Twenty-five years' experience with isolated bicuspid aortic valve repair: impact of commissural orientation.

OBJECTIVES: Repair of the bicuspid aortic valve (BAV) has evolved in the past 25 years. The aim of this study was to review and analyse the long-term durability of isolated BAV repair with particular focus on commissural orientation (CO). METHODS: All patients who underwent BAV repair for severe aortic regurgitation between October 1998 and December 2022 were included. The study group consists of all patients operated after 2009, i.e. since CO modification. The control group includes patients who were operated before 2009. CO was classified as symmetric, asymmetric and very asymmetric. RESULTS: Overall, 594 adult patients (93% male; mean age 42 years) were included. At 15 years, survival was 94.8% [standard deviation (SD): 2.2]; freedom from reoperation was 86.8% (SD: 2.3). Freedom from aortic insufficiency ≥II was 70.8% (SD: 4.7) at 15 years. Modification of CO by sinus plication was performed in 200 (33.7%) instances. Using competing risks analysis, the absence of effective height measurement (P = 0.018), very asymmetric CO (P = 0.028), the presence of calcification (P < 0.001), the use of pericardial patch (P < 0.001), the use of subcommissural sutures (P < 0.001) and preoperative endocarditis (P = 0.005) were identified as independent predictors for reoperation. Follow-up was 97% complete (4228 patient-years); mean follow-up was 7 years (SD: 5). CONCLUSIONS: Isolated BAV repair leads to good survival and durability in all morphologic types if cusp repair is guided by effective height, suture annuloplasty is performed, and CO is modified using sinus plication in asymmetrical valves. Very asymmetrical valves may should be treated with a lower threshold for replacement.

Segmental analysis of aortic basal ring dimensions in normal and dilated tricuspid aortic roots.

OBJECTIVES: In patients with aortic root aneurysm, the aortic basal ring is frequently dilated. It has been speculated that the muscular part of the basal ring dilates most. The purpose of this study was to analyse the segmental dilatation of the basal ring, comparing normal and dilated roots in patients with tricuspid aortic valves. METHODS: Retrospective analysis of computed tomography studies in patients with normal and dilated aortic roots was performed. Lengths of segments of the basal ring corresponding to each of the 3 sinuses, and to the muscular and fibrous parts were measured. Fractions of these segments relative to the total basal ring perimeter were calculated. RESULTS: We analysed 152 normal and 126 dilated aortic roots and 86 propensity-matched pairs. Basal ring dilatation was present in all segments of dilated aortic roots with subtle differences between the segments corresponding to the 3 sinuses. The muscular part of the basal ring dilated proportionately to its fibrous part, with no difference in fractions of measured muscular part in normal and dilated roots [42.2% (interquartile range 4.3%) vs 42.1% (interquartile range 6.3%)]. CONCLUSIONS: Basal ring dilatation was present in all segments corresponding to the 3 sinuses in dilated aortic roots. Both muscular and fibrous parts dilated equally, supporting the need to stabilize the entire basal ring when performing aortic valve repair surgery.

Systematic adjustment of root dimensions to cusp size in aortic valve repair: a computer simulation.

OBJECTIVES: Aortic valve repair requires the creation of a normal geometry of cusps and aortic root. Of the different dimensions, geometric cusp height is the most difficult to change while annular and sinotubular dimensions can be easily modified. The objective of this study was to investigate, by computer simulation, ideal combinations of annular and sinotubular junction size for a given geometric height. METHODS: Based on a literature review of anatomical data, a computational biomechanics model was generated for a tricuspid aortic valve. We aimed to determine the ideal relationships for the root dimensions, keeping geometric height constant and creating different combinations of the annular and sinotubular junction dimensions. Using this model, 125 virtual anatomies were created, with 25 different combinations of annulus and sinotubular junction. Effective height, coaptation height and mechanical cusp stress were calculated with the valves in closed configuration. RESULTS: Generally, within the analysed range of geometric heights, changes to the annular diameter yielded a stronger impact than sinotubular junction diameter changes for optimal valve configuration. The best results were obtained with the sinotubular junction being 2-4 mm larger than the annulus, leading to higher effective height, normal coaptation height and lower stress. Within the range tested, stenosis did not occur due to annular reduction. CONCLUSIONS: In tricuspid aortic valves, the geometric height can be used to predict ideal post-repair annular and sinotubular junction dimensions for optimal valve configuration. Such an ideal configuration is associated with reduced cusp stress.

Late-Onset Prosthetic Endocarditis with Paraaortic Abscess Caused by Cutibacterium acnes.

Cutibacterium acnes, an integral component of the skin's customary bacterial flora, represents a Gram-positive anaerobic bacterium characterized by its low virulence. Despite its low virulence, the pathogen can cause profound-seated infections as well as infections linked to medical devices. We report a case study of a prosthesis endocarditis accompanied by a paraaortic abscess caused by C. acnes, a development occurring five years prior to composite aortic root and valve replacement. At the point of admission, the patient presented with a combination of symptoms hinting at a subacute progression, such as weight loss, chest pain, and limitations of cardiopulmonary functionality. An anaerobic pathogen, namely C. acnes, was detected in a singular blood culture vial. Since first-line imaging modalities such as echocardiography did not reveal any signs of inflammation, and in the case of a suspected diagnosis for IE, did not show high pretest probability, further diagnostic imaging such as 18F-FDG PET CT was put to use. Here, a highly elevated glucose metabolism around the aortic valve ring was detected, pointing to an inflammatory process. The patient received adjusted intravenous antibiotic therapy over a course of six weeks; he then underwent surgical therapy via re-replacement of the aortic root and valve using a composite conduit. Advanced microbiological analyses, including the amplification of PCR and valve sequencing via 16S rDNA, mainly detected one pathogen: C. acnes. Delayed onset with mild symptoms and laboratory findings is characteristic of infective endocarditis by C. acnes. Due to its high rate of complications, mortality, and morbidity, an infection should not be disregarded as contamination. Recommendations from different studies underline a combination of a positive blood culture and microbiological evidence to differentiate between contamination and true infection in the case of an infection involving C. acnes. Serial blood cultures with prolonged incubation, advanced microbiological analyses, and modified Duke criteria including second-line imaging techniques should be utilized for further evaluation.

Valve-sparing aortic root replacement-for all patients?

BACKGROUND: Valve-sparing root replacement (VSRR) has been associated with good survival and low rates of valve-related complications (VRCs). Whether these advantages are present irrespective of patient comorbidity or age is unclear. The aim of this study was to analyze survival and frequency of VRCs in relation to patient comorbidity and age. METHODS: Between October 1995 and December 2021, 1156 patients with a bicuspid or tricuspid aortic valve were treated by root remodeling. The mean patient age was 53.3 ± 14 years, and 973 (84%) were male. The mean duration of follow-up was 6.7 ± 5.5 years (median, 5.9 years), and follow-up was 95% complete (7746 patient-years). We analyzed the population according to comorbidity and age at surgery. A discriminating cutoff for the effect of age was determined using receiver operating characteristic curve (ROC) analysis. RESULTS: Mean survival at 15 years was 74.7 ± 2.5%. Deceased patients were older (mean, 65.3 ± 12 years vs 51.6 ± 14.1 years; P < .001) at the time of surgery and had more comorbidities (coronary artery disease [CAD], 28.4% vs 9.8%; P < .001). The sole significant adjusted predictor was age (P < .001). By ROC analysis (area under the curve, 0.780), the optimal cutoff for age was 61 years. Survival was 87.1 ± 2.8% at 15 years in patients age <61 years, compared to 55.3 ± 4.3% in patients age >61 years (P < .0001). Using competing risk analysis, VRC-free survival at 15 years was 66.8% at 15 years, including 76.7% in patients age <61 years and 52.4% in those age >61 years (P < .0001). CONCLUSIONS: VSRR is associated with a low incidence of VRC and excellent durability. Survival is decreased in the presence of comorbidities, mainly CAD, and patient age >61 years. Despite lower survival, freedom from VRC is good.

Aortic root remodeling.

Aortic root remodeling was originally designed in the late 1980s to treat patients with tricuspid aortic valves (TAVs), aortic regurgitation (AR), and root aneurysm to normalize root dimensions. The late results showed a relevant proportion of patients who required reoperation for recurrent AR. Later observations revealed that cusp prolapse is frequently present after correction of root dilatation. We showed that such prolapse could be detected by measuring effective height (eH) and corrected by concomitant cusp repair. In the past 13 years, we have added a suture annuloplasty to improve aortic valve function further. The operation starts with ascertaining adequate cusp size by measuring geometric cusp height. The dilated aortic wall is resected, and a Dacron graft is tailored to create three tongues. These tongues are sutured to the cusp insertion lines. Starting the suture in the nadir allows for easy extension of tongue length to avoid commissural height restriction. A suture annuloplasty is added at nadir level and tied around a Hegar dilator to normalize annular diameter. The valve is assessed visually and by measuring eH. Cusp prolapse (eH <9 mm) is frequent and corrected by free margin plication until all free margins are at equal level and eH is 9 mm. We have employed root remodeling in more than 710 instances of root aneurysm and TAVs. Mean myocardial ischemic time has been 65±13 minutes for isolated remodeling, operative mortality has been 1.5% for elective procedures. With suture annuloplasty, 10-year freedom from reoperation is 95%, even without suture annuloplasty 20-year freedom from reoperation is 85%. In our experience, root remodeling has been a valid form of valve-preserving surgery with low morbidity and mortality and excellent long-term results.

Prolapse repair for aortic regurgitation in tricuspid aortic valves.

OBJECTIVE: Cusp prolapse is an important cause of aortic regurgitation (AR) in tricuspid aortic valves (TAVs) and can be caused by myxomatous degeneration or cusp fenestration. Long-term data for prolapse repair in TAVs are scarce. We analyzed the results of aortic valve repair in patients with TAV morphology and AR caused by prolapse and compared the results for cusp fenestration and myxomatous degeneration. METHODS: Between October 2000 and December 2020, 237 patients (221 male; 15-83 years) underwent TAV repair for cusp prolapse. Prolapse was associated with fenestrations in 94 (group I) and myxomatous degeneration in 143 patients (group II). Fenestrations were closed using a pericardial patch (n = 75) or suture (n = 19). In myxomatous degeneration, prolapse was corrected by free margin plication (n = 132) or triangular resection (n = 11). Follow-up was 97% complete (cumulatively 1531, mean 6.5, median 5.8 years). Cardiac comorbidities were present in 111 patients (46.8%), and more frequent in group II (P = .003). RESULTS: Ten-year survival was better in group I (I: 84.5%; II: 72.4%; P = .037), and patients without cardiac comorbidities (89.2% vs 67.0%; P = .002). Ten-year freedom from reoperation (P = .778), moderate or greater AR (P = .070), and valve-related complications (P = .977) were similar in both groups. AR at discharge was the only significant predictor for reoperation (P = .042). The type of annuloplasty did not affect repair durability. CONCLUSIONS: Repair of cusp prolapse in TAVs with preserved root dimensions can be performed with acceptable durability, even in the presence of fenestrations.

Remodeling of the aortic root-a 28-year journey.

Background: Root remodeling is one form of valve-preserving root replacement for aortic regurgitation and root aneurysm. The objective of this review was to summarize our experience with root remodeling encompassing 28 years. Methods: We performed root remodeling in 1,189 patients (76% male, mean age 53±14 years) between October 1995 and September 2022. The original valve morphology was unicuspid in 33 (2%), bicuspid in 472 (40%) and tricuspid in 684 (58%) patients. Fifty-four patients (5%) had Marfan's syndrome. Objective measurement of valve configuration was performed in 804 (77%) and an external suture annuloplasty was added in 524 patients (44%). Cusp repair was performed in 1,047 (88%) patients, most commonly for prolapse (n=972; 82%). Mean follow-up was 6.7±5.5 years [1 month to 28 years]. Follow-up was 95% complete (7,700 patient-years). Results: Survival was 71% at 20 years; freedom from cardiac death was 80%. Freedom from aortic regurgitation ≥2 was 77% at 15 years. Freedom from reoperation was 89% and was higher in tricuspid aortic valves (94%) compared to bicuspid (84%) and unicuspid valves (P<0.001). Since the introduction of effective height measurement, freedom from reoperation has remained stable at 15 years (91%). With the addition of a suture annuloplasty, freedom from reoperation was 94% at 12 years. The difference with or without annuloplasty (91%) was not significant (P=0.949). Conclusions: Root remodeling is a viable option in valve-preserving root replacement. Concomitant cusp prolapse is frequent and can be corrected reproducibly by intraoperative measurement of effective height. The long-term benefit of an annuloplasty still needs to be defined.

Twenty-five years of root remodelling for root aneurysm and tricuspid aortic valve.

OBJECTIVES: The aim of this retrospective study was to assess the long-term results of root remodelling with tricuspid aortic valves and the effects of concomitant cusp repair and annuloplasty. METHODS: Between October 1995 and December 2021, 684 patients with root aneurysm and regurgitant tricuspid valves were treated by root remodelling. The mean age was 56.5 [standard deviation (SD): 14] years, and 538 (77.6%) were male. Relevant aortic regurgitation was present in 68.3%. Concomitant procedures were performed in 374 patients. The long-term results were analysed. The mean follow-up of 7.2 (SD: 5.3) years (median 6.6 years); it was 95% complete (4934.4 patient-years). RESULTS: Cusp prolapse was repaired in 83%, and an annuloplasty was added in 353 instances (51.6%). Hospital mortality was 2.3%, and survival was 81.7% (SD: 1.2) and 55.7% (SD: 5.8) at 10 and 20 years; age and measurement of effective height were independent predictors for death. Freedom from Aortic insufficiency (AI) II was 90.5 (SD: 1.9) at 10 years and 76.7 (SD: 4.5) at 20 years. Cusp repair of all cusps showed a lower freedom from recurrent AI ≥II at 10 years (P < 0.001). Suture annuloplasty showed a lower freedom from recurrent AI II at 10 years (P = 0.07). Freedom from reoperation was 95.5 (SD: 1.1) and 92.8 (SD: 2.8) at 10 and 20 years. The addition of an annuloplasty showed no difference (P = 0.236). Cusp repair had no effect on valve durability (P = 0.390). CONCLUSIONS: Root remodelling leads to good long-term stability. The addition of cusp repair improves the valve stability over time. The addition of suture annuloplasty improves early valve competency; it showed no effect on freedom from reoperation up to 10 years.

The Ross procedure versus repair for treatment of a unicuspid aortic valve in adults†.

OBJECTIVES: Aortic stenosis or regurgitation in patients with a unicuspid valve morphology requires interventions early in life. We have performed either primary valve repair or the Ross procedure. The goal of this study was to compare the midterm results of repair and pulmonary autograft replacement. METHODS: Between December 1998 and April 2022, a total of 345 patients (77% male; mean age 34 ± 9.7 years) underwent treatment of a unicuspid aortic valve. Patients were excluded if they were <18 years (n = 84) or >54 years (n = 3) at the time of the operation. The remaining cohort was divided into 2 groups: 167 (64%) patients underwent valve repair; 91 (36%) patients underwent pulmonary autograft replacement.The indications for surgery were aortic regurgitation (n = 104), aortic stenosis (n = 45), combined disease (n = 103) and endocarditis (n = 6). Fifty-one patients had root dilatation (>43 mm) with aortic regurgitation (repair n = 23; Ross n = 28). Mean follow-up was 5.9 years (SD: 5 years) [range 0.1-22.3 years]. RESULTS: There were 1 early and 3 late deaths; 47 patients required reintervention. Survival at 10 years was 95% in the Ross group and 97% after valve repair (P = 0.769). Freedom from reintervention at 10 years was 98% in the Ross group and 80% after valve repair (P = 0.012). A receiver operating characteristics curve analysis showed a trend towards better durability in patients < 26 years. CONCLUSIONS: The ideal treatment of the unicuspid aortic valve remains debatable. Repair of a unicuspid valve can be considered a bridge to pulmonary autograft replacement, at least in younger patients. The appropriate times to replace and to repair require further investigation.

Significance of Effective Height and Mechanism of Regurgitation in Tricuspid Aortic Valve Repair.

BACKGROUND: Isolated repair of the regurgitant tricuspid aortic valve has become an increasingly practiced alternative to replacement, even though durability data are scarce. We analyzed the midterm results of tricuspid aortic valve repair to determine whether the mechanism of regurgitation or operative technique influences the results. METHODS: Between December 1997 and August 2014, 264 patients underwent isolated tricuspid aortic valve repair in our institution. The mean age was 59 ± 16 years; 77% (n = 203) were male. Clinical and operative data were recorded. The patients were observed clinically and echocardiographically. RESULTS: Survival was 76.7% ± 3.5% after 10 years and 57.2% ± 11.5% after 15 years (median, 224 months). Intraoperative measurement of effective height was significantly associated with improved long-term survival (P = .001). Cumulative freedom from reoperation was 88.1% ± 2.1% after 5 years and 73.3% ± 4.2% after 10 years. Freedom from recurrent aortic regurgitation 2+ was 85.9% ± 5.2% after 5 years and 66.9% ± 5.2% after 10 years. Freedom from reoperation was significantly higher in patients with cusp prolapse compared with retraction as the primary regurgitation mechanism (P = .041). The use of circular annuloplasty had no significant influence on survival or durability. CONCLUSIONS: Long-term survival after tricuspid aortic valve repair is good, considering the age of the patients. Repair of cusp retraction has a poorer durability compared with repair of prolapse. The use of effective height in tricuspid aortic valve repair is associated with improved survival.

Aortic cusp abnormalities in patients with trileaflet aortic valve and root aneurysm.

BACKGROUND: The frequency of concomitant cusp pathology in aortic root aneurysm with or without aortic regurgitation is not well known, and the sensitivity and specificity of two-dimensional trans-oesophageal echocardiography (2D TEE) in its detection has not yet been specified. OBJECTIVES: We analysed the type and frequency of concomitant cusp alterations in root aneurysm referred for surgery. Sensitivity and specificity of 2D TEE in detecting these alterations were determined. METHODS: In 582 patients (age 56.8±15.4 years, 453 male) with trileaflet aortic valves undergoing root replacement for regurgitation (n=347) or aneurysm (n=235), details of valve morphology were analysed. In a subcohort (n=281), intraoperative TEEs were analysed retrospectively and correlated with the intraoperative findings. RESULTS: Any cusp pathology was present in 90.9% (prolapse: n=473; retraction: n=30; calcification: n=14; fenestration: n=12), morphologically normal cusps were seen in only 52 patients (8.93%). Valve-sparing surgery was performed in 525 (90.2%) instances, composite replacement in 57 (9.8%). Preoperative TEE correctly identified any postroot repair prolapse in 70.6% and any retraction in 85%. The sensitivity of TEE in detecting any prolapse was 68.6% (specificity of 79.5%). The sensitivity was highest for the right cusp and intermediate for the non-coronary. CONCLUSIONS: Cusp prolapse is frequent in root aneurysm and trileaflet aortic valves. Prolapse is underdiagnosed by 2D TEE in many cases because pre-existent stretching of cusp tissue is masked by the geometric effects of root dilatation.

Endovascular Rescue Aortic Fenestration After Accidental False Lumen TEVAR in Type B Dissection.

PURPOSE: Unintended false-lumen thoracic endovascular aortic repair (TEVAR) is under-reported and often fatal. We present percutaneous endovascular rescue techniques for true-lumen reperfusion with strategies to address the peripheral artery perfusion needs unique to each case. CASE REPORT: Two patients deteriorated 24 hours after uncomplicated and complicated acute aortic type-B dissection TEVAR treatment at a tertiary community hospital. Reevaluation of index and repeated imaging studies revealed inadvertent false-lumen TEVAR with severe visceral and peripheral ischemia. Stepwise subtraction angiography was used to confirm continuous true-lumen catheterization from femoral puncture into the thoracic aorta. Retrograde fenestration distal to the misplaced TEVAR from the true- into the false-lumen allowed for snorkeling by distal stent-extension across the dissection membrane. In one case, TEVAR stent graft extension resulted in true-lumen re-expansion and in the other case, bare-metal stent-extension for stabilization of the dissection membrane resulted in true-lumen re-expansion in addition to preservation of visceral and peripheral perfusion via the false-lumen. Despite excellent acute hemodynamic results and initial signs of recovery, both patients eventually died (multiorgan failure; cerebral hemorrhagic infarction). CONCLUSION: Correct indication and prompt recognition of potential inadvertent false-lumen stenting is critical to avoid disastrous sequelae, for example, malperfusion. Endovascular salvage is feasible for restoration of correct perfusion and must be performed in a timely manner. CLINICAL IMPACT: Clinically apparent, complicated type-B dissection necessitates instantaneous treatment. Prerequisite for an endovascular approach is a true-lumen guidewire continuously from access to the ascending aorta. DSA after TEVAR and prompt clinical re-evaluation are to verify effective visceral and peripheral restoration of blood flow. Despite these measures, inadvertent false-lumen TEVAR may occur rarely. Immediate recognition may allow for timely true-lumen re-expansion using percutaneous endovascular salvage techniques e.g. retrograde fenestration from the true- into the false-lumen for distal snorkeling of the misplaced TEVAR across the dissection membrane. However, morbidity and mortality are very high, if erroneous stent graft placement is not identified early.

Failures of Valve-sparing Aortic Root Replacement Using the Root Remodeling Technique.

BACKGROUND: Valve failure may occur after valve-sparing aortic root replacement. Little is known about the exact mechanisms of failure. This study analyzed reoperations after aortic root remodeling to determine failure modes, operative risk, and long-term outcome. METHODS: Between November 1995 and December 2019, 1084 patients were treated by root remodeling. Of these, 54 (49 male; aged 8 to 79 years) underwent reoperation for valve failure (1 week to 16 years postoperatively). The indications for reoperation were aortic regurgitation (n = 39), aortic stenosis (n = 6), endocarditis (n = 7), or ventricular septal defect (n = 2). The main causes of valve failure were cusp repair failure (n = 29), endocarditis (n = 7), and cusp retraction (n = 8). The patients were treated by valve replacement (n = 40) or cusp repair (n = 14). In 6 individuals, combined replacement of valve and root was performed. All 54 patients were followed up (mean, 69 ± 54 months after reoperation), and 1 patient was lost to follow-up. RESULTS: No patient died in the hospital or had atrioventricular block development; 12 patients died late, with 10- and 15-year survivals of 87% ± 5.1% and 64% ± 10.6%, respectively. Of the 14 patients who underwent repeat cusp repair, 7 (50%) are still alive with stable valve function, 17 months to 15 years after their reoperation. Eleven patients required a second reoperation leading to a freedom from repeat reintervention rate of 68% ± 9.7% at 15 years. CONCLUSIONS: The main causes of failure of root remodeling are cusp related. Reoperations can be performed with low morbidity and mortality. In selected patients, isolated cusp repair may be an option.

A New Technique of Aortoventricular Patch Enlargement and Root Replacement for Annular Hypoplasia.

The Ross-Konno operation is effective for enlargement of a hypoplastic aortic annulus and left ventricular outflow tract. It is, however, an invasive operation with the potential for early and late cardiac morbidity. We propose a new technique of annular and outflow tract enlargement that avoids the septal incision while effectively opening up the outflow tract and aortic annulus.

Which Aortic Valve Can Be Surgically Reconstructed?

PURPOSE OF REVIEW: Preservation or repair of the aortic valve has evolved dynamically in the past 20 years. It leads to a high freedom from valve-related complications if an adequate valve durability can be achieved; it may possibly also improve survival. To date, little structured information is available about which valves can be repaired and which should better be replaced. RECENT FINDINGS: For surgical decision-making, the size of the aortic root is important and the anatomy of the aortic valve must be considered. In the presence of root aneurysm, most tricuspid and bicuspid aortic valves can be preserved. In aortic regurgitation and normal aortic dimensions, the majority of tricuspid and bicuspid aortic valves can be repaired with good long-term durability. In bicuspid aortic valves, the morphologic characteristics must be taken into consideration. Unicuspid and quadricuspid aortic valves can be repaired in selected cases. Generally, cusp calcification is a sign of a poor substrate for repair; the same is true for cusp retraction and cusp destruction due to active endocarditis. They are associated with limited valve durability. Using current concepts, many non-calcified aortic valves can be repaired. Modern imaging, in particular three-dimensional transesophageal echocardiography (TEE), should be able to define repairable aortic valves with a high probability.

Graft Dilatation May Cause Secondary Regurgitation in Aortic Valve-Sparing Operations.

Aortic valve-sparing operations are meant to stabilize the root in order to provide stable aortic valve function. The possibility of graft dilatation has been known in other forms of aortic replacement but is largely ignored in valve-preserving surgery. We describe graft dilatation as a cause of failure late after aortic valve reimplantation. It was corrected by applying the concepts of aortic valve repair.

Aortic Root Remodeling in Acute Aortic Dissection.

OBJECTIVES: To evaluate the long-term results of remodeling in acute aortic dissection type A (AADA) to define operative risk and root and valve stability. METHODS: Between October 1995 and December 2018, a total of 352 patients were treated surgically for AADA. Of these, 90 patients with AADA (<2 weeks from onset; age: 57 ± 15 years; 70 males) with a root diameter of >43 to 45 mm (depending on patient size) (48 ± 4.1 mm) underwent aortic root remodeling and were analyzed further. As the control group, we chose the patients with normally sized aortic roots who had been treated by tubular replacement only (n = 227). Other procedures were performed in 35 cases. RESULTS: Early mortality was 9% in the remodeling group versus 15% in the tubular ascending aortic replacement (TAR). Actuarial survival at 10 and 15 years was 68 ± 5% and 58.3 ± 6.4%, respectively, in the root remodeling group versus 68 ± 4% and 66 ± 4% in the TAR group (p = 0.99). Freedom from reoperation on the aortic valve or root was 95 ± 3% at 10 years and at 89 ± 6% at 15 years. Freedom from proximal reoperation after TAR at 10 and 15 years was 93 ± 3% and 91 ± 3% (n = 31 patients at risk), respectively, not statistically different from that after remodeling (p = 0.75). CONCLUSIONS: The long-term stability of aortic root remodeling for enlarged roots with AADA was comparable to TAR preserving a normal aortic root.

Aortic root remodeling in bicuspid and tricuspid aortic valves-long-term results.

BACKGROUND: Root remodeling is one form of valve-preserving root replacement to treat patients with aortic regurgitation (AR) and root aneurysm. We have consistently used it for patients with and without connective tissue disease and different aortic valve morphologies. The objective of this retrospective study was to review 23 years of experience with root remodeling. METHODS AND PATIENTS: Between 10/95 and 9/2018, 1004 of 1038 root remodeling procedures were performed in patients with tricuspid (n = 589) or bicuspid (n = 414) anatomy of the aortic valve in our institution. Aortic aneurysm was present in 932 cases, 73 procedures were performed for acute aortic dissection type A. The severity of aortic regurgitation ranged from grade I to grade IV (mean 2.5 ± 0.8). RESULTS: All patients underwent root remodeling, concomitant operations were performed in 433, and cusp repair in 883 instances. Hospital mortality was 2%. Overall freedom from reoperation was 92% at 10 years and 89% at 15 years. It was 94% for tricuspid valves at 10 and 15 years, and 88% for bicuspid aortic valves at 10 years and 80% at 15 years (p = 0.003). CONCLUSION: In conclusion, root remodeling is a viable option in valve-preserving root replacement. If combined with careful assessment and, if necessary, correction of aortic valve form reproducible restoration of aortic valve function can be achieved.