Aortic Root Replacement in Patients With Ventricular Septal Defect

Aortic root replacement is increasingly being performed in the treatment of aortic root and valve pathology. While many of these procedures are performed during the fifth or sixth decade of life, differences in outcomes based on age remain largely unknown. Therefore, we examined short- and long-term outcomes of root replacement stratified by age. From 2004 to 2021, all adult patients undergoing aortic root replacement in a retrospective database were included. A total of 2748 patients were divided into 6 age groups: 18-29 (n = 163.6%), 30-39 (n = 286.10%), 40-49 (n = 451.16%), 50-59 (n = 628.23%), 60-69 (n = 741.27%), 70-79 (n = 386.14%), and ≥80 years (n = 93.3%). The mean age of the cohort was 55 years, and 81% were male. Valve-sparing root replacement and mechanical Bentall utilization decreased with age. The overall stroke rate was 3.4% and significantly higher among the ≥80 group (9.7%, P = .01). The ≥80 group had significantly more complications, including renal failure on dialysis, prolonged ventilation, longer hospital stays, and higher in-hospital mortality (13%). Four percent of patients required reoperation of the proximal aorta or aortic valve during follow-up, with rates of reoperation highest among 30-39-year (7.3%) and 40-49-year (5.8%) age groups. Ten-year survival was 78% (95% CI, 76%-80%) overall and worse among groups 70-79 (63%) and ≥80 (49%) compared to other groups (P < .0001). Aortic root replacement can be performed across all adult ages with acceptable clinical results; however, operative outcomes and long-term survival were significantly worse in patients ≥80 years old. The decision to perform aortic root replacement in patients beyond the seventh decade of life should be made with critical analysis of the clinical indications and overall risk:benefit ratio.

BackgroundGeneralization of standardized surgical techniques to treat aortic valve (AV) and aortic root diseases has benefited large numbers of patients. As a consequence of the proliferation of patients receiving aortic root surgeries, surgeons are more frequently challenged by reoperative aortic root procedures. The aim of this study was to evaluate the outcomes of redo-aortic root replacement (ARR).MethodsWe retrospectively reviewed 66 patients (36 male; mean age, 44.5±9.5 years) who underwent redo-ARR following AV or aortic root procedures between April 1995 and June 2015.ResultsEmergency surgeries comprised 43.9% (n=29). Indications for the redo-ARR were aneurysm (n=12), pseudoaneurysm (n=1), or dissection (n=6) of the residual native aortic sinus in 19 patients (28.8%), native AV dysfunction in 8 patients (12.1%), structural dysfunction of an implanted bioprosthetic AV in 19 patients (28.8%), and infection of previously replaced AV or proximal aortic grafts in 30 patients (45.5%). There were 3 early deaths (4.5%). During follow-up (median, 54.65 months; quartile 1–3, 17.93 to 95.71 months), there were 14 late deaths (21.2%), and 9 valve-related complications including reoperation of the aortic root in 1 patient, infective endocarditis in 3 patients, and hemorrhagic events in 5 patients. Overall survival and event-free survival rates at 5 years were 81.5%±5.1% and 76.4%±5.4%, respectively.ConclusionDespite technical challenges and a high rate of emergency conditions in patients requiring redo-ARR, early and late outcomes were acceptable in these patients.

This meta-analysis aimed to compare the mid-term clinical outcomes of reimplantation versus remodelling techniques for valve-sparing aortic root replacement (VSARR) in patients with connective tissue disorders (CTD). Literature was screened and identified following PRISMA guidelines from PubMed, Web of Science and Embase databases. Forest plots were produced using Review Manager 5.3. Studies comparing early and mid-term clinical outcomes of reimplantation versus remodelling VSARR in CTD patients with a mean age ≥18 were included. Sensitivity analysis excluded studies and subgroups of patients that received ring or suture annuloplasty in addition to remodelling surgery. Literature selection identified 9 eligible studies. Following analysis of the study period and location for patient cross-over, 7 retrospective studies consisting of 597 patients (301 reimplantation, 296 remodelling) were pooled. Pooling revealed no significant difference in postoperative mortality (estimated mean follow-up of 10.5 years) (odds ratio [OR], 0.66; 95% confidence interval [CI], 0.30 to 1.48; I2= 30 %; p=0.32), reoperation (OR, 0.35; CI 0.04 to 3.30; I 2= 81%; p=0.36), or occurrence of postoperative aortic regurgitation of ≥2 (OR, 0.56; CI 0.31 to 1.02; I2= 47%; p=0.06). Sensitivity analysis excluding annuloplasty demonstrated improved mortality (OR, 0.19; CI 0.06 to 0.64; I2= 0%; p=0.007) and decreased aortic regurgitation of ≥2 (OR, 0.23; CI 0.10 to 0.53; I2= 47%; p=0.0005) in reimplantation VSARR. Rates of reoperation remained insignificant in the sensitivity analysis (OR, 0.43; CI 0.05 to 3.53; I2= 71%; p=0.43). In conclusion, this meta-analysis has demonstrated no significant difference in mid-term clinical outcomes of reimplantation versus remodelling techniques of VSARR. Sensitivity analysis excluding studies and patient subgroups that received remodelling and annuloplasty suggests remodelling alone to be inferior to reimplantation in patients with connective tissue disorders. Further research is required to assess remodelling and annuloplasty against reimplantation in patients of this demographic, as the current literature does not allow for sufficient analysis.

Dilatation of the Remaining Aorta After Aortic Valve or Aortic Root Replacement in Patients With Bicuspid Aortic Valve: A 5-Year Follow-Up

Outcomes of reoperative aortic root surgery

Valve-sparing and valve-replacing techniques for aortic root replacement in patients with Marfan syndrome: Analysis of early outcome

&lt;p dir="ltr"&gt;Background&lt;/p&gt;&lt;p dir="ltr"&gt;ATAAD is a lethal condition, and emergency surgery is warranted for almost all patients. Despite advances in surgical techniques, as well as medical and anesthetic management, surgery for ATAAD continues to carry a high risk of major complications and early mortality. The optimal approaches to organizational, surgical, and medical management of ATAAD remain subjects of ongoing debate. The overall aim of this work was to investigate differences in management of ATAAD, as well as factors associated with short- and long-term adverse outcomes, with the goal of improving clinical decision-making and optimizing the management of ATAAD.&lt;/p&gt;&lt;p dir="ltr"&gt;Methods and results&lt;/p&gt;&lt;p dir="ltr"&gt;Study I - Type A aortic dissection repair in patients with prior cardiac surgery. All patients who underwent surgery for ATAAD between 2005 and 2014 identified from the NORCAAD database were included in the study. Patients who had undergone PCS (n=40) were compared with those who had not undergone PCS (n=1119). The primary outcome measure was 30-day mortality, and the secondary outcome measure was a composite outcome of early major complications: 30-day mortality, perioperative stroke, postoperative cardiac arrest, or de novo dialysis. Patients with PCS had higher 30-day mortality (30% vs 17.8%, p=0.049) and a higher prevalence of major complications (52.5% vs 35.7%, p=0.030). However, PCS was not an independent predictor for 30-day mortality (OR 0.78; 95% CI 0.30-2.07, p=0.624) or major complications (OR 1.07, 95% CI 0.45-2.55, p=0.879).&lt;/p&gt;&lt;p dir="ltr"&gt;Study II - Improving outcomes of surgery for acute type A aortic dissection. All patients (n=204) who underwent surgery for ATAAD between 2015 and 2020 at Karolinska University Hospital were included. Patients were divided into two groups: recent (n=102) and earlier (n=102). Uni- and multivariable statistical analysis were performed to identify predictors of early mortality. A significantly lower 30-day mortality was observed in the recent group (recent: 3.9% vs earlier: 14.6%, p=0.014). There was no statistically significant difference in early mortality between high- and low-volume surgeons. Biological composite graft, concomitant coronary artery bypass grafting (CABG), intraoperative adverse event, preoperative lactate, non-normal left ventricular ejection fraction (LVEF) and dissection of any arch vessel were identified as independent predictors of 30-day mortality.&lt;/p&gt;&lt;p dir="ltr"&gt;Study III - Late aortic reinterventions after surgery for acute type A aortic dissection. All patients (n=225) who underwent surgery for ATAAD at least a decade earlier (2005-2013) at Karolinska University Hospital were included. Information regarding the indication for and type of reintervention(s) were obtained from local databases and medical records. Measurements of aortic diameters were obtained from serial computed tomography (CT) scans. A Fine- Gray multivariable model, treating death and contraindication to reintervention as competing risks, was used to investigate factors associated with reintervention. The median follow-up was 10.3 years (5.0-13.4). A total of 37 patients underwent at least one aortic reintervention. Aortic root diameter &gt;45 mm and no root replacement at index repair, bicuspid aortic valve (BAV), and age were associated with proximal reintervention. Failure to completely resect the primary tear and connective tissue disease (CTD) were associated with distal aortic reintervention. Event-free survival at 1, 5, 10 and 15 years was 82% (77-87), 72% (65-77), 48% (41-54) and 33% (26-40), respectively.&lt;/p&gt;&lt;p dir="ltr"&gt;Study IV - Management of acute type A aortic dissection in the Nordic countries. A questionnaire with 32 questions regarding strategies for pre-, peri- and postoperative management of ATAAD was sent to participating centers in NORCAAD2. Of the 17 centers that received the questionnaire, 12 centers (71%) responded. Regarding the primary site of arterial cannulation, seven centers (58%) used femoral artery cannulation. Nine centers (75%) used cerebral perfusion in most cases requiring hypothermic circulatory arrest (HCA). Five centers (42%) reported that total arch replacements and valve-sparing root replacements were never performed. The number of annual ATAAD cases ranged from 5-50, and the number of surgeons performing ATAAD repairs ranged from 3 to 8. Regarding postoperative surveillance, 42% of centers had unlimited follow-up time, 25% followed patients for 10 years and 33% followed patients for 5 years. All centers reported that they used a CT scan interval of 6-12 months.&lt;/p&gt;&lt;p dir="ltr"&gt;Conclusions&lt;/p&gt;&lt;p dir="ltr"&gt;Patients with PCS had a higher prevalence of major complications. However, PCS itself was not independently associated with adverse events. Previous cardiac surgery should not deter emergency surgery.&lt;/p&gt;&lt;p dir="ltr"&gt;Early outcomes after surgery for ATAAD improved in the most recent era. Possibly, having fewer surgeons performing more procedures, adopting a relatively conservative surgical approach, and ensuring adequate cerebral protection may have contributed to the improvement.&lt;/p&gt;&lt;p dir="ltr"&gt;With sufficient follow-up, event-free survival following ATAAD repair appears to be substantially compromised. Potentially, aortic root replacement in patients with moderate aortic root dilatation and ensuring complete resection of the primary tear may reduce the need for future aortic reinterventions.&lt;/p&gt;&lt;p dir="ltr"&gt;NORCAAD2 comprises low-, medium- and high-volume centers, each employing different strategies for cannulation, cerebral protection, extent of aortic resection, surgical techniques, and postoperative surveillance. These variations make NORCAAD2 an excellent opportunity to study these contested topics in a large patient population.&lt;/p&gt;&lt;h3&gt;List of scientific papers&lt;/h3&gt;&lt;p dir="ltr"&gt;I. &lt;b&gt;Bjurbom M,&lt;/b&gt; Olsson C, Geirsson A, Gudbjartsson T, Gunn J, Hansson E, Hjortdal V, Jeppsson A, Mennander A, Ede J, Zindovic I, Ahlsson A, Wickbom A, Dalén M. Type A aortic dissection repair in patients with prior cardiac surgery. Ann Thorac Surg 2023;115:591-9.&lt;br&gt;&lt;a href="https://doi.org/10.1016/j.athoracsur.2022.05.033" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1016/j.athoracsur.2022.05.033&lt;br&gt;&lt;br&gt;&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;II. &lt;b&gt;Bjurbom M,&lt;/b&gt; Dalén M, Franco-Cereceda A, Olsson C. Improving outcomes of surgery for acute type A aortic dissection. Scand Cardiovasc J 2023 Dec;57(1):2210275&lt;br&gt;&lt;a href="https://doi.org/10.1080/14017431.2023.2210275" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1080/14017431.2023.2210275&lt;br&gt;&lt;br&gt;&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;III. &lt;b&gt;Bjurbom M,&lt;/b&gt; Ma K, Dalen M, Franco-Cereceda A, Olsson C. Late aortic reinterventions after surgery for acute type A aortic dissection. Ann Thorac Surg [Submitted]&lt;/p&gt;&lt;p dir="ltr"&gt;IV. &lt;b&gt;Bjurbom M,&lt;/b&gt; Franco-Cereceda A, Olsson C. Management of acute type A aortic dissection in the Nordic countries. Scand Cardiovasc J [Submitted]&lt;/p&gt;

The performance of the Ross procedure in the case of geometric mismatch between pulmonary autograft and a bicuspid aortic root has not yet been fully evaluated. To prevent geometrically caused autograft dysfunction, a modification of the surgical technique is necessary. Between January 1996 and January 2007, 50 patients (33 male, 17 female; mean age 50+/-14 years; range 13-63 years) underwent replacement of a diseased bicuspid aortic valve (stenosis in 14 cases; insufficiency in 21; combined disease in 15) with a Ross procedure. The pulmonary autograft was inserted partially in supra-annular position to correct the geometric mismatch between the deeper base of the non-coronary sinus and the right/left coronary sinus. In 24 of these patients, additional tailoring of the non-coronary sinus was necessary. In eight patients the non-coronary sinus was covered with a glutaraldehyde treated autologous pericardial patch to prevent pseudoaneurysm formation. Patients were followed up 1, 2, 5 and 10 years postoperatively. There were no early or late deaths. There were six reoperations. One patient was reoperated because of persistent severe aortic valve insufficiency 9 months postoperatively. Three patients were reoperated for formation of subannular pseudoaneurysm, 6, 9 and 30 months postoperatively. One patient was reoperated for closure of a paravalvular dehiscence. Another patient was reoperated 1 year postoperatively because of a severe pulmonary stenosis due to excessive calcification of the bioprosthesis. Echocardiographic follow-up of the remaining patients showed no evidence of residual or recurrent pulmonary autograft regurgitation or progression of aortic root dilatation. Autograft replacement of the bicuspid aortic valve is challenging, as the geometric mismatch has to be adjusted. Valve dysfunction is avoided by a supra-annular implantation technique, but pseudoaneurysm formation at the base of the non-coronary sinus is a worrying aspect. Patch reinforcement may solve this issue.

The objective was to review the operative risk and outcomes of redo aortic root replacement. From July 1990 to December 2001, aortic root replacement was performed in 165 patients who had at least one previous cardiac operation. Their mean age was 49 +/- 16 years and 78% were men. Twenty-eight patients had a previous aortic root replacement. The principal indication for surgery was prosthetic aortic valve dysfunction. All the patients had a dilated, calcified, ruptured, or some other abnormality of the aortic root. The follow-up was complete and extended from 0 to 12.5 years, mean of 3.8 years. There were 12 operative (7%) and 20 late deaths (12%). The survival at 8 years was 68%+/- 6%. The principal cause of death was cardiovascular related. Age at increments of 5 years (risk ratio: 1.2; CI: 95%; 1.1 to 1.4) and preoperative New York Heart Association functional class IV (risk ratio: 2.2; CI: 95%: 1.1 to 4.7) were the only two independent predictors of death. Two patients had a stroke and died; two patients developed three episodes of prosthetic valve endocarditis and died. Three patients were reoperated on because of endocarditis in one, bioprosthetic valve failure in one, and dehiscence of a prosthetic mitral valve in one. The freedom from reoperation at 8 years was 93%+/- 5%. Redo aortic root replacement can be done with low operative mortality in elective patients and the risk increases in those who need emergent surgery and are older. The long-term results are satisfactory and similar to those for patients who have aortic root replacement for the first time.

Valve-sparing root replacement after the Ross procedure

Valve-sparing aortic root replacement in patients with the Marfan syndrome

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures prevents a number of cardiac surgeons from incorporating them into their practice. The aim of this protocol is to describe a simplified and user-friendly technique of an aortic valve-sparing root replacement (VSRR) procedure by re-implantation of the aortic valve. Proper selection of patients and limitations of the technique are discussed. In 54 consecutive patients, normal appearing aortic valves were re-implanted in a commercially available polyester prosthesis with pre-shaped sinuses by a simplified and standardized technique. Placement of the first row of the proximal suture line, choice of the prosthesis size, and adjustment of the height of the commissures of the patient to the fixed height of the sinus portion of the prosthesis were slightly modified from the reference techniques with the aim of increasing its feasibility for use by other cardiac surgeons. Early mortality and morbidity as well as 5-year survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were collected in all patients. Thirty-day mortality, re-sternotomy for bleeding, re-sternotomy for mediastinitis, and the incidence of stroke were very low, 1.8% for each (1 of 54). No patient required permanent pace-maker implantation. At 5 years, survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were 97.5%, 95.2%, and 91.6%, respectively. Mid-term results of our standardized technique of re-implantation of the aortic valve for valve-sparing aortic root replacement are very good and compare with more complex techniques reported by experienced surgeons. By following the present protocol of the standardized re-implantation technique, a greater number of cardiac surgeons can perform this procedure with comparable good results.

Complete aortic root replacement in patients with small aortic annulus

During a 16-year interval ending in October 1990, 168 patients underwent 172 aortic root replacements. Thirty patients (18%) had Marfan syndrome. Annuloaortic ectasia (81 patients) and aortic dissection (63 patients) were the principal indications for operation. Twenty-seven patients (16%) had previous operations on the ascending aorta or aortic valve. The hospital mortality rate was 5% and the duration of cardiopulmonary bypass was the only significant independent predictor of early death (p = 0.017). Major modifications in technique were made in 1981, when the inclusion/wrap technique employing a composite graft (used in the first 105 procedures) was abandoned in favor of an open technique (used in 51 procedures), and in 1988, when aortic allografts and pulmonary autografts were introduced for selected conditions (reoperations, dissection, endocarditis, isolated aortic valve disease) in 16 patients. The mean duration of follow-up was 81 months. Forty-six patients were followed for more than 10 years. The actuarial survival rate was 61% at 7 years and 48% at 12 years. No significant difference in survival rate was observed between the patients with annuloaortic ectasia and aortic dissection, or between the inclusion/wrap and open techniques. However the frequency of pseudoaneurysm formation at suture lines and the frequency of reoperations on the ascending aorta and aortic valve were less with the open technique. The actuarial freedom from thromboembolism for the 152 patients with prosthetic valves was 82% at 12 years. One early and one late death occurred among the 16 patients with allograft or autograft root replacement. Anticoagulant therapy was not used in these patients and no thromboembolic episodes occurred in the follow-up period (mean, 7 months). The satisfactory results observed with extended follow-up support the continued use of the composite graft technique as the preferred method of treatment for patients with annuloaortic ectasia, persistent aneurysms of the sinuses of Valsalva following previous operations, and for patients with ascending aortic dissection who require aortic valve replacement. The availability of aortic root allografts and the perfection of techniques for safe implantation of the autologous pulmonary root into the aortic position have broadened the indications for aortic root replacement.

Bentall Operation With Biological Conduits