Survival and freedom from aortic valve-related reoperation after valve-sparing aortic root replacement in 1015 patients.

OBJECTIVES: The aim of this study was to characterize mortality and aortic valve replacement after valve-sparing aortic root replacement (V-SARR) in a multicentre cohort. METHODS: Between 1994 and 2014, 1015 patients had V-SARR with (n = 288, 28%) or without cusp/commissure repair (n = 727, 72%) at the centres of Lübeck (n = 343, 34%), Stuttgart (n = 346, 34%), Hamburg (n = 109, 11%) and Freiburg (n = 217, 21%), Germany. Comparative survival of an age- and gender-matched general population was calculated. Log-rank tests and multiple logistic regression were used to identify risk factors. RESULTS: The mean follow-up was 5.2 ± 3.9 years. Cumulative follow-up comprised 2933 patient-years. Early survival was 98%. NYHA status and aneurysm size were predictive of death during mid-term follow-up (P = 0.025). Freedom from aortic valve replacement was 90% at 8 years, with the type of V-SARR (root remodelling, David II) being a risk factor (P = 0.015). Bicuspid aortic valve (P = 0.26) and initial valve function (P = 0.4) did not impact reoperation. The need of additional valve repair (cusps/commissures) was not linked to reoperation: freedom from aortic valve replacement at 8 years was 84% if cusp repair was performed versus 90% if V-SARR alone was performed (P = 0.218). Marfan syndrome had no impact on survival or on aortic valve replacement. CONCLUSIONS: Mid-term survival of patients after V-SARR is comparable with that of a matched general population. The regurgitant bicuspid aortic valve is a favourable substrate for V-SARR. Prophylactic surgery should be performed before symptoms or large aneurysms are present to achieve optimal mid-term outcomes.

Residual and Progressive Aortic Regurgitation After Valve-Sparing Root Replacement: A Propensity-Matched Multi-Institutional Analysis in 764 Patients.

BACKGROUND: Residual/progressive aortic regurgitation (rAR, pAR) after valve-sparing aortic root replacement (V-SARR) can lead to reoperations. We sought to characterize risk factors of mild rAR and pAR after V-SARR in a multicenter cohort. The effect of additional cusp repair on valve function was analyzed using propensity matching. METHODS: A total of 1,015 patients after V-SARR were identified with (n = 288, 28%) or without additional cusp/commissure repair (n = 727, 72%) at four cardiac units in Germany. A total of 764 patients fulfilling transthoracic echocardiography follow-up-criteria comprised the study cohort. Logistic regression was used for risk factor analysis with endpoints rAR, new onset AR, and pAR. t tests and analyses of variance were used for between-group differences. The effects of additional cusp repair on valve function were studied comparing propensity-matched quintiles. RESULTS: The incidence of rAR was 29%, with influencing factors aneurysm size (p = 0.07) and preoperative aortic valve function (p = 0.08). It was found more often among nonsyndromic patients (34% vs. 14%; OR, 0.4; p < 0.001). Progression of rAR was detectable in 30% after a mean of 4.3 years. The progression rate of rAR ∼ 0.3 grades per patient-year within the first 5 years. When quintiles identified by propensity score were compared, additional cusp repair was linked to new onset AR (p = 0.016) while it was not linked to rAR (p = 0.14) or pAR (p = 0.5). CONCLUSIONS: The incidences of rAR and pAR are considerable after V-SARR. Patients should be operated on before large aneurysms are present. New onset AR after an initially good functional result is more likely after an additional cusp repair, while rAR and pAR are not influenced by cusp repair.

Aortic valve/root procedures in patients with an anomalous left circumflex coronary artery and a bicuspid aortic valve: anatomical and technical implications.

An anomalous origin of the left circumflex coronary artery that arises as a side branch of the right coronary artery from the right coronary sinus of Valsalva encircling the aortic annulus is usually an incidental finding. However, in patients undergoing aortic valve procedures, its existence can significantly complicate the surgical treatment. We report our operative strategy in patients with an anomalous left circumflex coronary artery, a bicuspid aortic valve morphology and different aortic valve pathologies.

The David procedure for salvage of a failing autograft after the Ross operation.

BACKGROUND: Dilatation of the pulmonary autograft is a major fear after the Ross procedure. We analyzed the results after reoperation for autograft dysfunction using a valve-sparing reimplantation technique (David procedure). METHODS: From 1995 to 2012, 645 Ross operations were performed, with 630 (98%) of these as freestanding root replacements (mean follow-up, 8.3 ± 4.6 years). Forty-nine autograft reoperations occurred in 46 patients (0.89%/patient-year). Between 2005 and 2013, reoperation using a David procedure was performed in 18 of 35 patients (52%) with autograft dilatation at a mean interval of 11 ± 3.2 years after the Ross operation. RESULTS: The mean age of 18 patients receiving a David procedure as reoperation was 49.8 ± 13.9 years; 83% were male. The 30-day reoperative mortality was zero. The mean vascular graft size used for reimplantation was 29.5 ± 1.7 mm. At a mean follow-up time of 3.2 ± 2.3 years (100% complete), all patients (18 of 18) were alive and in New York Heart Association functional class I. One patient (5%) needed valve replacement for recurrent aortic regurgitation 2.6 years after the David procedure. In the remaining patients (95%), freedom from aortic regurgitation of grade 2 or greater was 100% at 3 years (regurgitation grade <1, 14 of 17; 82%). Aortic valve gradients were clinically insignificant at 5.8 ± 2.1 mm Hg. CONCLUSIONS: Performing a David procedure was successful in the vast majority of patients with dilatation of the pulmonary autograft after a Ross operation and revealed good function of the preserved autograft at midterm follow-up. Reoperations could be performed with low perioperative morbidity and mortality.

The David procedure in different valve pathologies: a single-center experience in 236 patients.

BACKGROUND: Reports of the long-term outcome after the David procedure in different valve pathologies are limited. We compared our results in patients with tricuspid and bicuspid aortic valves, including those who required additional cusp repair. METHODS: Between 1997 and 2011, 236 patients (76% males; mean age, 56 ± 15; range, 12 to 79 years) underwent valve-sparing aortic root replacement (David procedure) for aortic regurgitation and were prospectively followed up clinically and echocardiographically. RESULTS: The follow-up was 94% complete. Cumulative follow-up time was 896 patient-years (mean follow-up time, 4.5 ± 2.7; range, 0.6 to 13.7 years). The 30-day mortality was 1.7% (4 of 236), and late mortality was 4% (10 of 232), with one cardiac-related death due to aortic valve regurgitation. Overall freedom from valve replacement was 94% and 87% at 5 and 10 years, respectively. In 201 patients with tricuspid aortic valves, freedom from reoperation was 94% and 90% at 5 and 10 years, respectively. This was comparable to the 53 patients with bicuspid aortic valves, with a freedom from reoperation of 97% at 5 years (p = 0.632). Forty-two patients (18%) required additional cusp repair and had a 100% freedom from reoperation at 5 years. Overall, 10 patients (4%) required reoperation, with a mean interval of 11.5 ± 10.7 months. Reasons for reoperation were recurrent aortic valve regurgitation grade II (n = 6), aortic stenosis (n = 2), endocarditis (n = 1), and a ruptured central plication (n = 1). CONCLUSIONS: The David procedure revealed excellent long-term outcomes independently from the valve morphology. Rates of reoperations and valve-related morbidity were acceptably low. Additional cusp repair was no predictor for failure of this procedure.

Approaching a paradigm shift: endoscopic ablation of lone atrial fibrillation on the beating heart.

BACKGROUND: Percutaneous catheter ablation has been the preferred treatment strategy for many patients with symptomatic drug-refractory atrial fibrillation (AF). However, incomplete ablation lines and varying success rates remain a problem in certain subgroups. This article evaluates the feasibility and efficacy of endoscopically performed left atrial ablation in patients with lone AF. METHODS: Epicardial bipolar radiofrequency ablation was performed on the beating heart through a bilateral endoscopic approach in 89 consecutive patients with lone AF. This included isolation of the pulmonary veins using a clamp; isolation of the posterior left atrial wall, including a trigonal line to the aortic noncoronary sinus using a linear ablation device; and resection of the left atrial appendage (LAA). Preoperative, perioperative, and postoperative data were collected prospectively and included questionnaires and 24-hour Holter monitoring at 6 and 12 months and annually thereafter. RESULTS: Mean follow-up was 12±6 months (range, 4-28 months). No patients were lost to follow-up. Mean duration of AF was 6.4±5.7 years, with 35% paroxysmal AF and 65% persistent or long-standing persistent AF. Mean operation time was 180±43 minutes. There were no deaths, no conversion to sternotomy, and no early or late stroke. Freedom from AF was 88%, 90%, and 90% at 6, 12, and 24 months, respectively. Freedom from AF without antiarrhythmic drugs was 71%, 82%, and 90% at 6, 12, and 24 months, respectively. CONCLUSIONS: Endoscopic radiofrequency ablation on the beating heart reveals high success rates with low procedure-related morbidity. For improvement of future treatment strategies, a randomized trial is advisable to compare this procedure with catheter ablation in certain patient subgroups.