoperation at 8 years was 99% ± 1% for the first group and 97% ± 2% for the second. In patients who had aortic root aneurysms, 3 developed severe aortic insufficiency (AI), and 15 developed moderate AI, for an 8-year freedom from significant AI of 67% ± 7%. But freedom from AI was 90% ± 3% after the technique of reimplantation, and 55% ± 6% after the technique of remodeling (p = 0.02). In patients with ascending aortic aneurysms, the freedom from AI greater than 2+ at 8 years was 67% ± 11%.
CONCLUSIONS: The long-term results of aortic valve sparing for aortic root aneurysms are excellent, and reimplantation of the aortic valve may provide a more stable repair of the aortic valve than remodeling of the aortic root.
Aortic valve-sparing operations were developed to preserve the native aortic valve in patients with aortic root aneurysms with or without aortic insufficiency, and also in patients with ascending aorta aneurysms with aortic insufficiency secondary to dilation of the sinotubular junction and relatively normal aortic cusps, annulus, and sinuses.
The long-term results of aortic valve-sparing operations in these two groups of patients are quite different and will be examined separately in this study.
Patients and methods
From 1988 to 2001, 230 patients underwent aortic valve-sparing operations at Toronto General Hospital. These operations were performed for aortic root aneurysms in 151 patients and for ascending aortic aneurysms with aortic insufficiency (AI) in 79. Table 1 shows the clinical profile of these two groups of patients.
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Replacement of the ascending aorta with adjustment of the diameter of the sinotubular junction was performed in 79 patients with ascending aortic aneurysms and moderate or severe AI [1, 2].
A number of patients from both groups had an elongated free margin of one or more aortic cusps, which was shortened by plication of the free margin [2]. Table 2 shows the operative data
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Statistical analysis
Descriptive statistics are reported as the means ± SD for continuous variables and as frequencies and percentages for categorical variables, unless otherwise noted. Comparisons between groups were made with unpaired t tests for continuous variables and 
2 or Fisher’s exact test for categorical variables. Estimates for long-term survival or freedom from morbid events were made by the Kaplan-Meier method.
Results
Aortic root aneurysms
There were two operative deaths, both due to myocardial infarction. Fifteen patients required reexploration for bleeding; 4 patients suffered a stroke with complete recovery, and 1 patient required aortic root replacement on the first postoperative day because of AI. There were no other complications. There were 12 late deaths: two sudden, three due to complications of acute or chronic dissection, and seven noncardiovascular. The survival at 8 years was 83% ± 5%. Figure 1
shows the long-term survival.
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One paraplegic patient developed an aortic root abscess due to Enteroccus faecalis 11 years postoperatively, and was successfully treated with aortic root replacement with an aortic homograft.
Three patients developed severe AI: 1 underwent aortic root replacement on the first postoperative day, the second 9 years postoperatively, and the third patient is scheduled for elective surgery. The first patient had had reimplantation of the aortic valve and the other 2 had remodeling of the aortic root. Figure 2 shows freedom from aortic valve replacement.
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At the most recent follow-up, 118 (88%) patients were in New York Heart Association (NYHA) functional class I; 15 (11%) were in class II, and 1 patient was in class III.
Ascending aorta aneurysms
There was one operative death 1 month after surgery due to pneumonia. Eight patients needed reexploration for bleeding and 4 suffered a stroke, with complete recovery in 2. There were 16 late deaths: four due to myocardial infarction, one sudden, three due to complications of aortic dissection, two due to rupture of thoracic or abdominal aorta aneurysm, two strokes, and four noncardiovascular. The survival at 8 years was 36% ± 14%.
Five patients suffered a thromboembolic complication: four strokes (two fatal) and one transient ischemic attack. The freedom from thromboembolism at 8 years was 86% ± 6%.
One patient developed infective endocarditis and required aortic valve replacement. Another patient required aortic valve replacement because of severe AI. The freedom from reoperation was 97% ± 2% at 8 years. Seven patients required surgery on the remaining thoracic and abdominal aorta; 1 patient died during surgery for ruptured thoracoabdominal aortic aneurysm.
At the last follow-up, 60 patients were alive and 45 (75%) were in NYHA class I, 13 (22%) in class II, and 2 patients were in class III.
Echocardiographic data
Aortic root aneurysms.
Three patients developed severe AI: 2 underwent reoperation, and 1 patient was scheduled for repeat surgery at the time of the last follow-up. Fifteen patients had moderate AI with normal left ventricular dimensions and no symptoms. The freedom from moderate or severe AI (AI > 2+) was 67% ± 7% at 8 years (Fig 3).
However, aortic valve function appeared to be more stable in patients who had reimplantation of the aortic valve than in those who had aortic root remodeling. The freedom from AI more than 2+ at 8 years was 90% ± 3% in patients who had reimplantation of the aortic valve, and 55% ± 6% in those who had remodeling of the aortic root (p = 0.02).
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Comment
The long-term survival after aortic valve-sparing operations was excellent for aortic root aneurysms, at 83% ± 5% at 8 years. Yacoub and associates reported similar survival in their experience with 158 patients [3]. Of the two main types of aortic valve-sparing operations, reimplantation of the aortic valve, and remodeling of the aortic root, we now believe that the first provides a more stable repair. In our experience, the freedom from AI more than 2+ was significantly lower in patients who had the reimplantation technique. This is due to multiple factors. One of them is that patients with aortic root aneurysm often have annuloaortic ectasia, which may have a temporal expression, particularly in patients with the Marfan syndrome, and may not be apparent at surgery [4]. The aortic annulus may continue to dilate after the remodeling procedure. Another important factor is that minor elongation of the free margins of the aortic cusps is common in patients with aortic root aneurysms, and when the reimplantation procedure is used, one can precisely assess prolapse by simple inspection of the aortic cusps because the entire aortic valve is contained inside a rigid structure. This is assessed less easily after the remodeling procedure because the aortic annulus is unsupported and the aortic cusps may move away during the cardiac cycle.
The technique of reimplantation of the aortic valve has been criticized because it places the aortic valve inside a cylindrical structure without aortic sinuses and may increase mechanical stress on the cusps [5]. This problem can be overcome by creating aortic sinuses as the operation is performed [6]. We reconstruct the aortic root based on the size of the aortic cusps, and use only grafts sizes 30 to 34 mm in diameter. Plication of the graft at the levels of the aortic annulus and sinotubular junction creates neo-aortic sinuses. Conversely, one can use the commercially available grafts with neo-aortic sinuses developed by de Paulis and associates [7]. We continue to prefer the first method because the graft can be tailored to the size of the aortic cusps as the operation is performed. Determination of graft size by measuring various components of the aortic root is not entirely reliable, and remains one of the most difficult aspects of this operation [6]. When the cusps are entirely normal, the diameter of the sinotubular junction is estimated by gently pulling the three commissures upward and approximating them until the cusps touch centrally. The diameter of an imaginary circle that includes all three commissures is the diameter of the sinotubular junction. The aortic annulus should have a similar diameter. The problem is that most patients with aortic root aneurysms have slightly elongated aortic cusps and may also have a dilated aortic annulus. In these cases, we estimate the diameters of the aortic annulus and sinotubular junction by measuring the height of the cusps and the length of their free margin [6]. The diameter of the aortic annulus should be approximately 1.5 to 1.6 times the average height of the cusps and 0.8 to 0.9 times the average length of the free margin. These are empiric relationships that we have developed based on the functional anatomy of the aortic root [2]
The long-term survival after aortic valve-sparing operations in patients with ascending aorta aneurysms was disappointingly low, at 36% at 8 years. However, our patients were much older than patients who had aortic root aneurysms, and had extensive vascular disease; many had transverse arch aneurysms and almost one-third of them had mega-aorta syndrome. Repair of AI in these patients is relatively simple because all that is required is a reduction in the diameter of the sinotubular junction. A number of our patients also had aortic cusp prolapse, which required shortening of the free margin.
Patients with aortic root or ascending aortic aneurysms need continued medical surveillance of the remaining thoracic and abdominal aorta because of the risk of rupture or dissection. Thus, in addition to annual Doppler echocardiographic studies to assess aortic valve function, computed tomographic scan or magnetic resonance imaging of the entire aorta should be obtained annually if they have had aortic dissection or mega-aorta syndrome. Long-term therapy with a ß adrenergic blocker was used in patients with Marfan’s syndrome and aortic dissections.
Valve-related complications such as thromboembolism and endocarditis are also a potential problem in these patients. It is unlikely that the native aortic valve is the source of emboli, but the Dacron graft or the remaining aortic arch can be. Long-term therapy with an antiplatelet agent has been added to our management protocol of these patients. ([8])
References
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