Modified Bentall procedure with mitral valve replacement in a patient with Marfan syndrome: a case report

Marfan syndrome (MFS) is an autosomal dominant connective tissue disorder characterized by fibrillin-1 protein abnormalities, predisposing individuals to cardiovascular complications such as aortic root dilation and mitral valve prolapse (MVP). Management often requires surgical intervention, with the modified Bentall procedure being a standard approach for aortic root replacement. However, managing concomitant mitral valve pathology poses additional challenges due to the complex anatomical relationship between the two valves and the prolonged nature of the procedure. We present a case report of a 35-year-old male with Marfan syndrome who underwent a successful simultaneous modified Bentall procedure and mitral valve replacement for concurrent aortic root aneurysm and mitral valve prolapse. Surgical interventions involved meticulous attention to detail to mitigate risks associated with malpositioned coronary ostial sutures, debridement of the severely calcified mitral valve, and achieving hemostasis. Following surgery, the patient exhibited favorable postoperative outcomes, with evidence of optimal valve function and improved systolic and diastolic parameters, indicative of a successful recovery.

Reemplazo de la raíz aórtica con preservación valvular en niños y adolescentes: experiencia y resultados en una institución pública en Argentina / Valve-Sparing Aortic Root Replacement in Children and Adolescents: Experience and Results in a Public Institution in Argentina

RESUMEN Background: La cirugía de reemplazo de la raíz aórtica con preservación valvar tipo reimplante (RRAoPV) está indicada en pacientes con aneurisma de la raíz aórtica. Objetivos: Evaluar los resultados a mediano plazo de esta técnica quirúrgica en niños y adolescentes de nuestra institución. Material y métodos: Estudio retrospectivo. Se incluyó a 21 pacientes a quienes se realizó cirugía de RRAoPV entre julio de 2006 y julio de 2022. Se evaluó la relación entre las variables basales y la progresión de insuficiencia aórtica (IAo). Resultados: La mediana de edad fue de 13 años. Diecisiete pacientes tenían enfermedad del tejido conectivo, (3 de ellos además con aorta bicúspide), 2 cardiopatías congénitas operadas aisladas, 1 válvula aórtica bicúspide aislada y 1 síndrome de Turner. Trece pacientes tenían IAo leve y 5 moderada en el preoperatorio. Tres pacientes requirieron reemplazo aórtico precoz, 2 por endocarditis y uno por IAo aguda grave. La mediana de seguimiento fue de 4,1 años. De 17 pacientes en seguimiento, 2 evolucionaron con IAo leve-moderada, 2 moderada y 3 grave. Uno de ellos requirió cirugía de Bentall. No se encontró asociación del grado de IAo preoperatoria, ni de la presencia de aorta bicúspide, con la progresión de la IAo postoperatoria. No hubo asociación entre el tipo de coaptación valvular postoperatorio y el desarrollo de la IAo mayor que leve en el seguimiento. Conclusiones: El RRAoPV tipo reimplante es una técnica quirúrgica viable en pacientes pediátricos con buenos resultados a mediano plazo y baja tasa de reoperación.

ABSTRACT Background: Valve-sparing aortic root replacement (VSARR) with reimplantation technique is indicated in patients with aortic root aneurysm. Objective: To evaluate the mid-term outcomes of this surgical technique in children and adolescents in our institution. Methods: Retrospective study. Twenty-one patients who underwent VSARR surgery were included between July 2006 and July 2022. The relationship between baseline variables and progression of aortic regurgitation (AR) was assessed. Results: The median age was 13 years. Seventeen patients had connective tissue disorders (3 with bicuspid aortic valve), 2 operated congenital heart disease, 1 isolated bicuspid aortic valve and 1 Turner syndrome. Thirteen patients had mild AR and 5 had moderate AR preoperatively. Three patients underwent early aortic replacement, 2 due to endocarditis and 1 due to severe acute AR. The median follow-up was 4.1 years. Of 17 patients at follow-up, 2 developed mild-moderate AR, 2 moderate AR and 3 severe AR. One of them underwent Bentall surgery. No association was found between the degree of preoperative AR or the presence of bicuspid aortic valve and the progression of postoperative AR. There was no association between the type of postoperative valve coaptation and the development of AR greater than mild at follow-up. Conclusions: VSARR with reimplantation is a feasible surgical technique with favorable mid-term outcomes and low reoperation rate in pediatric patients.

Clinical effectiveness of valve-sparing aortic root replacement in the treatment of patients with dilated aortic root after operation for tetralogy of Fallot / 中国胸心血管外科临床杂志

@#Objective     To evaluate the clinical effectiveness of valve-sparing aortic root replacement (VSARR) in the treatment of patients with dilated aortic root after operation for tetralogy of Fallot (TOF). Methods     A retrospective analysis was conducted on clinical data of TOF patients with aortic root dilation who underwent VSARR in our hospital from 2016 to 2022. Results     Finally 14 patients were collected, including 8 males and 6 females, with a median age of 22 years ranging from 12-48 years. Among them, 5 patients had severe aortic valve regurgitation, 4 moderate regurgitation, and 5 mild or no regurgitation. Six patients had sinus of valsalva dilation, and 8 significant dilation of the ascending aorta. One patient had residual shunt due to ventricular septal defect, and 9 severe pulmonary valve regurgitation. The David procedure was performed in 10 patients, Yacoub procedure in 2 patients, and Florida sleeve in 2 patients. There was no perioperative mortality in the group. The median follow-up time was 2.9 years (ranging from 0.4 to 6.0 years). One patient had mild aortic valve regurgitation, and the rest had minimal or no regurgitation. One patient had mild stenosis of the left ventricular outflow tract, and the rest patients had no obvious stenosis. Conclusion     VSARR is a satisfactory treatment for aortic root dilation in patients with TOF, with no significant increase in the incidence of left ventricular outflow tract stenosis or aortic regurgitation during mid-term follow-up.

Research progress on aortic root repair by modified sandwich technique for acute Stanford type A aortic dissection / 中国胸心血管外科临床杂志

@#Acute Stanford type A aortic dissection has the characteristics of acute onset, severe condition and high mortality. Once making a definite diagnosis, surgical treatment is needed as soon as possible. It is difficult for cardiac surgeons to treat the acute aortic dissection involving the aortic sinus, which is an important risk factor for death. Improving the surgical treatment for the aortic sinus can be a key to improving the prognosis. In this review, we will introduce the modified sandwich technique for acute Stanford type A aortic dissection and the prognosis, and summarize the experiences of different modified sandwich techniques. However, there is still no unified standardized technique in aortic root repair, and there is a lack of large studies with long-term follow-up, so it is necessary to further improve the aortic root repair techniques.

Mid-to-long term fate of neo-aortic root after arterial switch operation for Taussig-Bing anomaly: A retrospective study in a single center / 中国胸心血管外科临床杂志

@#Objective To explore growth pattern of neo-aortic root as well as development of neo-aortic regurgitation after arterial switch operation (ASO) for Taussig-Bing anomaly. Methods From 2002 to 2017, the patients who received ASO, and were discharged alive from Shanghai Children’s Medical Center and followed up for more than 3 years were retrospectively involved in this study. Results A total of 127 patients were enrolled. There were 98 (77.2%) males, the median age at ASO was 73.0 d and the average weight was 4.7 kg. Forty-five (35.4%) children were complicated with mild or mild-to-moderate pulmonary insufficiency (PI) before ASO. The average follow-up time was 7.0 years. During the follow-up, 14 (11.0%) children presented moderate or greater neo-aortic regurgitation (neo-AR). The diameter of neo-aortic annulus and sinus of Valsalva was beyond normal range during the entire follow-up. The average diameter of neo-aortic annulus was 18.0 mm at 5 years and 20.5 mm at 10 years. The average diameter of sinus of Valsalva was 25.9 mm at 5 years and 31.1 mm at 10 years. Neo-AR continued to develop over time. The diameter of children who developed moderate or greater neo-AR was constantly larger than that of children who did not (χ2=18.3, P<0.001). Preoperative mild or mild-to-moderate PI was an independent risk factor for the development of moderate or greater neo-AR during mid-to-long term follow-up (c-HR=3.46, P=0.03). Conclusion The diameters of neo-aortic annulus and sinus of Valsalva of Taussig-Bing children who receive ASO repair continue to expand without normalization. The dilation of annulus correlates with the development of neo-AR. PI before ASO repair increases the risk of neo-AR development.

A Case of Takayasu's Arteritis with Aortic Root Abscess after AVR and during Biologic Drug Administration / 日本心臓血管外科学会雑誌

A 32-year-old woman was diagnosed with Takayasu's arteritis 5 years ago and underwent aortic valve replacement for aortic regurgitation 1 year ago. She had been taking Prednisolone and Azathioprine for Takayasu's arteritis, but these drugs were switched to subcutaneous Tocilizumab 4 months ago. One month ago, she had dyspnea on exertion, and 2 days ago, chest discomfort appeared, and she came to our hospital. Blood tests showed CRP 0.02 mg/dl, and echocardiography and CT showed perivalvular leakage and aortic root pseudoaneurysm, which led us to suspect aortic root pseudoaneurysm due to Takayasu's arteritis and to perform emergency surgery. Although a circumferential pseudoaneurysm was observed at the aortic root, no destruction of the prosthetic valve was observed. The suture from the previous surgery was attached to the sawing cuff of the prosthetic valve, and the prosthetic valve was not fixed to the aortic annulus and could be easily removed. The Bentall operation was performed using a bioprosthetic valve. The histopathological diagnosis was subacute infective endocarditis, and the patient was diagnosed with a pseudoaneurysm of the aortic root due to infection. The patient had a good postoperative course and was discharged home on the 19th day. We report a case of Takayasu's arteritis with valve annular abscess after AVR, which was treated surgically during biologic drug administration.

A Successful Aortic Valve-Sparing Root Replacement Operation (Reimplantation) to Repair Root Dilatation and Aortic Valve Regurgitation after a Ross Procedure / 日本心臓血管外科学会雑誌

We report a successful case of aortic valve-sparing root replacement for dilated aortic root after a Ross procedure. A 29-year-old male underwent a Ross procedure when he was 11 years old for congenital aortic bicuspid valve. The right ventricular outflow tract was reconstructed using an autologous pericardium as a single leaflet valve. Aortic root dilatation and moderate aortic valve regurgitation were noted. Further investigation with enhanced computed tomography and ultrasonic cardiography revealed good quality of leaflets and sufficient geometric height, and aortic valve-sparing root replacement was performed. In addition, we performed pulmonary valve replacement with a biological valve. The post-operative course was uneventful and the patient was discharged after 8 days with a completely controlled aortic valve regurgitation. No recurrence of aortic valve regurgitation was observed 1 year later. Because surgical outcomes of congenital heart diseases have improved and more patients have an increasing life expectancy, several other problems were revealed, such as the occurrence of aortic root dilatation after a Ross procedure. Aortic roots may dilate due to arterial pressure; however, valve-sparing procedures may be performed if the volume of the leaflets is sufficient.

Evaluation of the Aortic Root Using 3D-CT Following Aortic Valve Replacement Employing the Bo Yang Root Enlargement Technique / 日本心臓血管外科学会雑誌

A 65-year-old male was diagnosed with severe aortic stenosis with an indication for surgery and referred to our department. The patient opted for aortic valve replacement using a bioprosthesis. Due to the patient's relatively small native aortic valve area, a concurrent root dilatation maneuver (Bo Yang method) was performed to prevent patient-prosthetic mismatch and to allow for the implantation of a sufficiently larger bioprosthesis, facilitating the valve-in-valve procedure. The successful implantation of an Inspiris 25-mm bioprosthesis was achieved. Post-operative 3D-computed tomography revealed no tilting or misalignment of the bioprosthesis, and a properly sized, undistorted Valsalva sinus was observed. Aortic valve replacement using the Bo Yang root enlargement technique is considered a promising alternative for relatively younger patients requiring aortic valve intervention.

Minimally Invasive Surgery with the Bentall-De Bono Technique. Initial Experience at Hospital Italiano de Buenos Aires / Cirugía de Bentall de Bono por abordaje miniinvasivo. Experiencia inicial del Hospital Italiano de Buenos Aires

ABSTRACT Background : Cardiac surgery avoiding full sternotomy began to emerge in the 1990s with the first hemi-sternotomies and mini-thoracotomies. Aortic valve and root surgery is one of the most common procedures in our field. In this paper, we analyze our experience in minimally invasive cardiac surgery (MICS) for the aortic root with the Bentall-De Bono technique (MICS-Bentall). Objective : To analyze the surgical results in the first 10 patients underwent a MICS-Bentall procedure at our site. Materials and Methods : A retrospective observational study was carried out including patients with valve disease and aortic root dilation who underwent a surgery with the MICS-Bentall procedure in a tertiary care hospital from December 2019 to December 2020. Continuous variables were expressed as mean and standard deviation or median and interquartile range according to the observed distribution. Categorical variables were expressed as absolute and relative frequency. Results : Out of 165 patients undergoing aortic root surgery, 10 patients were included. Mean age was 56 ± 17.03 years, 70% male; all cases were elective. Median (interquartile range, IQR) STS PROM % was 1.48 (1- 2.02). Eighty percent had bicuspid valve. Fifty percent of patients were extubated within 6 hours. In the 30-day follow-up, no death was recorded, and two complications were registered: one patient experienced atrial fibrillation without hemodynamic decompensation and another a wound infection. The mean hospital length of stay was 5 days. Conclusion : In our experience, MICS using the Bentall technique showed satisfactory results in terms of low perioperative mortality, early extubation, and short hospital stay.

RESUMEN Introducción : La cirugía cardíaca libre de esternotomía completa surge en los años 90 con las primeras esternotomías y toracotomías mínimas. La cirugía de la válvula y la raíz aórtica constituyen uno de los procedimientos más frecuentes en nuestro campo. En este trabajo analizamos nuestra experiencia en Cirugía Cardíaca Miniinvasiva (MICS) de la raíz aórtica con la técnica Bentall de Bono (MICS-Bentall). Objetivo : Analizar los resultados quirúrgicos en los primeros 10 pacientes intervenidos con MICS-Bentall en nuestra institución. Material y métodos : Se realizó un estudio observacional retrospectivo en el que se incluyeron los casos de valvulopatía y dilatación de la raíz aórtica intervenidos quirúrgicamente mediante MICS-Bentall en un hospital de alta complejidad durante el periodo diciembre 2019 - diciembre 2020. Las variables continuas se expresan como media y desvío estándar o mediana y rango intercuartílico según la distribución observada. Las variables categóricas como frecuencia absoluta y relativa. Resultados : Sobre 165 pacientes sometidos a cirugía de la raíz aórtica, se incluyeron 10 pacientes. La edad media fue de 56 ± 17,6 años, 70% de sexo masculino, todos fueron electivos. La mediana de STS PROM % fue de 1,48 (1-2,02). En el 80% la válvula aórtica era bicúspide. El 50% de los pacientes fue extubado dentro de las 6 horas. En seguimiento a 30 días no se registraron óbitos, y hubo 2 complicaciones: un paciente presentó fibrilación auricular sin descompensación hemodinámica, y otro, infección de herida. La estadía hospitalaria fue en promedio de 5 días. Conclusión : En nuestra experiencia con MICS con la técnica Bentall se obtuvieron resultados satisfactorios con baja mortalidad perioperatoria, extubación precoz y tiempos cortos de estancia hospitalaria.

Relationship between Aortic Root Diameter and Type 2 Diabetes in Hypertensive Patients

Background: Diabetes mellitus (DM) involves a series of metabolic conditions associated with hyperglycaemia which is caused by defects in insulin secretion and./or insulin action. The aim of this work was assessment of the relationship between Aortic Root (AOR) diameter and type 2 diabetes mellitus (T2DM) in Hypertension (HTN) cases. Methods: This prospective case control study was carried out on 80 HTN cases. Cases were divided in to three groups: Group A (30 HTN cases) with type 2 DM with good metabolic control (Hb AIC ? 7.0), group B: (30 HTN cases) with type 2 DM with poor metabolic control (Hb AIC > 7.0) and C (Control group) 20 HTN, non-DM subjects of the same age and sex group with no other comorbid conditions. Results: FS had a significant decline in group A (P2 = 0.001) and in group B (P3 <0.001) than C. EF had a significant difference among all groups (P <0.001). Early wave declaration time (DT) had a significant decline in group A (P2 = 0.049) and in group B (P3= 0.023) than C. Tissue doppler early velocity wave had a significant difference among all groups (P = 0.004). Tissue doppler early velocity wave had a significant decline in group A and B than C. (P2 = 0.038. P3 = 0.003). Conclusions: AOR in HTN cases had a significant decline in DM cases compared with non-DM cases. In our results, glycaemic control didn’t play a significant role in aortic root.

Surgical strategy and clinical outcomes of reoperative aortic root replacement after prior aortic valve replacement / 中国胸心血管外科临床杂志

@#Objective    To summarize the surgical strategy of reoperative aortic root replacement after prior aortic valve replacement (AVR), and analyze the early and mid-term outcomes. Methods    From April 2013 to January 2020, 75 patients with prior AVR underwent reoperative aortic root replacement in Fuwai Hospital. There were 54 males and 21 females with a mean age of 56.4±12.7 years. An emergent operation was performed in 14 patients and an elective operation in 61 patients. The indications were aortic root aneurysm in 38 patients, aortic dissection involving aortic root in 30 patients, root false aneurysm in 2 patients, prosthesis valve endocarditis with root abscess in 2 patients, and Behçet's disease with root destruction in 3 patients. The survival and freedom from aortic events during the follow-up were evaluated with the Kaplan-Meier survival curve and the log-rank test. Results    The operative procedures included prosthesis-sparing root replacement in 45 patients, Bentall procedure in 26 patients, and Cabrol procedure in 4 patients. Operative mortality was 1.3% (1/75). A composite of adverse events occurred in 5 patients, including operative death (n=1), stroke (n=1), and acute renal injury necessitating hemodialysis (n=3). The follow-up was available for all 74 survivors, with the mean follow-up time of 0.5-92.0 (30.3±25.0) months. Four late deaths occurred during the follow-up. The survival rate at 1 year, 3 years and 6 years was 97.2%, 91.4% and 84.4%, respectively. Aortic events developed in 2 patients. The rate of freedom from aortic events at 1 year, 3 years, and 6 years was 98.7%, 95.0% and 87.7%, respectively. There was no difference in rate of survival or freedom from aortic events between the elective patients and the emergent patients. Conclusion    Reoperative aortic root replacement after prior AVR can be performed to treat the root pathologies after AVR, with acceptable early and mid-term outcomes.

A meta-analysis of aortic root remodeling and replantation in acute Stanford type A aortic dissection / 中华胸心血管外科杂志

Objective:To systematically compare the safety and reliability of remodeling and reimplantation in aortic root valve preservation surgery for acute Stanford type A aortic dissection.Methods:We searched the databases of CNKI, VIP, Wanfang, CBM, Pubmed, EMBASE, Cochrane Central Register of Controlled Trials ( CENTRAL ) to find the clinical controlled research literature on acute type A aortic dissection remodeling and replantation. The relevant outcome indicators were analyzed by Review Manager 5.3 combined with Stata15.0 statistical software.Results:Seven studies involving 356 patients were included. Remodeling surgery versus replantation surgery. There was a higher incidence of postoperative grade Ⅱ or Ⅲ aortic regurgitation( OR=5.56, 95% CI: 1.89-16.41, P<0.05 ), higher 5-year reoperation rate ( OR=7.50, 95% CI: 2.11-26.65, P<0.05 ), shorter cardiopulmonary bypass time ( MD=-20.81, 95% CI: -35.08-6.54, P< 0.05 ), and longer aortic occlusion time ( MD=35.23, 95% CI: 21.21-49.26, P<0.05 ). The 30-day/in-hospital mortality( OR=1.09, 95% CI: 0.56-2.13, P>0.05) , postoperateive secondary thoracotomy for hemostasis( OR=2.91, 95% CI: 0.34-24.99, P>0.05), the rate of reoperation 1 year after surgery( OR=1.22, 95% CI: 0.20-7.56, P> 0.05) and 5-year mortality( OR=7.50, 95% CI: 2.11-26.65, P>0.05), were no significant difference between remodeling surgery group and replantation surgery group. Conclusion:Compared with replantation surgery, remodeling surgery in patients with acute type A aortic dissection has a higher incidence of grade Ⅱ or Ⅲ aortic insufficiency, a higher rate of reoperation 5 years after surgery, a shorter duration of cardiopulmonary bypass, and a longer duration of aortic occlusion. There were no statistically significant differences in postoperative hospitalization/30-day mortality, postoperative secondary thoracotomy, reoperation rate 1 year after surgery, and late mortality using remodeling and replantation techniques, which could be selected according to the actual situation of the aortic root and the experience of the surgeon.

Application of neoadventitia technique in root repair of acute type A aortic dissection / 中华胸心血管外科杂志

Objective:To evaluate the safety and efficacy of the neoadventitia technique for root repair in acute type A aortic dissection(ATAAD).Methods:From January 2019 to February 2022, a total of 94 patients with ATAAD who underwent surgical treatment in Beijing Anzhen Hospital were retrospectively analyzed. According to the different treatment methods for the aortic root, the patients were divided into the neoadventitia technique group(58 cases) and the Bentall group(36 cases). The perioperative data and postoperative follow-up results of the two groups were compared, and the efficacy of the new adventitia technique in acute type A aortic dissection was analyzed.Results:There were no intraoperative deaths. The 30-day mortality was 3.4% and 5.6% in the neoadventitia group and Bentall group, respectively ( P=0.636). The cardiopulmonary bypass time[(154.3±29.8)min, P<0.001] and aortic clamp time[(94.7±20.6)min, P<0.001)]were significantly shorter in the neoadventitia group, compared with the Bentall group. Aortic regurgitation was significantly improved after the operation (0.33±0.50 vs. 1.02±0.80, P<0.001). No aortic root-related secondary intervention occurred during follow-up. There was no significant difference in mortality between the two groups( P=0.248). Conclusion:Neoadventitia root repair is a safe and feasible method for the treatment of ATAAD, which has good short-term and mid-term efficacy.

Research Progress in Valve-sparing Aortic Root Replacement / 中山大学学报(医学科学版)

With continuous improvements in surgical techniques， medical engineering and material science， root replacement with composite valve graft （CVG） or Bentall procedure has become the standard procedure for aortic root lesions. As an alternative to the Bentall procedure， valve-sparing aortic root replacement （VSRR） avoids the complications associated with lifelong anticoagulation and mechanical valves； reduces the incidence of thromboembolic and bleeding events； and its favorable haemodynamics and potentially lower risk of endocarditis ensure durable postoperative aortic valve function and a much better quality of patient survival. This article reviews the indications for root replacement with preservation of the aortic valve， the key points of the standardized technique and its long-term results in different patients.

Síndrome de Marfan, una enfermedad genética con complicaciones cardiovasculares / Marfan syndrome, a genetic disease with cardiovascular complications

RESUMEN El síndrome de Marfan es un trastorno de herencia autosómica dominante causado por una alteración genética en el cromosoma 15; afecta a múltiples órganos y sistemas del tejido conjuntivo, fundamentalmente cardiovascular. Tiene la misma probabilidad de aparecer en ambos sexos, y puede ser hereditario o resultado de una mutación genética espontánea. Las complicaciones más peligrosas son las que afectan al corazón y a los vasos sanguíneos. El diagnóstico es clínico y depende de la combinación de varios criterios, lo que permite evaluar la progresión de las lesiones cardiovasculares, a la vez que determina el momento oportuno para una opción quirúrgica. El síndrome requiere de una atención multidisciplinaria para lograr una reducción de la morbimortalidad. Se presenta el caso clínico de un paciente del sexo masculino que cumplió con los criterios diagnósticos de la enfermedad. El mismo tuvo alteraciones sistémicas y complicaciones que rápidamente evolucionaron de forma desfavorable, falleciendo a pesar de los cuidados médicos.

ABSTRACT Marfan syndrome is an autosomal dominant inheritance disorder caused by a genetic alteration on chromosome 15; it affects multiple organs and systems of connective tissue, mainly cardiovascular. It is equally likely to appear in both sexes and it can be hereditary or the result of a spontaneous genetic mutation. The most dangerous complications are those that affect the heart and blood vessels. The diagnosis is clinical and depends on the combination of several criteria, which allows to evaluate the progression of cardiovascular lesions, while determining the opportune moment for a surgical option. The syndrome requires multidisciplinary care to achieve a reduction in morbidity and mortality. The clinical case of a male patient who meet the diagnostic criteria for the disease is presented. He had systemic alterations and complications that rapidly evolved unfavorably and, despite medical care, he died.

" Watching without dealing" aortic root repair in the treatment of acute Stanford type A aortic dissection: a prospective observational study / 中华胸心血管外科杂志

Objective:To evaluate the clinical effects of " watching without dealing" aortic root repair technique in acute Stanford type A aortic dissection(ATAAD).Methods:From October 2017 to October 2018, " watching without dealing" technique was performed in ATAAD patients with mild aortic root involvement. The proximal aortic anastomosis was at the level of the sinotubular junction, without " pursuing" complete excision of the intra-sinus dissections. The perioperative clinical data and follow-up imaging results of the patients were collected and analyzed to evaluate early and mid-term efficacy of the technique.Results:A total of 20 patients received " watching without dealing" technique in our hospital, including 15 males and 5 females with a mean age of(48.0±12.1) years old(34-73 years old). The preoperative aortic sinus diameter was(41.3±3.6)mm and the aortic sinotubular junction diameter was(43.9±6.6) mm. All patients underwent ascending aortic replacement and total arch replacement plus frozen elephant trunk surgery. The cardiopulmonary bypass time was(179.5±41.5)min(132~255 min), the cross-clamp time was(120.3±23.7) min(95~180 min), and the circulatory arrest time was(8.8±7.6) min(2~22 min). During perioperative period, no adverse events such as death, secondary opening, renal failure, cerebral infarction, and paraplegia occurred. The CTA examination of the aorta before the patients were discharged showed that all residual false lumen in the sinus disappeared, the diameter of the aortic sinus was(30.8±2.6) mm, and the diameter of the aortic sinotubular junction was(27.2±2.5) mm. The patients were followed up for mean(28.5±7.8) months(3~35 months). No surgical re-intervention of the aortic root occurred. The aortic CTA during follow-up period showed no residual or new dissection in the aortic sinus, the diameters of the aortic sinus and aortic sinotubular junction were(30.9±2.4) mm and(27.5±2.7) mm respectively; the ultrasonic cardiogram showed normal aortic valve structure and function. No statistically significant differences were found when comparing the aortic sinus diameter and aortic sinotubular junction diameter between two time points of at discharge and follow-up.Conclusion:The " watching without dealing" aortic root repair technique for ATAAD is relatively simple to learn and safe in the perioperative period. Early and mid-term follow-up imaging showed normalization of the aortic sinus structure. Further follow-up and observation were necessary to figure out the long-term clinical outcome of this modified aortic root repair.

Short-term effects of extended adventitial inversion with graft eversion anastomosis technique in the root treatment of acute type A aortic dissection / 中国胸心血管外科临床杂志

@#Objective    To evaluate the short-term therapeutic effect of extended adventitial inversion with graft eversion anastomosis technique in the root treatment of acute type A aortic dissection (ATAAD). Methods    From November 2019 to July 2020, 28 patients with ATAAD were treated by extended adventitial inversion with graft eversion anastomosis technique in the Department of Cardiovascular Surgery, Dalian Municipal Central Hospital, including 19 males and 9 females, aged 60.11±11.11 years. The intima of the ascending aorta was trimed to 5 mm above the sinotubular junction. The adventitia of the ascending aorta was longitudinally cut to the reserved intima margin along the junction of the three aortic valves. The extended adventitial inversion was sutured continuously, no coronary sinus was sutured over the aortic annulus, and the left and right coronary sinus was sutured above the coronary ostium. The anastomotic graft was everted and inserted into the aortic lumen, and the everted graft was continuously sutured at the level of sinotubular junction which was 5 mm away from the edge of graft. Results    There was no intraoperative death, intractable root hemorrhage, residual root false lumen, root dilatation, anastomotic hematoma or other complications. There was no recurrence of the pain in the back of all patients, and the results of the CT angiography were not significantly changed. In 22 patients with no regurgitation, only 1 (4.55%) patient had a mild regurgitation. In 6 patients with mild aortic regurgitation, the disappearance rate of regurgitation was 50.0% (3/6). Conclusion    The treatment of extended adventitial inversion with graft eversion anastomosis technique in the root treatment of aortic dissection eliminates the residual dissection at the root. The anastomotic hemorrhage is prevented, the root structure of aortic dissection is reconstructed and strengthened, the root function is restored, and the possible expansion of the root is prevented. The short-term results are satisfactory.

Value of aortic root CTA assessment in aortic valve surgery / 中国胸心血管外科临床杂志

@#Objective    To evaluate the data of preoperative aortic root CT angiography (CTA), compare it with two-dimensional transthoracic echocardiography and investigate the correlation of the two measurements with the actual intraoperative measurement data. Methods    Clinical data of 53 patients with aortic valve diseases who underwent aortic valve repair in our hospital from January 2018 to August 2020 were retrospectively analyzed, including 38 males and 15 females with an average age of 42.9±18.3 years ranging from 10 to 77 years. Preoperative two-dimensional transthoracic echocardiography (TTE) and aortic root CTA measurements were collected, including aortic valve annulus (AVA), aortic sinus (Sinus) and sino-tubular junction (STJ). In comparison with the intraoperative measurements during the aortic valve repair surgery, the consistency analysis was performed. Results    Both the preoperative echocardiography AVA measurements and the CT AVA measurements were positively correlated with the intraoperative AVA measurements (P<0.001). Compared with the echocardiography AVA data [correlation coefficient (ρ)=0.74, mean squared error (MSE)=12.78], the CT AVA data were more accurate and consistent with the intraoperative AVA measurements (ρ=0.95, MSE=2.72). CT AVA data had a higher correlation coefficient with the intraoperative measurements, compared to that of  the echocardiography AVA data (P<0.001). Conclusion    In comparison with two-dimensional transthoracic echocardiography, preoperative morphological evaluation of aortic root CTA is more consistent with the actual intraoperative measurements during aortic valve repair surgery.

Application of aortic root repair in acute type A aortic dissection with aortic sinus involvement / 中华胸心血管外科杂志

Objective:To evaluate the outcomes of aortic root repair in acute type A aortic dissection (ATAAD) with aortic sinus involvement.Methods:The clinical data of patients with ATAAD involving the aortic sinus and an aortic root diameter of ≤45 mm who were treated from January 1, 2015, to December 31, 2016, were collected. Patients were divided into group A (involvement of one aortic sinus or part of one aortic sinus) and group B (involvement of more than one aortic sinus). The effectiveness of aortic root repair in ATAAD with sinus involvement was analyzed by comparing the preoperative imaging characteristics and postoperative results between the two groups.Results:The study cohort comprised 155 patients, including 100 patients in group A and 55 in group B. There were no differences between the two groups in baseline characteristics, aortic root diameter, 30-day mortality, and complication rates. During an average follow-up of(49.1±14.6) months, there was no difference between the two groups in the survival rate (92.0% vs. 89.5%, P=0.61). The aortic root diameter at follow-up showed no progressive expansion compared with preoperatively in either of the two groups[(38.1±3.6) mm vs. (37.9±3.5)mm, P=0.92, A; (38.4±4.1) mm vs. (38.3±3.6) mm, P=0.74, B]; furthermore, there was no difference between the two groups in aggravation of aortic regurgitation. Conclusion:Aortic root repair achieves satisfactory medium-term outcomes in ATAAD with more than one aortic sinus involved, but the long-term outcomes need to be evaluated.

Short-and mid-term results after adventitial inversion technique for root repair in acute type A aortic dissection / 中华胸心血管外科杂志

Objective:To evaluate the safety and effectiveness of adventitial inversion technique for root repair in patients with acute type A aortic dissection(ATAAD).Methods:Between 2015 and 2018, ATAAD patients with dissected root and underwent open surgery were included. The exclusion criteria were as follows: previous root intervention, traumatic dissection and patient underwent root replacement(Bentall or David procedure). 490 ATAAD patients were included, 366(74.69%) male and 124(25.31%) female, aged(51.28±10.99) years(range 24-77 years). The clinical data were retrospectively analyzed with ANOVA/ nonparametric test and Chi- square test. Follow-up mortality and reoperation were displayed with Kaplan- Meier curve. Results:All patients were technically divided into three groups: adventitial inversion(A), direct suture(B) and Cabrol-shunt(C). The mean age in group A was(53.05±11.09) years, whereas worse cardiac and renal function occurred in group C. The mean duration of HCA, CPB and ACC were shortest, with a highest average of minimum rectal temperature during surgical interval in group A. Postoperative complications and early mortality were similar among groups. There were no significant differences of mid-term mortality and reoperation among these three techniques. Though no late reintervention for aortic root was found in both group A and B, the root diameter was more stable in group A during follow-up period[(33.14±3.74)mm vs.(34.51±3.83)mm vs.(33.89±3.89)mm, P=0.008]. Conclusion:Adventitial inversion technique is safe and effective for root repair in patients with ATAAD, achieving satisfactory short- and mid-term effects.