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Long-term experience with valve-sparing reimplantation technique for the treatment of aortic aneurysm and aortic regurgitation

Open ArchivePublished:November 26, 2018DOI:https://doi.org/10.1016/j.jtcvs.2018.10.155

      Abstract

      Objective

      To analyze our long-term experience with valve-sparing reimplantation technique for the treatment of isolated root aneurysm, aneurysm with significant aortic regurgitation, and for isolated aortic regurgitation.

      Methods

      Between 1999 and 2017, 440 consecutive patients underwent valve-sparing reimplantation in our institution. The mean age of this cohort was 49 ± 15 years. Time-to-event analysis was performed with the Kaplan-Meier method, whereas significant predictors of late outcomes were explored with Cox proportional hazard model.

      Results

      In-hospital mortality was 0.7% (n = 3). Four hundred fourteen patients were available for long-term analysis. Median duration of follow-up was 5 years (interquartile range, 2-8.5 years). Thirty-six patients (8.5%) died during follow-up; therefore, survival was 79.7% ± 3.8% at 10 years. During follow-up we observed a linearized rate of 0.37%, 0.73%, and 0.2% patient-year, respectively, for major bleeding, thromboembolic events, and infective endocarditis. Nineteen patients required late aortic valve reoperation and freedom from valve reoperation was 89.6% ± 2.9% at 10 years and was not significantly different between groups or between tricuspid or bicuspid valve phenotypes.

      Conclusions

      Our study shows that valve-sparing reimplantation is associated with low perioperative mortality, a remarkably low rate of valve-related complications, and excellent long-term durability. Further, it can be safely performed also in patients with isolated aortic regurgitation and the durability of valve repair is similar regardless of the indication for surgery of valve phenotype.

      Key Words

      Abbreviations and Acronyms:

      AR (aortic regurgitation), AV (aortic valve), BAV (bicuspid aortic valve), LVEDD (left ventricle end diastolic volume), NYHA (New York Heart Association), STJ (sinotubular junction), TAAD (type A acute aortic dissection), VAJ (ventriculoaortic junction), VSR (valve sparing root replacement with the reimplantation technique)
      Figure thumbnail fx1
      A bicuspid AV reimplanted into a Valsalva graft and central plication of both cusps.
      Aortic valve sparing with the reimplantation technique is associated with excellent long-term results that are similar regardless of the indication for surgery or valve phenotype.
      Aortic valve-sparing root replacement with the reimplantation technique is questioned in cases of severe AR with or without root dilatation. Nonetheless valve reimplantation provides fixing of the functional aortic annulus at both the VAJ and STJ. This analysis shows that VSR can be safely performed also in patients with severe AR with or without root dilatation and provide excellent results.
      See Commentaries on pages 24 and 25.
      Valve-sparing aortic root replacement with the reimplantation technique (VSR) has emerged as an attractive alternative to valve replacement in patients with aortic root aneurysm.
      • David T.E.
      • Feindel C.M.
      An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta.
      • David T.E.
      • Feindel C.M.
      • Bos J.
      Repair of the aortic valves in patients with aortic insufficiency and aortic root aneurysm.
      VSR can reduce the risk of prosthesis-related complications, including thromboembolism, endocarditis, and anticoagulation-related hemorrhage.
      • Minakata K.
      • Schaff H.V.
      • Zehr K.J.
      • Dearani J.A.
      • Daly R.C.
      • Orszulak T.A.
      • et al.
      Is repair of aortic valve regurgitation a safe alternative to valve replacement?.
      • Aicher D.
      • Fries R.
      • Rodionycheva S.
      • Schmidt K.
      • Langer F.
      • Schafers H.J.
      Aortic valve repair leads to a low incidence of valve-related complications.
      • Price J.
      • de Kerchove L.
      • Glineur D.
      • Vanoverschelde J.L.
      • Noirhomme P.
      • El Khoury G.
      Risk of valve-related events after aortic valve repair.
      Further, repaired native valve supposedly has a better hemodynamic profile and potentially better survival than any valve prosthesis.
      • Kvidal P.
      • Bergstrom R.
      • Horte L.G.
      • Stahle E.
      Observed and relative survival after aortic valve replacement.
      However, the durability of the aortic valve (AV) is questioned in the presence of severe or eccentric aortic regurgitation (AR) that is usually associated with cusp disease. Further, because of its technical complexity, VSR is not usually considered for the treatment of AR without root dilatation.
      The aim of this study was to analyze our long-term experience with VSR for the treatment of root dilatation without significant AR (ie, the conventional indication), root dilatation with severe AR (ie, debated indication), and also for the treatment of isolated AR (ie, nonconventional indication).

      Materials and Methods

      This observational cohort study with unidentified patient data was approved by the review ethics board of our hospital and a waiver of consent was obtained. All adult patients who underwent VSR between 1998 and January 2017 at our institution were included in this analysis. The VSR operation was considered for all patients presenting with aortic root aneurysm or severe AR at our institution during the study period.
      Clinical follow-up data were collected by telephone contact with the patient or the referring physician. Subsequent hospitalization and routine visit data were collected from hospital records and cardiologist reports.
      Morbidity and mortality were reported according to the 2008 Society of Thoracic Surgeons/American Association for Thoracic Surgery/European Association for Cardio-Thoracic Surgery guidelines.
      • Akins C.W.
      • Miller D.C.
      • Turina M.I.
      • Kouchoukos N.T.
      • Blackstone E.H.
      • Grunkmeier G.L.
      • et al.
      Guidelines for reporting mortality and morbidity after cardiac valve interventions.
      Early mortality was defined as any death occurring during hospital stay or during the first 60 days after the operation; any other death was considered a late death. Clinical outcomes of interest included the incidence of systemic embolism, major bleeding events, endocarditis, and reoperation on the AV for any cause.

      Surgical Technique

      VSR has been previously described in detail.
      • de Kerchove L.
      • Nezhad Z.M.
      • Boodhwani M.
      • El Khoury G.
      How to perform valve sparing reimplantation in a tricuspid aortic valve.
      Briefly, after aortic crossclamp and cardioplegic arrest of the heart, a horizontal aortotomy 1 cm above the sinotubular junction (STJ) is performed and the valve is carefully examined. External root dissection and preparation is followed by excision of the Valsalva sinuses. The proximal suture line is therefore carried out with 10 to 12 pledget stitches at the level of the ventriculoaortic junction (VAJ). The size of the vascular graft is then chosen by means of the height of the commissure at the level of the noncoronary/left-coronary commissure as previously described.
      • de Kerchove L.
      • Boodhwani M.
      • Glineur D.
      • Noirhomme P.
      • El Khoury G.
      A new simple and objective method for graft sizing in valve-sparing root replacement using the reimplantation technique.
      After completion of the proximal suture line, the valve is reimplanted within the graft starting from the 3 commissures. The valve is then reexamined and residual prolapse or any other lesion is addressed and corrected. The techniques of cusp repair have been previously described
      • de Kerchove L.
      • Glineur D.
      • Poncelet A.
      • Boodhwani M.
      • Rubay J.
      • Dhoore W.
      • et al.
      Repair of aortic leaflet prolapse: a ten-year experience.
      and consist mainly of free margin plication and free margin resuspension. The special considerations in case of bicuspid valve (BAV) have been reported elsewhere.
      • Boodhwani M.
      • de Kerchove L.
      • Glineur D.
      • Rubay J.
      • Vanoverschelde J.L.
      • Noirhomme P.
      • et al.
      Repair of regurgitant bicuspid aortic valves: a systematic approach.
      Briefly, in type 0 BAV, the symmetry of cusps and sinuses was respected during valve reimplantation. In type 1 BAV with a restrictive raphe and a deficit of cusp tissue on the conjoined cusp, the valve was made symmetric by compressing the VAJ relatively more on the side of the conjoined cusp and by reimplanting the commissures with an orientation of 180°.

      Echocardiographic Follow-up

      Serial standardized echocardiogram examinations have been performed in our institution. At follow-up transthoracic echocardiogram, AR was graded as 0 for no regurgitation, 1+ for a regurgitant volume <30 mL, 2+ for a regurgitant volume of 30 to 44 mL, 3+ for a regurgitant volume of 45 to 60 mL, and 4+ for a regurgitant volume >60 mL.

      Statistical Analysis

      Continuous variables were reported as the mean ± standard deviation for variables with a normal distribution or as median and interquartile range (IQR) for non-normal distributions. Categorical variables were reported as proportions. Between-group comparison was made with analysis of variance and post-hoc Bonferroni correction for continuous variables and with the χ2 or the Fisher exact test as appropriate for categorical variables. The follow-up time was calculated from the date of operation until either the date of death or the date of the last verified contact with the living patient. Similarly, the time to reoperation was calculated from the date of the VSR until the date of the reoperation if present or the date of the last verified contact with the patient. The time for other valve-related events was calculated until the last valid assessment of these complications. For the purpose of the study, the follow-up period was closed in June 2017 to have at least 6 months of potential follow-up for the final patients who underwent operation during 2017. Completeness of follow-up was calculated according to Clark and colleagues.
      • Clark T.G.
      • Altman D.G.
      • De Stavola B.L.
      Quantification of the completeness of follow-up.
      Length of follow-up was calculated with the reverse Kaplan-Meier method.
      • Schemper M.
      • Smith T.L.
      A note on quantifying follow-up studies of failure time.
      Seventeen patients (3.9%) were lost to follow-up following discharge from hospital. The median duration of follow-up for the full cohort was 5 years (IQR, 2-8.5 years) with a total cumulative follow-up of 2179 patient-years. The completeness of follow-up was 78%.
      Time to event analysis was performed with the product-limit method (Kaplan-Meier). Survival curves were compared with the Tarone-Ware test. A proportional hazard model (Cox regression) was used to identify significant predictors of late survival. Predictors of late AV reoperation were analyzed accounting for the competing risk of death with competing-risk regression model with the Fine-Gray method.
      • Fine J.P.
      • Gray R.J.
      A proportional hazards model for the subdistribution of a competing risk.
      The proportionality assumption was checked through the interaction of the candidate predictor with time. For the hazard of reoperation over time, the following covariates were considered: age, gender, body mass index, valve morphology, degree of aortic insufficiency, indication for surgery (ie, group), preoperative diameter of the VAJ, left ventricle end diastolic volume (LVEDD), preoperative New York Heart Association (NYHA) functional class, previous cardiac surgery, presence of connective tissue disorder, size of graft, concomitant procedures, concomitant cusp repair, and use of patch.
      For the hazard of late death, the following covariates were considered: age, gender, body mass index, valve morphology, preoperative NYHA functional class, preoperative left ventricle ejection fraction (as 4 categories: >50%, 31%-50%, 21%-30%, and <21%), LVEDD, pre-existing comorbidities (eg, chronic renal failure, pulmonary hypertension, chronic obstructive pulmonary disease, peripheral arteries disease, or diabetes), indication for surgery (ie, group), previous cardiac surgery, presence of connective tissue disorder, type A acute aortic dissection (TAAD), concomitant procedures, AV reoperation and cardiac reoperation. Reoperation on the AV was considered as a time-varying covariate. Univariable analysis was performed to identify clinical variables potentially associated with the outcome; variables that resulted significantly (P < .05) at this point were included altogether into a multivariable model to assess their independent effect.
      The longitudinal evaluation of echocardiographic data (degree of AR over time) was performed using multivariate mixed-effects ordered logistic regression allowing for random patient intercept and slope. For this analysis we considered only patients who were alive and we did not adjust for the competing risk of death but for the degree of AR at discharge from hospital; further, patients were nested into the 3 groups of interest.
      All analyses were conducted with Stata IC version 15.1 (StataCorp LP, College Station, Tex).

      Results

      Between 1999 and 2017, a total of 923 adult patients were treated for AV repair at our institution. Of them, 440 consecutive patients (47.7%) underwent VSR and are the subject of this study. For the purpose of this study patients were dived into 3 groups according to the indication for surgery: aortic root aneurysm without AR in 139 patients (31.6%) (group 1), aneurysm with significant AR in 212 (48.2%) (group 2), and isolated AR in 76 patients (17.3%) (group 3). Further, 13 patients (2.9%) presented with TAAD and make a standalone subgroup.
      Patients' characteristics and perioperative data are presented in Tables 1 and 2. Mean age for the full cohort was 49 ± 15 years and 91% of patients were men. A connective tissue disorder (mainly Marfan syndrome) was present in 34 patients who usually presented with isolated aortic aneurysm (group 1). These patients were also significantly younger than the others (35 ± 15 years vs 50 ± 14 years; P < .0001).
      Table 1Clinical characteristics of patients according to the Indication for surgery
      CharacteristicAneurysm (n = 139 group 1)Aneurysm + AR (n = 212 group 2)Isolated AR (n = 76 group 3)P value
      Mean age (y)47 ± 1451 ± 1542 ± 13.05
      Men128 (92.1)191 (90.1)70 (92.1).7
      Bicuspid AV49 (35.2)76 (55.9)52 (68.4)<.001
      Grade of aortic regurgitation<.001
       0-100
       270 (33.0)6 (7.9)
       3103 (48.6)58 (76.3)
       4139 (100)39 (18.4)12 (15.8)
      NYHA functional class<.001
       I112 (80.6)105 (49.5)41 (53.9)
       II23 (16.5)79 (37.3)30 (39.5)
       III3 (2.2)28 (13.2)5 (6.6)
       IV1 (0.7)00
      LV ejection fraction.03
       ≥50%132 (95)175 (82.5)69 (90.8)
       31%-49%7 (5)33 (15.6)7 (9.2)
       ≤30%04 (1.9)0
      LVEDD (mm)53 ± 561 ± 863 ± 7.02
      VAJ (mm)27 ± 3
      VAJ was significantly different only for group 1 versus group 3.
      28 ± 429 ± 4
      VAJ was significantly different only for group 1 versus group 3.
      .007
      VAJ was significantly different only for group 1 versus group 3.
      Previous cardiac surgery3 (2.1)4 (1.9)5 (6.6).09
      Connective tissue disorder19 (13.7)14 (6.6)1 (1.3).004
      Values are presented as mean ± standard deviation or n (%). AR, Aortic regurgitation; AV, aortic valve; NYHA, New York Heart Association; LV, left ventricle; LVEDD, left ventricle end diastolic volume; VAJ, ventriculoaortic junction.
      VAJ was significantly different only for group 1 versus group 3.
      Table 2Perioperative outcomes of patients according to the indication for surgery
      OutcomeAneurysm (n = 139 group 1)Aneurysm + AR (n = 212 group 2)Isolated AR (n = 76 group 3)P value
      Graft size (mm)303030.3
      Cardiopulmonary bypass time (min)145 ± 35150 ± 34151 ± 26.6
      Concomitant procedures37 (26.6)54 (25.5)13 (17.1).2
       Mitral valve repair5 (5.0)13 (6.1)6 (7.9)
       Hemiarch4 (2.9)12 (5.6)0
       Coronary artery bypass graft18 (0.7)9 (4.2)4 (5.2)
      Cusp repair76 (54.7)170 (80.2)74 (97.4)<.001
       Patch1 (0.7)15 (7.1)4 (5.2).02
      Re-exploration for bleeding21 (15.1)23 (10.9)8 (10.5).4
      Permanent pacemaker insertion9 (6.5)7 (3.3)5 (6.6).3
      30-d death1 (0.7)00.3
      Values are presented as median, mean ± standard deviation, or n (%). AR, Aortic regurgitation

      Early Outcomes

      The proportion of associated procedures, mainly mitral valve repair, and duration of cardiopulmonary bypass were comparable among groups. Some type of cusp repair was added in more than half of patients in each group and in almost 100% of patients with isolated AR. A pericardial patch was used in a minority of patients and almost never in patients without significant AR. Three patients (0.6%) died early after surgery (2 with preoperative TAAD) and 1 patient (0.2%) required early (during the same hospitalization) reoperation on the AV (underwent re-repair). Median follow-up in group 3 (3.5 years; IQR, 1.7-5.8 years) was shorter than in the other 2 groups (group 1: 4.7 years [IQR, 2-8.5 years] and group 2: 5.5 years [IQR, 2.2-9.7 years) revealing that VSR for isolated AV repair was introduced in our practice in more recent years.

      Late Reoperations

      Nineteen patients (4.6%) required late AV reoperation for a linearized rate of re-intervention of 0.8% patient-year. Median interval of reoperation was 5.2 years (IQR, 2.8-9.6 years). No patient died at reintervention. Indications for reoperations were recurrent severe AR (n = 9: 6 underwent AV re-repair and 3 underwent replacement), severe aortic stenosis (n = 3: all 3 underwent AV replacement), AV endocarditis (n = 4: all 4 underwent AV replacement), and severe mixed AR and stenosis (n = 3: all 3 underwent AV replacement). Freedom from reoperation on the AV was 100% at 1 year, 96.5% (95% confidence interval [CI], 93.4%-98.2%) at 5 years, and 89.6% (95% CI, 82.7%-94%) at 10 years. Freedom from reoperation was not different among groups (P = .09) and between tricuspid AV and BAV (P = .1) (Figure 1, A and B). At univariable regression analysis, only age at surgery (subdistribution hazard ratio [SHR], 0.96; 95% CI, 0.93-0.99; P = .008), preoperative LVEDD (SHR, 1.05; 95% CI, 1.00-1.1; P = .04) and connective tissue disorder (SHR, 3.5; 95% CI, 1.1-10.8; P = .03) were significant predictors of late reoperation. Due to the limited number of events, a multivariable analysis was not performed.
      Figure thumbnail gr1
      Figure 1A, Freedom from reoperation on the aortic valve by groups. At 10 years: 91% ± 5.8% for group 1, 92.2% ± 2.9% for group 2, and 65.9% ± 19.8% for group 3 (P = .2). B, Freedom from reoperation by valve morphology. At 10 years: 90.2% ± 2.9% for tricuspid aortic valve (TAV) and 88% ± 6.3% for bicuspid aortic valve (BAV) (P = .07). AR, Aortic regurgitation; AI, aortic insufficiency; CI, confidence interval.
      Three more patients underwent reoperation for mitral valve repair: 1 for coronary artery bypass grafting, 1 heart transplantation for end-stage heart failure, and 2 balloon dilatations of the pulmonary homograft (patients with previous Ross operation before VSR). Freedom from all cardiac reoperation was therefore 93.5% ± 2% at 10 years.

      Other Valve-Related Complications

      No patient presented valve thrombosis, but systemic embolism and major bleeding events occurred in 8 patients (1.9%) and 10 patients (2.3%) during follow-up for a linearized rate of 0.3% and 0.4% patient-year, respectively. Five patients (0.4%) presented infective endocarditis of the AV for a linearized rate of 0.2% patient-year.

      Long-Term Survival

      During follow-up there were 36 late deaths (8.7%) for a linearized mortality rate of 1.6% patient-year. Ten deaths were cardiac-related (4 sudden or unexplained, 3 chronic heart failure, 2 cerebral hemorrhage, and 1 following reoperation for myocardial revascularization); 26 deaths were from noncardiac causes: 10 cancer, 6 sepsis (not infective endocarditis), 2 acute type-B aortic dissection, 1 ruptured abdominal aortic aneurysm, 3 trauma, 2 chronic renal failure, 1 bowel ischemia, and 1 Parkinson disease. Overall survival is depicted in Figure 2, A, and was 95.2% (95% CI, 91.9%-97.2%) and 79.8% (95% CI, 71.1%-86.0%) at 5 and 10 years, respectively. Survival was also not different by group (Figure 2, B) after adjusting for age, preoperative NYHA functional class, left ventricle ejection fraction, and presence of connective tissue disorder (P = .3) in a multivariable Cox regression analysis (hazard ratio [HR], group 2 vs group 1, 1.2 [P = .7] and HR group 3 vs group 1, 0.5 [P = .5]). Further, freedom from valve-related deaths was 97.3% (95% CI, 93.2%-98.8%) at 10 years.
      Figure thumbnail gr2
      Figure 2A, Long-term survival for the full cohort. At 10 years: 79.8% ± 3.8%. B, Long-term survival by groups. At 10 years: 87.9% ± 4.2% for group 1, 75.8% ± 5.3% for group 2, and 98.4% ± 1.6% for group 3 (P = .3). CI, Confidence interval; AR, aortic regurgitation; AI, aortic insufficiency.
      Univariable Cox-regression analysis identified age (HR, 1.06; P < .001), male gender (HR, 0.35; P = .01), presence of BAV (HR, 0.19; P = .002), preoperative NYHA functional class (HR, 1.7 for every class increase; P = .02), peripheral artery disease (HR, 5.04; P = .03), and TAAD (HR, 7.04; P = .001) as significant predictors of late death. Reoperation on the aortic valve was not associated with late survival (P = .2). In a multivariable model only age, male gender, and TADD were significantly associated with death. Figure 3 shows AV reoperation-free survival and the competing risk of reoperation and death. At 10 years, reoperation-free survival is 71.5% (95% CI, 62.3%-78.8%).
      Figure thumbnail gr3
      Figure 3Aortic valve reoperation-free survival and the competing risks (cumulative incidence function) for reoperation on the aortic valve and death (without reoperation) at each moment in time in the overall cohort.

      Echocardiographic Studies

      Every patient underwent a transthoracic echocardiogram before discharge from hospital. At discharge, 227 patients (51.6%) had no AR, 205 (46.6%) had mild AR (ie, grade 1+) and 5 (1.1%) had mild to moderate AR (ie, grade 2+). During follow-up, 399 patients (96.4%) out of 414 had transthoracic echocardiogram for total of 2391 examinations. Each patient received a median of 5 scans (IQR, 2-7 scans) for a cumulative echocardiogram follow-up of 2122 patient-years. The 379 patients who did not require reoperation on the aortic valve had a last echocardiogram at a median follow-up of 4 years (IQR, 2-7 years) since surgery. A total of 2276 echocardiogram measurements of AR in 408 patients were available. Figure 4 shows the probability of developing AR over time considering patients who were alive. The percentage of patients in each grade of AR has changed significantly over time (P < .001). The percentage of patients with AR grade 0 decreases from 54% at 1 year to 34% at 10 years after the procedure, whereas the percentage of patients with grade 1 and 2 increased progressively from 40% to 51% and from 5% to 11%, respectively. The percentage of patients with grade 3 or 4 AR increased from 0% at discharge from hospital to 2% and 1%, respectively, at 10 years.
      Figure thumbnail gr4
      Figure 4Temporal trend of aortic regurgitation after the operation. Grade 0, blue; grade 1, red; grade 2, green; grade 3, yellow; grade 4, cyan.

      Discussion

      Preservation of the native valve with valve-sparing procedures potentially offers a reduction in the risk of prosthesis-related complications, particularly the anticoagulation-related complications with a mechanical prosthesis; the risk of valve degeneration and reoperation with a bioprostheses, particularly in young patients
      • Chan V.
      • Malas T.
      • Lapierre H.
      • Boodhwani M.
      • Lam B.K.
      • Rubens F.D.
      • et al.
      Reoperation of left heart valve bioprostheses according to the age at implantation.
      ; and a better hemodynamic profile compared with any valve prosthesis. In the present study, we reviewed our 20 years' experience with the valve-sparing reimplantation technique in patients presenting with aortic root aneurysm, aneurysm with significant regurgitation, or isolated severe AR. Our analysis shows that VSR can be safely performed also in patients with isolated AR and provide excellent results in terms of valve durability, valve-related complications, and long-term survival (Video 1). Our analysis further confirms the low rates of valve-related complications such as thromboembolism, bleeding, and infective endocarditis reported in a previous meta-analysis.
      • Arabkhani B.
      • Mookhoek A.
      • Di Centa I.
      • Lansac E.
      • Bekkers J.A.
      • De Lind Van Wijingaarden R.
      • et al.
      Reported outcome after valve-sparing aortic root replacement for aortic root aneurysm: a systematic review and meta-analysis.
      Figure thumbnail fx2
      Video 1In this short video, Dr Mastrobuoni explains the relevance of the valve-sparing root replacement with the reimplantation technique and the major findings of the study. Video available at: https://www.jtcvs.org/article/S0022-5223(18)33148-9/fulltext.
      The concern for the durability over time of the spared/repaired AV has slowed the diffusion of this technique in favor of the conventional Bentall operation. Our study shows an excellent durability of the AV with a freedom from reoperation of around 90% at 10 years also in patients who presented with severe AR at surgery.
      Recently, David and colleagues
      • David T.E.
      • David C.M.
      • Feindel C.M.
      • Manlhiot C.
      Reimplantation of the aortic valve at 20 years.
      presented long-term results with VSR and reported a freedom from reoperation of more than 95% at 10 years. Several differences between the 2 series may explain this disparity. In our cohort we had a higher prevalence of BAV (40.2% vs 13.5%) and a subgroup of patients (group 3, accounting for 17.3% of the cohort) presented with isolated AR. Therefore, cusp repair was needed in up to 72.7% of our patients, in almost all patients with BAV (97%), and a pericardial patch was used in 4.5% of patients (two-thirds of whom had a BAV). David and colleagues
      • David T.E.
      • David C.M.
      • Feindel C.M.
      • Manlhiot C.
      Reimplantation of the aortic valve at 20 years.
      reported a conservative approach and employs VSR only when the cusps are normal or have minimal abnormalities, and indeed they reported a cusp repair in 64% of patients and no patch use. We believe that VSR can be coupled with cusp repair in a certain proportion of patients who present with AR with severe cusp lesions and still provide good long-term results and a significant benefit compared with valve replacement. In these patients, at the expense of only a slightly increased risk of reoperation over time, we can spare them a prosthetic valve (most likely a mechanical valve considering the young age of the current cohort) and notably the prosthesis-related complications. Indeed, the rates of prosthesis-related complications in our series are notably lower than those from large recent registries
      • Chiang Y.P.
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      • Egorova N.N.
      Survival and long-term outcomes following bioprosthetic vs mechanical aortic valve replacement in patients aged 50 to 69 years.
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      in patients of similar age treated with valve replacement or Bentall procedure.
      • Mookhoek A.
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      • Di Centa I.
      • Lansac E.
      • Bekkers J.A.
      • et al.
      Bentall procedure: a systematic review and meta-analysis.
      It is nevertheless a matter of experience whether a valve with significant cusp lesion can be repaired with acceptable probability of long-term durability or if it should be replaced. Further, although some degree of AR develops over time, the risk of moderate or severe AR (ie, grade 3 and 4) is very low at 10 years and similar to David and colleagues.
      • David T.E.
      • David C.M.
      • Feindel C.M.
      • Manlhiot C.
      Reimplantation of the aortic valve at 20 years.
      It also noteworthy that in more than 50% of patients without significant AR before surgery underwent cusp repair. Reimplantation of the valve within a graft that is necessarily smaller than the native dilated aorta is invariably associated with increased cusp mobility afterward that may therefore result in cusp prolapse and regurgitation. Therefore, it is of paramount importance to reassess the cusps after reimplantation and to correct any residual prolapse or defect to improve the durability of repair.
      A growing number of patients with isolated AR and large VAJ (>28 mm), that is almost invariably present with a BAV, have been treated with VSR in our institution in recent years despite a normal or only slightly dilated aortic root (diameter, 40-45 mm) that, according to current guidelines,
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      2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCA/SCAI/SIR/STS/SVM. Guidelines for the diagnosis and management of patients with thoracic aortic disease. A report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine.
      • Nishimura R.A.
      • Otto C.M.
      • Bonow R.O.
      • Carabello B.A.
      • Erwin III, J.P.
      • Guyton R.A.
      • et al.
      AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on practice guidelines.
      would not need replacement. The use of VSR in these BAV patients was not primarily aimed to prevent late aortic events, whose risk seems to be low if the aorta size is normal at time of surgery,
      • Sundt T.
      Aortic replacement in the setting of bicuspid aortic valve: how big? How much?.
      but has the double purpose of stabilize the aortic annulus at both the level of VAJ and STJ and restore the valve symmetry. Previous studies have shown the role of VAJ on AR recurrence,
      • Aicher D.
      • Kunihara T.
      • Abou Issa O.
      • Brittner B.
      • Graber S.
      • Schafers H.J.
      Valve configuration determines long-term results after repair of the bicuspid aortic valve.
      and we have previously shown that durability of BAV repair is improved with VSR compared with subcommissural annuloplasty.
      • de Kerchove L.
      • Boodhwani M.
      • Glineur D.
      • Vandyck M.
      • Vanoverschelde J.L.
      • Noirhomme P.
      • et al.
      Valve-sparing root replacement with the reimplantation technique to increase the durability of bicuspid aortic valve repair.
      Cusp repair plus external ring
      • Lansac E.
      • Di Centa I.
      • Sleilaty G.
      • Lejeune S.
      • Khelil N.
      • Berrebi A.
      • et al.
      Long-term results of external ring annuloplasty for aortic valve repair.
      or suture annuloplasty
      • Schneider U.
      • Hofmann C.
      • Aicher D.
      • Takahashi H.
      • Miura Y.
      • Schäfers H.J.
      Suture annuloplasty significantly improves the durability of bicuspid aortic valve repair.
      have been proposed for these patients. Lansac and colleagues
      • Lansac E.
      • Di Centa I.
      • Sleilaty G.
      • Lejeune S.
      • Khelil N.
      • Berrebi A.
      • et al.
      Long-term results of external ring annuloplasty for aortic valve repair.
      reported on the influence of external ring plus cusp repair in a series of 62 patients with isolated AR. They reported a freedom from reoperation and freedom from AR grade ≥3 of 97.5% and 82.2%, respectively, at 7-year follow-up.
      • Lansac E.
      • Di Centa I.
      • Sleilaty G.
      • Lejeune S.
      • Khelil N.
      • Berrebi A.
      • et al.
      Long-term results of external ring annuloplasty for aortic valve repair.
      In our group 3 we had similar results in terms of freedom from reoperation (87%) and freedom from moderate-severe AR (84%) at 7 years. Nonetheless, important differences, particularly the prevalence of BAV (higher in our study) and use of pericardial patch (higher in the study by Lansac and colleagues
      • Lansac E.
      • Di Centa I.
      • Sleilaty G.
      • Lejeune S.
      • Khelil N.
      • Berrebi A.
      • et al.
      Long-term results of external ring annuloplasty for aortic valve repair.
      ), make the 2 series difficult to compare. Similarly, Schneider and colleagues
      • Schneider U.
      • Hofmann C.
      • Aicher D.
      • Takahashi H.
      • Miura Y.
      • Schäfers H.J.
      Suture annuloplasty significantly improves the durability of bicuspid aortic valve repair.
      recently reported the effect of suture annuloplasty on isolated repair of BAV. At 5 years they observed a freedom from reoperation of 92.6% and freedom from significant AR (ie, grade ≥ 2) of 79.5%. In our patients with BAV and isolated AR (n = 52), we recorded similar results with a freedom from reoperation of 97% and freedom from AR (ie, grade ≥ 2) of 78.3%. Although simpler to implement, we believe that these techniques (ie, external ring and suture annuloplasty) cannot reach the true level of the VAJ without deep root dissection, particularly at the level of the right coronary sinus; therefore, they provide only partial support on a supra-annular level and we fear that the effect may not be stable over time. We hope that longer follow-up studies will provide some answers.
      It has been proposed that BAV configuration, particularly the orientation of the commissure, may have an influence on valve durability.
      • Aicher D.
      • Kunihara T.
      • Abou Issa O.
      • Brittner B.
      • Graber S.
      • Schafers H.J.
      Valve configuration determines long-term results after repair of the bicuspid aortic valve.
      Therefore, our current practice with type-1 BAV is to restore the valve symmetry with the 2 commissures at the 180° configuration. Restoring valve symmetry also increases the mobility of the conjoined cusp and allows a direct closure after resection of the raphe avoiding the use of pericardial patch that has been associated with worse outcome.
      • Boodhwani M.
      • de Kerchove L.
      • Glineur D.
      • Rubay J.
      • Vanoverschelde J.L.
      • Noirhomme P.
      • et al.
      Repair of regurgitant bicuspid aortic valves: a systematic approach.
      According to these criteria, the proportion of patients with BAV and severe AR who undergo VSR in our institution has increased through the years and currently is more than 80%. Klotz and colleagues
      • Klotz S.
      • Stock S.
      • Sievers H.H.
      • Diwoky M.
      • Petersen M.
      • Stierle U.
      • et al.
      Survival and reoperation pattern after 20 years of experience with aortic valve-sparing root replacement in patients with tricuspid and bicuspid valves.
      recently reported a high rate of reoperation past 10 years in BAV patients and have questioned the appropriateness of VSR in these patients. We have observed a lower cumulative incidence of reoperation at 10 years (2.2% vs 5.3%) and have too few patients at risk after this point as to do a meaningful estimation of the risk afterward. Nonetheless, it is remarkable that in the series by Klotz and colleagues
      • Klotz S.
      • Stock S.
      • Sievers H.H.
      • Diwoky M.
      • Petersen M.
      • Stierle U.
      • et al.
      Survival and reoperation pattern after 20 years of experience with aortic valve-sparing root replacement in patients with tricuspid and bicuspid valves.
      a high proportion of BAV patients (around 12%) required a pericardial patch. This reveals the complexity of the valves they had to deal with and may explain the late failures.
      Also some patients with tricuspid AV and only mildly dilated root (40-45 mm) received a VSR in our series. Similarly, in these cases VSR was employed to stabilize a dilated VAJ or was used in cases where the aortic wall appeared particularly thin and fragile.
      For many years, we have been using a Valsalva graft (Gelweave Valsalva; Vascutek Ltd, Renfrewshire, Scotland) for this operation. It is still a matter of debate whether neosinuses should be recreated during the procedure because a clinical benefit has not yet been demonstrated. Nevertheless, we believe that the use of this graft simplifies rather than complicates the procedure. Indeed, we routinely use the height of the non/left commissure for the choice of the graft size and, because the height of the STJ in the graft equals its diameter, this commissure has to be reimplanted at the level of the neo-STJ. Also, the 2 other commissures should be reimplanted at this level but the graft is tailored proximally to match any difference in height of the left/right and right/noncommissures to avoid distortion.
      Finally, long-term survival is another important end point of this procedure. We observed a survival of around 80% and a stunning freedom from valve-related death of more than 95% at 10 years. Nonetheless, later survival of patients who required reintervention on the AV was not significantly different of those who did not. Survival at 10 years with VSR is therefore significantly better than with AV replacement (around 70% in large registries of patients of similar age
      • Chiang Y.P.
      • Chikwe J.
      • Moskowitz A.J.
      • Itagaki S.
      • Adams D.H.
      • Egorova N.N.
      Survival and long-term outcomes following bioprosthetic vs mechanical aortic valve replacement in patients aged 50 to 69 years.
      • Glaser N.
      • Jackson V.
      • Holzmann M.J.
      • Franco-Cereceda A.
      • Sartipy U.
      Aortic valve replacement with mechanical vs biological prostheses in patients aged 50-69 years.
      ). We can hypothesize that VSR eventually confers a survival benefit through a significant reduction of valve-related complications. Recently, Klotz and colleagues
      • Klotz S.
      • Stock S.
      • Sievers H.H.
      • Diwoky M.
      • Petersen M.
      • Stierle U.
      • et al.
      Survival and reoperation pattern after 20 years of experience with aortic valve-sparing root replacement in patients with tricuspid and bicuspid valves.
      showed that long-term survival was comparable to that of the matched general population in Germany. David and colleagues
      • David T.E.
      • David C.M.
      • Feindel C.M.
      • Manlhiot C.
      Reimplantation of the aortic valve at 20 years.
      reported even higher survival at 10 years. A slightly older mean age and a higher prevalence of associated procedures in our cohort, mainly mitral valve and coronary surgery, may explain this difference.

      Study Limitations

      Our study has several limitations that should be taken into account. We started the VSR program 20 years ago, although most of our patients underwent operation in recent years; the median follow-up is indeed short; and we have <10% of the initial cohort at risk at 12 years after surgery. The nonsignificant difference in outcomes between group 3 (isolated AR) and the other 2 groups may be due to the fact that group 3 included a smaller number of patients who were also younger and with a shorter follow-up. Further, this was a single-center experience with all operations carried out by a very limited number of surgeons and the results may not be generalizable. Finally, the limited number of adverse events, particularly valve failure, precludes any robust statistical analysis for the identification of significant predictors.

      Conclusions

      Our long-term experience with the AV-sparing aortic root replacement with the reimplantation technique confirms the excellent results in terms of patient survival and freedom from valve-related complications, including reoperation on the valve. Our study also confirms the excellent durability of the repair in cases of BAV. This operation can also be safely performed in patients without root dilatation. A longer follow-up well into the second decade will confirm if the valve function remains stable past 10 years, particularly in patients with isolated AR.

      Webcast

      Conflict of Interest Statement

      Authors have nothing to disclose with regard to commercial support.
      The authors acknowledge Mrs Corinne Coulon for her help with data collection.

      Supplementary Data

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      Linked Article

      • Commentary: Valve-sparing reimplantation: Is support the key to aortic valve repair?
        The Journal of Thoracic and Cardiovascular SurgeryVol. 158Issue 1
        • Preview
          The treatment for regurgitant aortic valve disease has progressed tremendously in the last 50 years, evolving from replacement, to repairing normal valves, to the possibility of repairing abnormal valves. Not surprisingly, this evolution followed the same trajectory as that of mitral valve repair and for some of the same reasons. Presumed or real advantages of a decrease in thromboembolic events, lower rates of endocarditis, and the avoidance of long-term anticoagulation all reinforce the preference of repair over replacement.
        • Full-Text
        • PDF
        Open Archive
      • Commentary: More is more: Root stabilization for regurgitant aortic valve repair
        The Journal of Thoracic and Cardiovascular SurgeryVol. 158Issue 1
        • Preview
          Most discussions regarding the optimal valve for replacement include the disclaimer that a perfect replacement does not exist today. The argument of mechanical anticoagulation versus tissue durability continues, despite advances in technique and technology. Since David and Feindel1 originally described the valve-sparing root procedure, the viability of aortic valve repair has become apparent. Discussion in valve repair forums, such as the article in this issue of the Journal by Mastrobuoni and colleagues2 from the Brussels group, have demonstrated that true, durable salvation of the aortic valve is not only feasible but also durable, with and without root dilation.
        • Full-Text
        • PDF
        Open Archive