A New Surgical Approach for Aortic Root Aneurysm and Small Aortic Annulus

Reconstruction of the aortic root in patients with aortic root aneurysm and small aortic annulus is an intricate surgical procedure. Here, we describe our technique performed in 2 patients, that involved aortic root enlargement with grafting in conjunction with annular implantation of the composite graft with a prosthetic mechanical valve, which allowed us to avoid incompatibility. This novel method offers an alternative combined surgical approach for patients with small aortic annulus and aortic root aneurysm that preserves the structure of the valved conduit at the level of the aortic annulus.

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Aortic Valve Replacement in Patients with Small Aortic Annulus: New Pericardial Stented Valves vs Aortic Root Enlargement Procedures.

10.22541/au.163943224.41477072/v1 ◽

2021 ◽

Author(s):

Ahmed Fouad ◽

ehab elshihy ◽

Mohammed Hassan ◽

Mohammed Maged ◽

Ashraf Mostafa Abd Raboh

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Aortic Root ◽

Mechanical Valve ◽

Aortic Annulus ◽

University Hospitals ◽

Small Aortic Annulus ◽

Postoperative Drainage ◽

Aortic Root Enlargement

Objectives: Newer generations of stented pericardial valves may offer hemodynamic benefit in patients with small aortic annulus. The aim of this study was to determine the effectiveness of isolated aortic valve replacement with one such valve, the Trifecta valve, when compared to Aortic root enlargement surgery in reducing postoperative gradients and the severity of PPM in patients with small aortic annulus. Patients and methods: A prospective observational study of 100 patients with SAA who underwent AVR from March 2020 to October 2021 in Cairo university hospitals and other centers. The cohort was divided into two groups based on surgical technique: Isolated AVR using Trifecta valve or ARE and mechanical valve placement. Preoperative characteristics, intraoperative times and postoperative outcomes were recorded and compared in all patients, including a pre-discharge echocardiography. Results: Increased operative times, increased ICU stay and need for blood products were observed in the ARE group and operative time was determined as an independent risk factor. Higher rate of complications such as need for permanent pacemaker as well increased postoperative drainage was also recorded in ARE group, with no difference between groups in in-hospital mortality. Higher incidence of PPM was recorded in the Trifecta group (24%) compared to the ARE group (8%). but, the severity of PPM within the Trifecta group was reduced compared to the ARE group, and no degree of PPM was observed in Trifecta valves sized 21. Conclusion The Trifecta valve offers excellent postoperative hemodynamics and significant reduction in severity of PPM in patients with SAA undergoing AVR, with gradients and iEOA almost comparable to larger sized valves implanted after ARE, making the increased surgical burden of ARE unnecessary in most patients.

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Aortic Root Enlargement in patients with small aortic annulus undergoing double valve replacement. A retrospective Comparative cohort study

10.21203/rs.3.rs-133500/v1 ◽

2020 ◽

Author(s):

Yasser Shaban Mubarak ◽

Ahmed Abdel Rahman Abdeljawad

Keyword(s):

Aortic Valve ◽

Valve Replacement ◽

Aortic Root ◽

Aortic Pressure ◽

Aortic Annulus ◽

Paravalvular Leak ◽

Double Valve Replacement ◽

Small Aortic Annulus ◽

Aortic Root Enlargement

Abstract Objectives Small Aortic Annulus (AA) is big issue during Aortic Valve Replacement (AVR) necessitating replacement of inappropriate-sized prostheses especially during Double Valve Replacement (DVR). Despite that small aortic valve prostheses can lead to Prosthesis-Patient Mismatch (PPM), there remains reluctance to perform aortic root enlargement (ARE) procedures fearing from morbidity and mortality. We evaluate clinical and echocardiographic outcomes in patients with small AA undergoing DVR. Methods The study included 100 consecutive patients underwent DVR for combined rheumatic aortic and mitral valve diseases, between June 2016 and November 2020. Only (50) patients had ARE with DVR. ARE was performed using an autologous or bovine pericardium or Dacron patch by Nick′s or Manouguian procedures. The estimated post-operative end-points were mortality, effective orifice areas (EOA), mean aortic pressure gradient and valve-related complications. The least post-operative follow-up period was 6 months. Results The study included 30 male and 70 female patients with mean age of 45 ± 10 years, body surface area (BSA) of 1.6 ± 0.50 m2, aortic annulus diameter was 20 ± 0.4 mm, EOAi was 0.80 ± 0.50 cm2/m2, and aortic mean gradient (PG) 80 ± 40 mm Hg. During follow-up period, there was a mild paravalvular leak (1%) with, (1%) heart block, and residual mean PG on prosthetic aortic valve with all cases of DVR alone. Conclusion Enlargement of aortic root by Nick′s or Manouguian technique is safe and effective in patients with small aortic annulus undergoing double valve replacements.

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Aortic Root Enlargement in Patients With Small Aortic Annulus Undergoing Double Valve Replacement: A Retrospective Comparative Cohort Study

The Heart Surgery Forum ◽

10.1532/hsf.3401 ◽

2021 ◽

Vol 24 (2) ◽

pp. E239-E242

Author(s):

Yasser Mubarak ◽

Ahmed Abdel Rahman Abdel jawad

Keyword(s):

Aortic Valve ◽

Pressure Gradient ◽

Valve Replacement ◽

Aortic Root ◽

Aortic Annulus ◽

Paravalvular Leak ◽

Double Valve Replacement ◽

Small Aortic Annulus ◽

Aortic Root Enlargement

Background: Small aortic annulus (AA) is a big issue during aortic valve replacement (AVR), necessitating replacement of an undersized prosthetic valve especially with double valve replacement (DVR). Despite the fact that small aortic valve prostheses can lead to prosthesis-patient mismatch (PPM), there remains reluctance to perform aortic root enlargement (ARE) procedures, fearing morbidity and mortality. Objective: To evaluate clinical and echocardiographic outcomes in patients with small aortic annulus (<18 mm) undergoing double valve replacement. Methods: The study included 100 consecutive patients who underwent DVR for combined rheumatic aortic and mitral valve diseases, between January 2016 and September 2020. Only 50 patients had ARE with DVR. ARE was performed using an autologous or bovine pericardium or Dacron patch by Nick's or Manouguian procedures. The estimated postoperative endpoints were mortality, effective orifice areas (EOA), mean aortic pressure gradient (PG), and valve-related complications. The shortest postoperative follow-up period was 6 months. Results: The study included 30 male and 70 female patients with mean age of 35±20 years, body surface area (BSA) of 1.7 ± 0.3 m2, aortic annulus diameter was 1.4 ± 0.4 mm, aortic orifice area was 0.8 ± 0.1 cm2, and mean pressure gradient 85 ± 2.5 mmHg. During the follow-up period, there was a mild to moderate paravalvular leak (1%) with 1% heart block and residual gradient on prosthetic aortic valve; this was all in DVR alone. Conclusion: Enlargement of the aortic root by Nick's or Manouguian technique is safe and effective in patients with small aortic annulus undergoing double valve replacements.

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Aortic Root Enlargement in patients with small aortic annulus undergoing double valve replacement. A retrospective Comparative cohort study.

10.22541/au.160555509.91363764/v1 ◽

2020 ◽

Author(s):

Yasser Mubarak ◽

Ahmed Abdeljawad

Keyword(s):

Aortic Valve ◽

Pressure Gradient ◽

Valve Replacement ◽

Aortic Root ◽

Aortic Annulus ◽

Paravalvular Leak ◽

Double Valve Replacement ◽

Small Aortic Annulus ◽

Aortic Root Enlargement

Background: Small Aortic Annulus (AA) is big issue during Aortic Valve Replacement (AVR) necessitating replacement of an undersized prosthetic valve especially with Double Valve Replacement (DVR). Despite that small aortic valve prostheses can lead to Prosthesis-Patient Mismatch (PPM), there remains reluctance to perform aortic root enlargement (ARE) procedures fearing from morbidity and mortality. Objective: To evaluate clinical and echocardiographic outcomes in patients with small aortic annulus undergoing double valve replacement. Methods: The study included 100 consecutive patients underwent DVR for combined rheumatic aortic and mitral valve diseases, between Jan. 2016 and Sept. 2020. Only (50) patients had ARE with DVR. ARE was performed using an autologous or bovine pericardium or Dacron patch by Nicks or Manouguian procedures. The estimated postoperative end-points were mortality, effective orifice areas (EOA), mean aortic pressure gradient and valve-related complications. The least postoperative follow-up period was 6 months. Results: The study included 30 male and 70 female patients with mean age of 35±20 years, body surface area (BSA) of 1.7 ±0.3 m2, aortic annulus diameter was 20±1.4 mm, aortic orifice area was 0.8±0.1 cm2, and mean pressure gradient 85±2.5 mmHg. During follow-up period, there was a mild to moderate paravalvular leak (1%) with, (1%) heart block, and residual gradient on prosthetic aortic valve; that was all in DVR alone. Conclusion: Enlargement of aortic root by Nicks or Manouguian technique is safe and effective in patients with small aortic annulus undergoing double valve replacements.

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Faculty Opinions recommendation of Assessment of long-term outcomes: aortic valve reimplantation versus aortic valve and root replacement with biological valved conduit in aortic root aneurysm with tricuspid valve.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.739102463.793580885 ◽

2020 ◽

Author(s):

John Augoustides

Keyword(s):

Aortic Valve ◽

Tricuspid Valve ◽

Aortic Root ◽

Long Term Outcomes ◽

Aortic Root Aneurysm ◽

Valved Conduit ◽

Aortic Valve Reimplantation

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Chronic Type A Aortic Dissection and Giant Aortic Root Aneurysm After Aortic Valve Replacement

Aorta ◽

10.12945/j.aorta.2016.15.028 ◽

2016 ◽

Vol 04 (03) ◽

pp. 108-110 ◽

Cited By ~ 2

Author(s):

Andrés Enríquez Puga ◽

Sara Castaño Rodríguez ◽

Blanca Mateos Pañero ◽

Beatriz Castaño Moreira ◽

Luis Fernando López Almodóvar

Keyword(s):

Valve Replacement ◽

Aortic Root ◽

Aortic Surgery ◽

Mechanical Valve ◽

Type A ◽

Chronic Type ◽

Type A Aortic Dissection ◽

Aortic Root Aneurysm ◽

Valve Conduit ◽

Type A Dissection

AbstractWe describe the case of a 61-year-old male with a giant aortic root aneurysm associated with chronic aortic Type A dissection. The patient had been operated on 16 years before due to aortic annuloectasia with mechanical valve replacement. The patient underwent revision aortic surgery with a Bentall-De Bono operation with Svensson modification, using a #21 On-X Valsalva mechanical valve conduit. The postoperative course was uneventful.

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Abstract 18662: Aortic Valve Orientation Angle is Associated With Aortic Morphology and Dissection Risk

Circulation ◽

10.1161/circ.130.suppl_2.18662 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Ashutosh A Hardikar ◽

Andrea Iannaccone ◽

Thomas H Marwick

Keyword(s):

Aortic Root ◽

Orientation Angle ◽

Aortic Disease ◽

Asymmetry Index ◽

Aortic Annulus ◽

Shear Stresses ◽

Aortic Dilatation ◽

Left Wall ◽

Root Angle ◽

Aortic Root Enlargement

Introduction: Asymmetric aortic root enlargement may lead to unequal thinning of the aortic wall, differential shear stresses and dissection. We sought the association of aortic root morphology with aortoventricular angle (AVAng), LVOT-root angle (RootAng), root-aorta angle (AortAng) [Fig 1] and outcomes. Methods: Demographic, morphometric and epidemiological parameters were gathered in 100 patients with aortic disease over last 6 years and 50 age and sex matched controls undergoing aortic CT. Two observers measured AVAng, RootAng, AortAng between the proximal aorta, aortic annulus and LV outflow tract [Figure 1] and orthogonal diameters along the thoracic aorta, noting the type of arch and other pathologies. The root axis was taken by joining the midpoints of aortic annulus and sinotubular junction, and asymmetry index (AI) [Fig 1] was calculated as the ratio of the maximal distance between axis and right wall, and axis to left wall in coronal view. There were 22 aortic dissections in the study group, and follow up was 32.3 months. Results: AortAng was different between TAV and BAV, but AI and AVAng were similar. AortAng [P= 0.008], AI [P= 0.004] and AVAng [p=0.013] had the strongest correlation with aortic dilatation [>40 mm], and were different in the dissection group (Table). The AI correlated well with root dilatation while AortAng and AVAng correlated with ascending aortic dilatation. TAV had a diffuse pattern of aortic dilatation as compared to BAV. Conclusions: AVAng and RootAng correlate with aortic dilatation patterns, and also aortic dissection. The AVAng and AortAng may explain the differential shear stresses seen along the 2 curvatures in aortic pathologies.

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Assessment of long-term outcomes: aortic valve reimplantation versus aortic valve and root replacement with biological valved conduit in aortic root aneurysm with tricuspid valve

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezaa389 ◽

2020 ◽

Author(s):

Tsuyoshi Yamabe ◽

Yanling Zhao ◽

Paul A Kurlansky ◽

Suzuka Nitta ◽

Michael A Borger ◽

...

Keyword(s):

Infective Endocarditis ◽

Aortic Valve ◽

Aortic Stenosis ◽

Tricuspid Valve ◽

Aortic Root ◽

Long Term Outcomes ◽

Aortic Root Aneurysm ◽

Valved Conduit ◽

Aortic Valve Reimplantation

Abstract OBJECTIVES We compared the long-term outcomes between aortic valve reimplantation [David V (DV)] and aortic valve and root replacement with biological valved conduit [Bentall–De Bono (BD)] for the patients with aortic root aneurysm with tricuspid valve. METHODS Among 876 patients who underwent aortic root replacement in our institution between 2005 and 2018, 371 patients who underwent DV (n = 199) or BD (n = 172) for aortic root aneurysm with tricuspid valve were retrospectively reviewed. Exclusion criteria included aortic stenosis, infective endocarditis, previous prosthetic aortic valve, bicuspid aortic valve, aortic dissection and mechanical Bentall procedure. Propensity score matching was performed based on the patient characteristics, matching 90 patients in each group. The primary end point was all-cause mortality. Secondary end points were reoperation for any cause and specifically for aortic valve-related cause. RESULTS After propensity score matching, DV and BD groups each had 1 in-hospital mortality (1.1%). Survival at 10 years was 95.3% [95% confidence interval (CI) 85.8–98.5] in DV and 98.6% (95% CI 90.8–99.8) in BD (P = 0.345). The cumulative incidences of reoperation at 10 years in DV versus BD were 3.9% (95% CI 0.7–11.8) vs 18.1% (95% CI 6.9–33.4) for any cause (P = 0.046) and 1.9% (95% CI 0.1–8.8) vs 15.9% (95% CI 5.5–31.4) for aortic valve-related causes (P = 0.032). The reasons for valve-related reoperation were aortic insufficiency (3/5 in DV vs 5/10 in BD), aortic stenosis (0/5 vs 2/10) and infective endocarditis (2/5 vs 3/10). CONCLUSIONS Both DV and BD procedures for patients with aortic root aneurysm with tricuspid valve resulted in excellent 10-year survival. All-cause and aortic valve-related reoperations were significantly less frequent with valve-sparing root replacement, suggesting an advantage of DV over biological BD.

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Management of Small Aortic Root during Aortic Valve Replacement

The Egyptian Cardiothoracic Surgeon ◽

10.35810/ects.v2i1.100 ◽

2020 ◽

Vol 2 (1) ◽

pp. 1-7

Author(s):

Ahmed Nabil Malek ◽

Mohamed A.K. Salama Ayyad ◽

Hussein Elkhayat ◽

Ahmed El-Minshawy

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Aortic Root ◽

Aortic Annulus ◽

Early Results ◽

Significant Difference ◽

Small Aortic Root ◽

Group A ◽

Aortic Root Enlargement

Background: Concomitant aortic root enlargement (ARE) increases the risk of aortic valve replacement (AVR). The objectives of this study were to identify the patients who needed aortic root enlargement and compare the outcomes and the risk of adding ARE to AVR. Methods: We retrospectively reviewed 62 patients who underwent isolated mechanical aortic valve replacement between 2017 and 2019. We divided the patients into two groups: group A included patients with small aortic root who had AVR with one of the different surgical strategies for small aortic annulus (n= 32) and group B, which included patients with a normal aortic annulus and underwent conventional AVR (n= 30). Group A was further sub-divided based on the surgical strategy into 4 categories; patients who had supra-annular implantation of size 19 mm St. Jude prosthetic valve (n= 11; 34.4%), Nicks procedure (n= 13 40.6%), Manougian procedure (n= 4; 12.5%), Konno procedure (n= 4; 12.5%). Results: Group A patients were significantly younger (26.16 ± 11.49 vs. 34.63 ± 8.9 years; p< 0.001) and had lower body weight (55.09 ± 21.41 vs. 69.80 ± 19.20; p= 0.01). Group A had significantly smaller valves (p = 0.03), and total cardiopulmonary bypass (148.65 ± 44.09 vs. 97.46 ± 20.90 minutes; p<0.001) and aortic cross-clamp times (118.13 ± 36.70 vs. 78.06 ± 16.01 minutes; p < 0.001) were significantly longer in group A. There was no significant difference in operative complications between groups. Among patients with small aortic root; Konno procedure had the longest bypass time (236.3 ± 19.70 minutes; p<0.001); cross-clamp time (192.5 ± 22.2 minutes; p <0.001); mechanical ventilation (4.75 ± 0.50 hours; p<0.001) and intensive care unit stay (6.50 ± 0.57 days; p <0.001). Patients with supra-annular implantation of the St. Jude valve had a significantly higher postoperative pressure gradient (14.64 ± 6.84 mmHg; p= 0.02). No difference in procedure complications was observed among aortic root enlargement procedures. Conclusion: Patients who had aortic root enlargement procedure were younger, with lower weight and body surface area. Surgical procedures used to manage small aortic root had comparable early results, and no technique was superior to the others.

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